Archives o f Sexual Behavior, Vol. 4, No.

1, 1975

Etiology and Treatment of Homosexuality: A Review

Frank X. Acosta, Ph.D.I

The major causal theories o f and treatment approaches to male and female
homosexuality are critically reviewed. Neither biological, psychoanalytic, nor
learning and social-learning theories are found to provide convincing evidence for
the etiology o f homosexuality. All o f these accounts, however, are viewed as
providing mixed empirical support for their predictions, with social-learning
research presenting the most consistent evidence. It is argued that both social-
learning research findings and results from retrospective studies suggest that
homosexuality may best be linked to the early qualitative learning and develop-
ment o f one's gender identity and gender role. Both psychoanalytic therapy and
behavior therapy are found to have minimal successes and many failures. Most
therapeutic successes seem to be with bisexuals rather than with exclusive homo-
sexuals. The combined use o f psychotherapy and specific behavioral techniques
is seen to offer some promise for heterosexual adaptation with certain kinds o f
patients. However, it is argued that better prospects for intervention in homo-
sexuality lie in its prevention through the early identification and treatment of
the potential homosexual child.
KEY WORDS: homosexuality; psychoanalytic theory; behavior therapy; social learning;
ethics; psychotherapy.

INTRODUCTION

Exclusive male or female homosexuals typically believe that they have

been born homosexuals (Hooker, 1965a). The homosexual is usually convinced
that he cannot change his sexual object preference to that of the opposite sex. In
contrast to these attitudes, our Western society popularly believes that the
homosexual is merely an uncooperative, rebellious, and sinful individual who has
little regard for social mores (West, 1967). Consequently, the homosexual has
been rejected as an undesirable minority member because of his socially inappro-
priate sexual behavior. He has also been often categorized by mental health
1Department of Psychology, University of California, Los Angeles, California.
9
@1975 Plenum Publishing Corporation, 227 West 17th Street, New Y o r k , N.Y. 10011. No
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10 Acosta

professionals as a deviant and pathologically disturbed individual (West, ~967).

While the above statements are both popular and pessimistic, they do not
accurately reflect the present state of knowledge about the development and
treatment of homosexuality. It is the purpose of this discussion to examine both
the controversial psychological and biological accounts which attempt to explain
the etiology of homosexuality and the therapeutic approaches which have been
followed in the treatment of homosexuals.
Some psychoanalytic theorists (Freud, 1938; Fenichel, 1945; Bieber etal.,
1962) have insisted that male and female homosexuality is a pathological condi-
tion which develops early in childhood and results from opposite-sex parental
fixations or neurotic fears of heterosexuality. This position has been strongly
contested by recent investigators (e.g., Bene, 1965a,b) who have found various
patterns of disturbed parental relationships in the childhood years of adult
homosexuals which do not fit psychoanalytic predictions. An increasing number
of investigators further argue that homosexuals are not necessarily psychologi-
cally disturbed individuals (e.g., Saghir et al., 1969; Hopkins, 1969; Green,
1972). In sharp contrast to a psychoanalytic account, learning and social-learn-
ing theorists (Feldman, 1966; Churchill, 1967; Bandura, 1969) maintain that
homosexuals have failed to learn appropriate sexual behaviors and preferences.
In opposition to both psychoanalytic and learning theorists, some investigators
argue that a common biological factor underlies the development of homo-
sexuality (e.g., Evans, 1972).
The above viewpoints and research will be considered in an effort to
determine the most useful explanation for the development of homosexuality, in
addition, the utility of some of the primary approaches tbllowed iv_ the treat-
ment of homosexuals will be examined. Contrasts will be particularly stressed
among the theory, research, and practice of therapists who adhere to a psycho-
analytic morality (e.g., Bieber et al., 1962; Mayerson and Lief, 1965) and those
behavior therapists who follow a learning approach (e.g., Bancroft, 1970;
MacCulloch and Feldman, 1967). An attempt will also be made to demonstrate
the feasibility and usefulness of a rapproachment between traditional psycho-
dynamic therapy and behavior therapy in the treatment of homosexuals.

DEFINITION

The concept of homosexuality has received several different definitions.

