The history of psychiatry’s attitude to homosexuality is revealing for what it shows of the changeability of psychiatric diagnostic practices over time, and the extent to which certain psychiatric diagnoses are subject to social, political and various other influences.
Homosexuality was listed as a mental disorder (sexual deviation) in the American Psychiatric Association’s iconic classification systems DSM-I (American Psychiatric Association, 1952) and DSM-II (American Psychiatric Association, 1968). This situation led to significant opposition and activism including demonstrations by gay rights groups at the Annual Meeting of the American Psychiatric Association in San Francisco in 1970 (Lieberman & Ogas, Reference Lieberman and Ogas2015). In 1973, the DSM-III task force decided to delete homosexuality from the classification system and that decision was confirmed by a referendum of members in 1974 (Shorter, Reference Shorter1997).
Before this point, however, there was a long history of psychological, psychoanalytic and psychiatric engagement with homosexuality, and, as is invariably the case, these engagements reflected broader social judgements about homosexuality: homosexuality was often judged negatively both medical and morally at this time (Pietikainen, Reference Pietikainen2015), and discrimination was widespread (Dickinson, Reference Dickinson2015). In 1979, Simpson, Emeritus Professor of Forensic Medicine to the University of London at Guy’s Hospital, bemoaned the fact that, in his view, psychiatrists seemed to condone homosexual acts, which he described as unnatural (Simpson, Reference Simpson1979).
There was always particular interest in homosexuality in the field of psychoanalysis (Dickinson, Reference Dickinson2015; Pietikainen, Reference Pietikainen2015; Scull, Reference Scull2015), although while psychoanalytic ‘treatment’ of homosexuality was provided, it was later reported as unhelpful and even more alienating for an already stigmatised, alienated group (Robson, Reference Robson1991; Lieberman & Ogas, Reference Lieberman and Ogas2015). Even more disturbingly, from 1933 onward homosexuality became a criterion for incarceration in psychiatric hospitals in Germany (Pietikainen, Reference Pietikainen2015).
This development formed part of a broader and, from today’s perspective, deeply disturbing psychiatric effort to re-orient homosexual persons to heterosexual preferences. Specific treatments in various countries included aversion therapies delivering painful electric shocks to homosexual men at the wrists, calves, feet (Dickinson, Reference Dickinson2015; Wise, Reference Wise2015) or genitals (Lieberman & Ogas, Reference Lieberman and Ogas2015) as they fantasised or viewed images of undressed males; administering emetic medication (such as apomorphine) to produce vomiting while similar materials were viewed; administration of testosterone followed by showing films of nude or semi-nude women; playing tape recordings every 2 hours outlining the alleged adverse effects of homosexual behaviour (in association with emetic medication); and, later, repeatedly playing tape recordings outlining the alleged positive consequences of no longer being homosexual (Dickinson, Reference Dickinson2015).
These disturbing ‘treatments’ for homosexuality have been clearly described as occurring in various countries around the world, but even though specialist clinics were established in London, Manchester, Birmingham, Glasgow and Belfast, such treatments never became mainstream in British psychiatry (King et al. Reference King, Smith and Bartlett2004). Did they occur in Ireland?
Homosexuality in Ireland
Recent decades have seen increased exploration of the history of sexuality in general (Ferriter, Reference Ferriter2009) and homosexuality in particular in Ireland (Lacey, Reference Lacey2008; Walshe, Reference Walshe2009). For much of the 20th century, Ireland was a very difficult place to be gay: same-sex sexual acts were criminal acts up until 1993, and between 1962 and 1972 there were some 455 convictions of men for crimes such as ‘indecency with males’ and ‘gross indecency’ (Ferriter, Reference Ferriter2009). There were, however, also some mixed attitudes to homosexual activity during this period. Some Gardaí assumed a humane and sympathetic approach (Irish Times, 25 June 1980) and in 1973 one letter-writer to the Irish Times advised against incarceration, albeit out of sympathy rather than considerations of justice:
It must be rather sad to be homosexual, sad and pathetic. Not for these people (as a rule) the joys of family life as we know them. If, on occasion, they find solace and pleasure in each other, then let us be charitable and understanding. It will do no good at all just to lock them up (Murphy, Reference Murphy1973).
From a mental health perspective, one 1963 volume, The Priest and Mental Health, considered homosexuality from several angles, with Reverend E. F. O’Doherty (Reference O’Doherty1963), Professor of Logic and Psychology at University College Dublin, stating that while being homosexual was not a sin, homosexual acts were sins, and while sexual deviations were not themselves illnesses, they were very often symptomatic of deeper pathological processes.
