Homosexuality and India

The shift in the understanding of homosexuality from sin, crime and pathology to a normal variant of human sexuality occurred in the late 20^th century.[1,2] The American Psychiatric Association, in 1973, and the World Health Organisation, in 1992, officially accepted its normal variant status. Many countries have since decriminalised homosexual behavior and some have recognised same-sex civil unions and marriage.

The new understanding was based on studies that documented a high prevalence of same-sex feelings and behavior in men and women, its prevalence across cultures and among almost all non-human primate species.[2] Investigations using psychological tests could not differentiate heterosexual from homosexual orientation. Research also demonstrated that people with homosexual orientation did not have any objective psychological dysfunction or impairments in judgement, stability and vocational capabilities. Psychiatric, psychoanalytic, medical and mental health professionals now consider homosexuality as a normal variation of human sexuality.

Human sexuality is complex.[2] The acceptance of the distinction between desire, behavior and identity acknowledges the multidimensional nature of sexuality. The fact that these dimensions may not always be congruent in individuals suggests complexity of the issues. Bisexuality, both sequential and concurrent, and discordance between biological sex and gender role and identity add to the issues. Medicine and psychiatry employ terms like homosexuality, heterosexuality, bisexuality and trans-sexuality to encompass all related issues, while current social usage argues for lesbian, gay, bisexual and transgender (LGBT), which focuses on identities.

The prevalence of homosexuality is difficult to estimate for many reasons, including the associated stigma and social repression, the unrepresentative samples surveyed and the failure to distinguish desire, behavior and identity. The figures vary between age groups, regions and cultures.

Medicine and science continue to debate the relative contributions of nature and nurture, biological and psychosocial factors, to sexuality.[2] Essentialist constructs argue for biology and dismiss personal and social meanings of sexual desire and relationships. On the other hand, constructivists support the role of culture and history. While essentialism and constructionism, on the surface appear contradictory, they may mediate orientation and identity, respectively.

Anthropologists have documented significant variations in the organisation and meaning of same-sex practices across cultures and changes within particular societies over time. The universality of same-sex expression coexists with variations in its meaning and practice across culture. Cross-cultural studies highlight the limits of any single explanation of homosexuality within a particular society.

Classical theories of psychological development hypothesize the origins of adult sexual orientation in childhood experience.[2] However, recent research argues that psychological and interpersonal events throughout the life cycle explain sexual orientation. It is unlikely that a unique set of characteristics or a single pathway will explain all adult homosexuality.

The argument that homosexuality is a stable phenomenon is based on the consistency of same-sex attractions, the failure of attempts to change and the lack of success with treatments to alter orientation.[2] There is a growing realisation that homosexuality is not a single phenomenon and that there may be multiple phenomena within the construct of homosexuality.

Anti-homosexual attitudes, once considered the norm, have changed over time in many social and institutional settings in the west. However, heterosexism, which idealises heterosexuality, considers it the norm, denigrates and stigmatises all non-heterosexual forms of behavior, identity, relationships and communities, is also common.

In addition to the challenges of living in a predominantly heterosexual world, the diversity within people with homosexual orientation results in many different kinds of issues.[2] Sex, gender, age, ethnicity and religion add to the complexity of issues faced. The stages of the life cycle (childhood, adolescence, middle and old age), family and relationships present diverse concerns. In most circumstances, the psychiatric issues facing gay, lesbian and bisexual people are similar to those of the general population. However, the complexities in these identities require tolerance, respect and a nuanced understanding of sexual matters. Clinical assessments should be detailed and go beyond routine labelling and assess different issues related to lifestyle choices, identity, relationships and social supports. Helping people understand their sexuality and providing support for living in a predominantly heterosexual world is mandatory. People with homosexual orientation face many hurdles including the conflicts in acknowledging their homosexual feelings, the meaning of disclosure and the problems faced in coming out.

Gay-affirmative psychotherapies have been developed, which help people cope with the awareness of being same-sex oriented and with social stigmatization. There is no evidence for the effectiveness of sexual conversion therapies.[2,3] Such treatments also raise ethical questions. In fact, there is evidence that such attempts may cause more harm than good, including inducing depression and sexual dysfunction. However, faith-based groups and counsellors pursue such attempts at conversion using yardsticks, which do not meet scientific standards. Clinicians should keep the dictum “first do no harm” in mind. Physicians should provide medical service with compassion and respect for human dignity for all people irrespective of their sexual orientation.

The landmark judgement of the Delhi High Court, which declared that Section 377 of the Indian Penal Code violates fundamental rights guaranteed by the constitution, was in keeping with international, human rights and secular and legal trends.[4] However, the anti-homosexual attitudes of many religious and community leaders reflect the existence of widespread prejudice in India.[5,6] Prejudice against different lifestyles is part of many cultures, incorporated into most religions, and is a source of conflict in Indian society.

There are few small case series in psychiatric literature detailing homosexuality in males and its treatment with aversion therapy.[7–10] Heterosexim and anti-homosexual attitudes among psychiatrists and mental health professionals have been documented.[5,6] The international classification of diseases-10 category (F66) employed to code egodystonic sexuality seems to be only employed in clinical practice only for homosexuality, suggesting continued pathologization. It places the responsibility on the individual without critically examining the social context, which is stigmatising and repressing.[6] The medicalization of sexuality and the political impact of labelling and its role in social control are often discounted. The ubiquitous use of disease models for mental disorders is rarely questioned.[6]

There is a dearth of Indian psychiatric literature that has systematically investigated issues related to homosexuality. Data on prevalence, emotional problems faced and support groups and clinical services available are sparse. Research into these issues is crucial for increasing our understanding of the local and regional context related to sexual behavior, orientation and identity in India.

Despite medicine and psychiatry arguing that homosexual orientation is a normal variant of human sexuality, mental health fraternity and the government in India are yet to take a clear stand on the issues to change widely prevalent prejudice in society. The fraternity needs to acknowledge the need for research into the context-specific issues facing LGBT people in India. The teaching of sexuality to medical and mental health professional needs to be perceptive to the issues faced by people with different sexual orientations and identities. Clinical services for people with such issues and concerns needs to be sensitive to providing holistic care. A positive and a non-judgemental attitude will go a long way in relieving distress. Professional societies need to increase awareness of these issues, transfer knowledge and skill and provide opportunities to increase the confidence and competence of mental health workers in helping people with different sexual orientations and identity. Psychiatrists and mental health professionals need to be educated about the human rights issues and possible abuses. The emphasis should not just be on education but also on a change of attitude. The development and dissemination of clinical practice guidelines is also essential.

Human sexuality is complex and diverse. As with all complex behaviors and personality characteristics, biological and environmental influences combine to produce particular sexual orientation and identity. We need to focus on people's humanity rather than on their sexual orientation.