On the one hand, some authors (e.g., Hooker, 1965a) consider individuals to be
homosexual if they so identify themselves and if their sexual desires and overt
sexual behavior are both predominantly directed to members of the same sex.
On the other hand, some (West, 1967; Bene, 1965a) consider a dominant fantasy
or sexual desire for members of the same sex as evidence of homosexuality
without the requirement of overt sexual behavior. What is clear, however, is that
Etiology and Treatment of Homosexuality 11

homosexuality in males and females occurs on a heterosexuality-homosexuality

continuum that varies from a minimal to a predominant or exclusive sexual
interest and/or contact with members of the same sex. The reality of such a
continuum has been particularly evidenced in the work by Kinsey et al. (1948,
1953). These authors found that a rating of adult sexual behavior was amenable
to a 7-point scale with 0 for individuals with a history of exclusive heterosex-
uality; 1 through 5 for individuals with a history of varying combinations of
heterosexual and homosexual desires and experience, a higher score indicating a
higher degree of homosexuality; and 6 for persons with a history of exclusive
homosexuality both in overt sexual behavior and in covert responses and erotic
interests. On this scale, individuals rated 3 show equal erotic response to both
heterosexual and homosexual stimuli and show no dominant sexual preference.
Persons at the level of 3 are often referred to as bisexuals. It should be noted
that the majority of research conducted with male and female homosexuals has
primarily included bisexuals- at the 3 or 4 rating--and exclusive or near-
exclusive homosexuals -- at the 5 or 6 rating. Thus, in the present discussion the
term "homosexuality" will primarily refer to exclusive homosexuals and
bisexuals.
While the majority of research on homosexuality has concentrated on the
male, some important psychosexual differences have been found between male
and female homosexuals. It appears that homosexuality occurs about three times
as often among males (Kinsey et al., 1948, 1953). The homosexual male is more
"promiscuous" than the female and tends to have very brief relationships and
frequent contacts with many sexual partners (Saghir et al., 1969, 1970a). Unlike
the male, the exclusive female homosexual tends to be more faithful to one
partner and to form emotional and long-lasting relationships (Saghir et al.,
1969). The compelling implication of these findings is that homosexuals
typically retain some of the masculinity-femininity differences found among
heterosexual males and females.

Gender Identity and Gender Role

The above implication warrants further distinction about the relationship

among the three important concepts of gender identity, gender rote, and sexual
orientation. Brief definitions of these concepts are as follows: (1) gender
identity, one's self-perception as male or female; (2) gender role, the degree of
masculinity or femininity of one's behaviors and attitudes, sexual or nonsexual;
and (3) sexual orientation, one's sexual object choice (Money and Ehrhardt,
1972). The overwhelming findings from current research on homosexuality
indicate that neither the majority of male homosexuals (Evans, 1969; Bieber et
al., 1962) nor the majority of female homosexuals (Gundlach and Riess, 1968;
Bene, 1965b) identify themselves with the opposite sex. Although a small
percentage of male homosexuals do fit the stereotype of an effeminate, high-
12 Acosta

voiced, and swishing individual, and do in fact see themselves as more feminine
than masculine (Evans, 1969; Miller, 1958), they seem to be a minority. Simi-
larly, the stereotyped caricature of a tough masculine lesbian does not fit the
typical female homosexual. However, one must be cautioned against dismissing
the functions of gender identity and gender role in the homosexual.
While the majority of adult male and female homosexuals may express a
correct gender identity, it is questionable how comfortable their gender roles
have been for them in their early lives and to what degree they have seen
themselves as masculine or feminine in their development (Bene, 1965a,b;
Gundlach, 1969). For example, some questionnaire studies with male homo-
sexuals who professed male identities have indicated that either the majority or a
large percentage manifested poor sex-typed behaviors as children and adolescents
(Evans, 1969), or had wished to be girls in childhood (Bene, 1965a). The
implications for the manifestation of homosexuality of the early development of
gender identity and sex-typed behaviors, attitudes, and preferences will be
discussed in greater detail later.