Professor John Dunne (Reference Dunne1963), Professor of Psychiatry at University College Dublin and Resident Medical Superintendent at St Brendan’s Hospital (Grangegorman), expressed the view that many ‘sexual deviations’ (a category in which he included homosexuality) had a compulsive obsessional component, whereas another contributor to The Priest and Mental Health associated homosexual acts in the intellectually disabled with inadequacy and inability to engage in adult relationships (Ryan, Reference Ryan1963).
As regards ‘treatment’ for homosexuality, there was awareness in Ireland in the early 1960s that aversion therapies were being used in Great Britain (Irish Times, 24 February 1964), but neither homosexuality nor aversion therapy were explicitly mentioned by Ireland’s 1966 Commission of Inquiry on Mental Illness. There was, however, a section devoted to ‘sexual deviates’ [a category which, at this time, included persons who engaged in homosexual acts, according to the American Psychiatric Association and World Health Organisation (WHO)]:
Sexual deviates are not necessarily mentally ill, but they are a vulnerable group who may be in need of help. In the past, the only measures adopted by society were punitive. In recent years, there has been a considerable change for the better in public attitudes as more insight is gained into the causes of, and the possibility of altering, deviant behaviour. It would be, however, an exaggeration to claim that the causation of such behaviour is fully understood or that much progress has been made in its treatment. Although this is so, the sexual deviate needs whatever help he can obtain from medical science. Apart from the fact that it may be contrary to the law of the land, deviant behaviour can result in considerable unhappiness. The deviate is usually aware that he or she is different and this often causes considerable stress and worry; deviant behaviour frequently results in the break-up of families, with resultant stress to children and other dependants (Commission of Inquiry on Mental Illness, 1966: 99).
Treatment was to consist ‘largely of counselling aimed at acquainting the patient with the social consequences of his deviation and helping him voluntarily to abandon his deviant behaviour. Counselling of this nature can be very effective, particularly at the adolescent stage’. Ultimately, the Commission recommended that:
-
∙ ‘Parents, teachers, general practitioners and other persons who may be aware of individual cases which would warrant psychiatric intervention should try to ensure that the persons concerned attend at the local psychiatric clinics’;
-
∙ ‘Psychological and psychiatric reports should be available to the Courts when dealing with sexual deviates’ (Commission of Inquiry on Mental Illness, 1966: xxix–xxx).
Progress with ‘counselling’ services was slow. In 1971 the Irish Times reported that ‘in the secondary schools, students with problems like homosexuality did not know to whom to turn, but with the development of psychological services in the psychiatric clinics more treatment would be available’ (O’Brien, Reference O’Brien1971). Three years later, Professor Thomas Lynch, Professor of Psychiatry at the Royal College of Surgeons in Ireland, noted that homosexuality was a constant feature in all societies over the course of history:
For the genuine exclusive homosexual the only realistic ‘treatment’ Professor Lynch points out, is ‘to make him a better adapted homosexual’, to help him to accept himself and to adjust to his role in society. Trying to ‘reform’ them is pretty pointless. Homosexuals themselves, not unnaturally, object strongly to references to ‘treatment’ or ‘reform’ or being regarded as problems or, worse again, ‘patients’. They feel that as homosexuality is a natural state, it should be accepted as such and that we should stop thinking of them as medical cases who need treatment. What they need, they say, is a more understanding and accommodating society which will stop regarding them as freaks and criminals and allow them to live normal lives (Murphy, Reference Murphy1974).
The following year, Dr Noel Browne made similar points in the Senate, reiterating that ‘homosexuality was in itself a form of sexuality that was completely normal’:
However, it was not looked on this way in Irish society and it was still a crime. It was odd that no attempt had been made to deal with this matter and it had been on the Statute books since 1885.
Dr Browne said it was absurd to pretend that there was no such thing as a homosexual problem in Ireland. It did exist and was the cause of an enormous amount of distress for a great number of people. He had experienced this in his psychiatric practice where homosexuals suffered an appalling sense of being rejected by the society, leading to alcoholism, social drop out, and, in some cases, suicides. ‘Suicide is a very common sequel to the problem’, he said.
He asked the Attorney-General to, at least, have a debate on the subject in the same way as contraception had been brought before the House. The law at the moment was outrageous where a person could be put in jail simply because he was a homosexual and people were adopting pathetic devises to protect themselves (Irish Times, 11 April 1977).