Homosexuality and Transsexualism

The differential aspects of gender identity, gender role, and sexual orienta-
tion are particularly evident in the relationships between homosexuality and
transsexualism. Some regard transsexualism to be at "the extreme of the homo-
sexual spectrum" (Money and Ehrhardt, 1972, p. 231). Several investigators of
male and female transsexuals report that the sexual orientation of these patients,
in both pre- and postoperation periods, was exclusive homosexuality (Money
and Primrose, 1969; Money and Brennan, 1969; Randell, 1969; Benjamin,
1966). It is important to note that these investigators have typically found the
more exaggerated effeminate males, in many cases living with complete adapta-
tion to the female role, among the male transsexuals. Similarly, the more
extreme masculine female has been typical among the female transsexuals.
Critical differences between homosexuals and transsexuals lie in the
repeated findings that, unlike homosexuals, transsexuals (1)have a conviction
that they belong to the opposite sex and (2) have a strong compulsion to behave
like and to have the body of the opposite sex, and to be accepted as one of its
members (Money and Ehrhardt, 1972). Interestingly, several studies have also
found that this conviction among groups of male and female transsexuals dates
from early childhood (Benjamin, 1966; Randell, 1969; Green, 1974). Green
(1969a) has further argued that both the differential development and the
factors of overlap and separation between homosexuality and transsexualism are
still not completely understood. The available data, however, do strongly suggest
that not only similarities but also critical differences can be found between
homosexuality and transsexualism.
Etiology and Treatment of Homosexuality 13

ETIOLOGY

Biological

Is the development of homosexuality directly related to biological causes

as many homosexuals maintain? It seems possible that some genetic, chromo-
somal, or hormonal factors may function to some degree in the onset of homo-
sexual behavior, but no substantial evidence to this effect has been established.
Genetic factors of homosexuality have primarily been investigated through
twin studies. Unfortunately, of the few twin studies reported most suffer either
from small and nonrepresentative samples or from experimenter bias (see
Rosenthal, 1970). A case for the hereditary basis of homosexuality was provided
by Kallman (1952) in his famous twin study with exclusive male homosexuals.
This investigator followed the typical twin study procedure of first identifying a
twin who was homosexual and then tracing the twin brother to determine the
brother's sexual orientation. The dramatic results of this study indicated that of
a total of 37 pairs of monozygotic (identical) twins all were concordant in
exclusive homosexuality, whereas no homosexual trend was found among 26
pairs of dizygotic (nonidentical) twins. Kallman concluded that genetic factors
did serve a critical function in the onset of homosexuality.
Rosenthal (1970) and others (e.g., West, 1967)have recently challenged
the merit of Kallman's findings. Rosenthat contends that Kallman's investigation
was not representative of the homosexual population since the majority of the
subjects showed a great deal of psychopathology and had primarily been selected
from correctional agencies. Rosenthal further argues that Kallman's finding of
100% concordance for the monozygotic twins indicated a strong experimenter
bias. According to Rosenthal, Kallman's method "led to a sample that missed
discordant pairs" (p. 252). It thus appears that neither Kallman's study nor
other twin studies have provided any definitive evidence for genetic factors of
homosexuality. At best, these studies provide some suggestion that genetic
factors may function to predispose an individual to homosexuality given particu-
lar life experiences and stresses. But this implication has not yet been substan-
tiated by empirical evidence.
A case for severe chromosomal deviation in male homosexuals was argued
by Lang (1940). Lang posited that male homosexuals may be genetic females
with male morphological sex characteristics, i.e., that the male homosexual's
chromosomal sex is female. Lang's hypothesis has been strongly refuted by a
number of investigations of male homosexuals' sex chromosome constitutions
(e.g., Pare, 1956; Pritchard, 1962). In his review of studies on male homosexuals'
sex chromosome constitutions, Pare (1956) has maintained that available evi-
dence indicates unequivocally that male homosexuals have normal male sex
chromosome constitutions.
In a review of research on the relationships between hormones and homo-
sexuality, Perloff (1965) has concluded that homosexuality is "a purely psycho-
14 Acosta

logical phenomenon, neither dependent on a hormonal pattern for its produc,

tion nor amenable to change by endocrine substances" (p. 68). More recently,
Money (1970) has reviewed investigations on the genetic, fetal, hormonal, and
central nervous system factors that may be related to behavioral homosexuality.
He argues that while some of the work on fetal disturbances may eventually
demonstrate a relationship to homosexual behavior, it has thus far failed to, as
have the investigations on genetic, hormonal, and neurological factors, tn a
review of current endocrine studies which typically compare measures of sex
hormonal metabolites in the urine and in the blood plasma of homosexuals and
heterosexuals, Money and Ehrhardt (1972) and Green (1974) have concluded
that these studies do not provide a clear clue to the origin of homosexuality or
heterosexuality.
In contrast to this tentative view, Evans (1972) has contested that there is
a biological factor in the development of homosexuality. In his study with large
groups of exclusive male homosexuals and heterosexuals, he found that the
homosexual men had less subcutaneous fat, smaller muscle/bone development,
and less muscle strength than the heterosexuals. He further found that the
homosexual group had significantly lower levels of nonandrogenic urinary
metabolites and lower levels of blood serum lipids. These results are difficult to
interpret because of their complex relationships. In addition, the two groups did
not appear to be well matched, nor did the homosexual group seem to be
representative.
Evans does not make any specific conclusions but does argue that his
findings support the hypothesis that an "unidentified" common biological factor
underlies the etiology of homosexuality. In spite of the above criticisms, Evans'
work does suggest the value of further investigations into the possible role of
biological factors in the development of homosexuality.

Psychoanalytic

Psychoanalytic theorists such as Fenichel (1945) have traditionally

stressed deficient parent-child relationships as the early source of homosexuality
in both males and females. Disturbed parent-child relationships are considered to
lead to the child's failure to successfully go through the identificatory processes
of "anaclitic identification" and "defensive identification" (Freud, 1938;
Fenichel, 1945). The consequence of this failure is likely to be homosexuality
which is based on a neurotic fear of heterosexuality (Fenichel, 1945).
In comparison with the father-child relationship, the majority of psycho-
analytic authors have claimed the central cause of homosexuality to be a
disturbed mother-child relationship. Fenichel (1945), for example, has argued
that male homosexuals tend to be mother-fixated and to have identified with
their mothers because these mothers were domineering in contrast to weak
fathers. Bergler (1958) and Caprio (1955) have asserted that girls may be pre-
Etiology and Treatment of Homosexuality 15

disposed to homosexuality by a hatred and rejection of their mothers which

leads them to other women for warmth and acceptance.
Unfortunately, there are few comprehensive empirical studies on homo-
sexuals which test psychoanalytic hypotheses, and in general these suffer from
methodological deficiencies. The now famous study by Bieber et al. (1962)
supported some of the psychoanalytic predictions about the parental causes of
homosexuality. In this study, Bieber et al. investigated the early family patterns
of 106 mainly exclusive male homosexual patients and of a group of nonhomo-
sexual male patients. The results from a questionnaire answered by the patients'
psychoanalysts indicated that, in accord with psychoanalytic predictions, the
mothers of the homosexual patients were described most often as seductive and
close-binding-intimate and the fathers as hostile-detached. In addition, the
parents' marital relationship was described as poor. Bieber et al. concluded that
homosexuality, at least for males, was related to the kind of history found for
their homosexual patients.
The conclusions drawn in the Bieber et al. (1962) study have been vigor-
ously attacked by Churchill (1967). Churchill contends that Bieber's sample of
homosexuals was a select patient population and not representative of the homo-
sexual population. He also contends that the data were based on answers by
psychoanalytically oriented therapists who were most probably biased since they
had already ascertained diagnoses of homosexuality for their patients. Churchill
further objects that these therapist-respondents based their answers to the ques-
tionnaire "not upon their own firsthand observations of the parents, but on the
basis of their impressions of the patients' impressions of the parents" (p. 263).
In a series of investigations with both male and female nonpatient homo-
sexuals, Bene (1965a,b) found some familial patterns that afforded mixed
support for some of the psychoanalytic hypotheses about the parent-child rela-
tions of homosexuals. She used a semiprojective technique and a questionnaire
to yield information on the subjects' early life. In her study with males, Bene
(1965a) found that, contrary to psychoanalytic expectations, the homosexuals
expressed somewhat more hostility and less affection with regard to their
mothers than did their comparison group. Confirming psychoanalytic predic-
tions, the homosexuals also expressed significantly more hostility and less affec-
tion both going toward and coming from their fathers than did the married men.
However, the results further indicated that, contrary to psychoanalytic hypo-
theses (e.g., Fenichel, 1945), the male homosexuals tended to have weak and
ineffectual fathers but not estpecially domineering mothers. Bene contended
that the results of her study with male nonpatients pointed out that a lack of
good relations between fathers and sons facilitates the development of homo-
sexuality. This conclusion is supported by the earlier findings of Westwood
(1960), who reported that his nonpatient male homosexual group showed more
evidence of inadequate fathers than of overpossessive or overprotective mothers.
As in her study with males (1965a), Bene (1965b) reported that the
parental relationship which seemed most disturbing to female homosexuals was
16 Acosta