The role of psychiatrists in prosecutions for homosexual acts
Even following the American Psychiatric Association’s de-listing of homosexuality as a mental disorder in 1973, Irish psychiatrists were still involved in court proceedings linked with homosexual acts. Some defendants were fined, given suspended sentences or ordered to see psychiatrists (Manning, Reference Manning1976; Ferriter, Reference Ferriter2009). In other cases which did not relate directly to homosexual acts, expert psychiatric evidence was given regarding homosexuality in the context of, for example, circumstances connected with manslaughter (Cork Examiner, 14 and 17 June 1983).
In 1975, Ms Nell McCafferty reported the cases of two men brought before Dublin District Court having been apprehended together in a public location. The prosecuting Garda stopped both accused and while ‘at that time, they denied everything’, later ‘they admitted all’:
A psychiatrist for the younger man, aged 25, was called to testify. The dependent had been referred to him by a priest.
‘He has been attending me regularly, five days a week, since this happened’, the doctor said. ‘The conclusion I came to is that first he is very sincere … I am very slow to come to conclusions about cases which are pending in court. But in this case I am convinced of his sincerity. He did not think in fact, that he could be treated, and was wrongly advised to this effect by a psychiatric nurse. Depending on his desire, he can be treated … with psychotherapy … no medication is being used’.
Was it fair to suggest that he was sexually immature, the solicitor asked. He was, the doctor agreed. […]
The other solicitor went into the case history of the married man. He has married two years ago, and unfortunately his job entailed his being away from home very often. ‘The only conclusion I can come to’, said the solicitor, ‘is that he was suffering from depression. He’d taken a few drinks that evening …’ (McCafferty, Reference McCafferty1975).
The judge described homosexual behaviour as ‘a completely unnatural performance’, but the men were not jailed:
‘Well’, said the Justice firmly, ‘It’s against the law here. The law’s the law and they broke the law. One answer is prison obviously. If they had been dealt with before a jury they could have gotten penal servitude, strange as it seems to say. In the interests of justice, I will bind them in their own bonds to keep the peace for a year. It goes without saying that their association must break up and there must be no repetition of this’.
Psychiatric ‘treatments’ for homosexuality in Ireland
In the 1975 case reported by McCafferty, the only reported ‘treatment’ for the younger man’s homosexuality was psychotherapy. Just 2 years later, however, Mr David Norris, Chairman of the Irish Gay Rights Movement and later Senator, suggested at a Rotary Club luncheon in Dublin that aversion therapy was also being used:
Mr Norris said that it was also necessary to call publicly for an urgent enquiry into the extent in Ireland of the practice of Aversion Therapy, saying that he knew of at least one psychiatrist who was seemingly quite proud of having used electric shock treatment in an attempt to alter homosexual orientation, and he invited comments from the medical profession in Ireland on the ethics of such treatment.
The psychiatric profession had largely abandoned the notion that homosexuality was a disease, Mr Norris said, pointing to the American Psychiatric Association’s decision to remove it from classification as a nervous disorder. There were, however, some vested interests in the ‘sickness theory’, such as a manufacturer of psycho-pharmacologic drugs who distributed free to the psychiatric profession a pamphlet containing the statement that psychiatrists agree unanimously that the homosexual is a sick person (Irish Times, 8 March 1977).
Senator Norris recalls the case of one gay man in the east of Ireland whose family sent him for treatment when he revealed his homosexuality and who reportedly received electro-convulsive therapy (ECT) in Ireland for this in the 1970s.Footnote 1 Later in life, the same man was badly harassed owing to his sexual orientation and saw a psychiatrist who reportedly taught him to ‘walk butch’ (i.e. in a stereotypically masculine fashion) in order to minimise harassment.
It is difficult to establish to what extent, if any, aversive therapies for homosexuality were systematically provided in Irish psychiatry. There are references to aversion therapy in the Irish popular press (Irish Times, 5 August 1977; Gillespie, Reference Gillespie1979; McCarthy, Reference McCarthy2015) and history texts (Ferriter, Reference Ferriter2009), and to lectures on the topic being given to Irish psychiatrists (O’Shea, Reference O’Shea2014), but there is a paucity of primary evidence about the extent, if any, to which various therapies other than psychotherapy were provided for homosexuality in Irish psychiatric hospitals or clinics during the 1900s. For this paper, I canvassed the opinions and memories of 10 prominent psychiatrists and clinical directors who practiced during the 1950s up to the 2000s, and none recalled hearing of psychiatric treatments being provided for homosexuality in Ireland.Footnote 2 This is an area in need of further study (Ryan, Reference Ryan2006), from the perspectives of both patients (Smith et al. Reference Smith, Bartlett and King2004) and professionals (King et al. Reference King, Smith and Bartlett2004).
There is also a need for further original research into the historical evolution of public, professional and legal views of homosexuality in Ireland and Great Britain, including most especially Irish responses to the Report of the Committee on Homosexual Offences and Prostitution (Committee on Homosexual Offences and Prostitution, 1957, September) (‘Wolfenden Report’), which included one psychiatrist (Dr Desmond Curran of St George’s Hospital, London), recommended that ‘homosexual behaviour between consenting adults in private be no longer be a criminal offence’ (Committee on Homosexual Offences and Prostitution, 1957: 115) (despite various contrary views); and led to the Sexual Offences Act of 1967. There is a need for systematic research into the extent and nature of the effects of these developments in Ireland and how, precisely, psychiatry, through its nosologies, has regarded and ultimately changed views on the issue from early ideas about ‘treatment’ of homosexuality as a ‘disorder’. Finally, the evolution of professional attitudes on this theme in Irish psychiatry is worthy of particular exploration, including the influence, if any, of the Royal College of Psychiatrists on professional views and practices. Elucidating these matters would require an extensive programme of research that is beyond the scope of the present paper but is worth pursuing in the years to come.
What is clear, however, is that medical, psychiatric and general attitudes towards homosexuality evolved, albeit slowly, throughout the 1970s, 1980s and 1990s. In November 1977, Norris began legal proceedings against the Attorney General in relation to the Offences Against the Person Act 1861 and also in connection with the Criminal Law (Amendment) Act 1885 (Norris, Reference Norris1977, Reference Norris2012; Irish Times, 25 June 1980). In the course of proceedings, Norris himself recounted seeing a psychiatrist owing to stress and anxiety. He states that the psychiatrist gave him ‘fatherly advice’Footnote 3 about the legal situation in Ireland and suggested that Norris’s anxiety would not occur if he lived in a country with different legal arrangements, such as England or France. Norris regarded that psychiatric report as the most important advantage he had in taking his case, which opened in June 1980 in the High Court.
During the proceedings, John P. Spiegel, an American psychiatrist and professor, gave evidence that decriminalising homosexual acts would relieve the stress on homosexual people that led to mental illness (Irish Times, 27 June 1980; Norris, Reference Norris2012). Professor Ivor Browne, Professor of Psychiatry at University College Dublin, also gave evidence and warned against treatment that tried to ‘change the homosexual into a heterosexual’ because this ‘was not the true nature of the problem’; such efforts, he said, ‘could cause harm’ (Irish Times, 28 June 1980).
The government did not produce expert psychiatric evidence in the case because, according to Norris, no psychiatrist was willing to risk his or her reputation (Norris, Reference Norris2012). Norris’s case was, nonetheless, defeated but, following further protracted and ultimately ground-breaking legal action, Norris finally prevailed in 1988, when the European Court of Human Rights ruled that Ireland’s law criminalising same-sex activities violated Article 8 of the European Convention on Human Rights concerning the ‘right to respect for private and family life’.
Homosexuality and Irish psychiatry in the 1980s and 1990s
The fact that the American Psychiatric Association’s DSM-III task force deleted homosexuality from the classification system in 1973 was an important development but it did not immediately dispel the association between homosexuality and psychiatry (Dickinson, Reference Dickinson2015). In Ireland in the late 1970s, for example, one gay man who experienced difficulties coming out consulted both a psychiatrist and a general practitioner (GP):
So, being almost suicidal – gay people have very high rates of alcoholism, psychiatric admissions and suicides – he went to a psychiatrist. ‘He asked me about my relationship with my parents and with my religion and if I played sports and concluded from the answers that there was no way I could be gay; that I should try to think positively’.
Earlier [he] had been to a GP but that was only worse. ‘When I told him the kernel of my, inverted commas, problem he nearly fell off the chair, said he knew nothing about the subject and told me to ring St Brendan’s [Psychiatric] Hospital for an appointment’ (Walsh, Reference Walsh1984).
Attitudes were, however, steadily changing in many areas of Irish life. In 1979, Fr Ralph Gallagher (Reference Gallagher1979), a Redemptorist priest in Dublin, wrote at some length about homosexuality in The Furrow, an Irish Roman Catholic theological periodical, arguing that no person should undergo behaviour modification or aversion therapy unless it was his or her free and conscious decision to do so. He noted that many within the medical profession had turned away from such treatments and highlighted the need for self-acceptance and reasonable adjustment to society.
The issue of self-image was further explored in a 1984 study of androgyny, depression and self-esteem in 49 homosexual men, 23 heterosexual men, 23 homosexual women and 17 heterosexual women in Ireland (Carlson & Baxter, Reference Carlson and Baxter1984). The researchers concluded that it was not one’s homosexuality or heterosexuality that affected psychological health, but how one perceived one’s own psychological masculinity or femininity. Another 1984 study, by researchers in Northern Ireland, found that homosexual men’s degree of integration into the homosexual community was significantly related to scores on relevant anxiety scales (Patterson & O’Gorman, Reference Patterson and O’Gorman1984). Clearly, acceptance and integration with the community were critical to well-being.
Acceptance and integration were still difficult to achieve, however, not least because it was not until 1990 that the WHO finally removed homosexuality from its list of mental disorders, some 17 years after the American Psychiatric Association had done so. Despite these developments, finding psychological support in Ireland was still difficult: in 1990, one Leaving Certificate student, struggling to come to terms with his homosexuality, went to see his GP but could not bring himself to tell the doctor the problem, even though the doctor was generally easy to talk to (Egan, Reference Egan2003; Collins, Reference Collins2004). The GP concluded that he was depressed and sent him to a psychiatrist. Later, the young man took an overdose owing to homophobic bullying and was admitted to psychiatric hospital for 6 weeks, where he reported finding little understanding.
Others, however, reported much more positive experiences with psychiatrists (Fielding, Reference Fielding2012) and in January 1990 Professor Anthony Clare offered clear evidence of evolving attitudes within Irish psychiatry, stating publicly that the primary purpose of psychiatric treatment was to assist homosexual persons in accepting their orientation and coping with a generally hostile society (Holmquist, Reference Holmquist1990). The following month, Clare (Reference Clare1990) revisited the theme in the letters column of the Irish Times:
In practice, the great majority of clinical psychiatrists do not regard homosexuality as a psychiatric disorder and do not regard it as warranting treatment. […] I take consolation from the fact that wherever repressive and intolerant regimes seize power and set about persecuting and intimidating minority and opposition groups they invariably include amongst those groups – homosexuals and psychiatrists. We must be doing something right.
Homosexuality and mental health needs
Over the course of the following two decades, there was growing awareness of the mental health needs of lesbian, gay, bisexual and transgender (LGBT) people in Ireland. In 2007, President Mary McAleese (Reference McAleese2008), President of Ireland, made particular reference to the psychological effects of bias and hostility towards gay people. In 2009, an online survey of some 1110 LGBT people showed that 86% had experienced feelings of depression at some point in their lives and 60% of those interviewed attributed this directly to social and/or personal challenges associated with LGBT identity (Mayock et al. Reference Mayock, Bryan, Carr and Kitching2009). A total of 25% of online participants had taken prescribed medication for depression or anxiety and 27% had self-harmed.
Another study of the mental health experiences and needs of LGBT people over the age of 55 years in Ireland confirmed that a significant number had mental health problems over the course of their lives and recommended that the mental health needs of older LGBT people be addressed in future strategic directives, supporting the principles of inclusion, equality and respect for diversity (McCann et al. Reference McCann, Sharek, Higgins, Sheerin and Glacken2013).
In 2011, the College of Psychiatry of Ireland and the Gay and Lesbian Equality Network published specific guidelines ‘to inform psychiatrists of what they need to know when providing a mental health service to a lesbian, gay or bisexual (LGB) person’ (2011). They advised ‘psychiatrists to challenge any anti-gay bias they may have’ so as to avoid behaviour such as ‘presuming patients are heterosexual’; ‘failing to appreciate any non-heterosexual form of behaviour, identity, relationship, family or community’; or ‘attempts to change a patient’s sexual orientation’. Psychiatrists were also advised to
-
∙ Be aware of LGB mental health issues and gay-specific stressors.
-
∙ Do not assume everyone is heterosexual.
-
∙ Respond supportively when patients disclose they are LGB.
-
∙ Challenge anti-gay bias and take a gay-affirmative approach.
-
∙ Demonstrate that your practice is inclusive of LGB people.
In May 2015, Ireland became the first country to decide to legalise same-sex marriage on a national level by popular vote.Footnote 4 Nonetheless, significant challenges remain, especially in the area of mental health. In 2014, one study of 125 LGBT people in Ireland found that 64% believe that mental health professionals still lack knowledge about LGBT issues and 43% believe that practitioners are unresponsive to their needs (McCann & Sharek, Reference McCann and Sharek2014). Matters have improved considerably in recent decades, but there is still, clearly, work to be done.
Acknowledgements
Material from the Irish Times is reproduced by kind permission of the Irish Times. The author is very grateful for the assistance of Senator David Norris, and the psychiatrists and clinical directors who discussed this theme with him as he prepared this paper. The author is very grateful to the reviewers for their comments and suggestions.
Financial Support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of Interest
None.