that between daughter and father. Although the lesbians in this study reported
feelings of hostility to and rejection of their m o t h e r s - which fits with most
traditional psychodynamic views (e.g., Bergler, 1958; Caprio, 1955)--their
hostile feelings toward their fathers were significantly more pronounced. This
latter finding sharply contradicted psychoanalytic predictions.
It is difficult to generalize from any of the retrospective studies discussed
thus far. One limitation is that retrospective studies usually deal only with a
select sample of volunteers and are thus not representative of the homosexual
population (Hooker, 1969). Another hazard of placing credence in these studies
is that the present biases which the respondents have about their parents can
easily affect the responses which they give about their early childhood.
Although not unanimous in their specification of problem areas, most
retrospective investigations strongly indicate that homosexuals have had very
disturbed parental relationships (e.g., Gundlach and Riess. 1968; West, 1959;
Evans, 1969). In a study with large groups of nonpatient predominantly exclu-
sive male homosexuals and heterosexuals, Evans (1969) used the Bieber etal.
(1962) questionnaire and found that parent-child relations in the homosexual
group were similar to those reported by Bieber et al. Interestingly, even though
the great majority of the homosexuals considered themselves to have an essen-
tially masculine identity, Evans reports that they saw themselves, in retrospect,
as "frail or clumsy as children and less often as athletic. More of them were
fearful of physical injury, avoided physical fights, played with girls, and were
loners who seldom played baseball and other competitive games." In spite of the
similarity of his results to those of Bieber, Evans does not attribute his findings
on the disturbed parent-child relationships as necessarily indicative of a cause for
male homosexuality. Instead, he refutes even Bieber's psychoanalytic position
and argues that it is the child himself who possessed certain innate and predis-
posing characteristics to homosexuality. He leaves these characteristics unspeci-
fied but argues (as does Green, 1974) that it is the child who fails to be reward-
ing to the father's interests and thus turns the father away.
Gundlach (1969) has sharply attacked Evans for ignoring his own evidence
in postulating that innate traits of the child lead to homosexuality. However,
Gundlach fails to answer Evans' criticism that the Bieber eral. study (1962)
overlooked the impact of the son's own characteristics and behaviors on the
parents' behaviors. Indeed, the objection that not enough attention has been
given to the role of the child as he affects the parents can be applied to most of
the retrospective studies on homosexuality.

Social Learning

Learning and social-learning theorists such as Churchill (1967), Bandura

(1969), West (1967), and MacCulloch and Feldman (1967) have vigorously
postulated that both heterosexual and homosexual preferences are learned
Etiology and Treatment of Homosexuality 17

behaviors. These theorists categorically reject the conclusiveness of the psycho-

analytic assumption that adult sexual drives which are regularly expressed in
homosexual ways are done so only because of early conflicts with parents or
because of fears of heterosexuality. Churchill (1967) and West (1967) both
argue that psychoanalytic explanations may account for the development of
homosexuality in a minority of homosexuals but not the majority. They assert
instead that children learn through social reinforcements and conditioning
patterns to express themselves sexually more toward one sex than the other. The
impact of learning sexual preferences and behaviors is particularly noted in the
anthropological report by Ford and Beach (1951) that in over half of 76
primitive societies some form of homosexual activity was considered normal and
acceptable.
There is presently sufficient empirical and clinical evidence to indicate that
some boys and girls fail to learn appropriate sex-typed behaviors and preferences
(Mischel, 1970; Green, 1974). The implications of this early failure for adult
homosexual behavior are suggested by several findings that both adult male and
female homosexuals who proclaim correct gender identities have seen themselves
as lacking in appropriate sex-typed skills and interests as children and/or have
expressed discomfort with their gender roles as children (Evans, 1969; Bene,
1965a; Gundlach, 1969). It thus appears that an adequate development of
gender identity and sex-typed preferences and behaviors does have an important
function in the child's later preference for heterosexuality or homosexuality.
But how does the child acquire his gender identity and learn appropriate sex-
typed behaviors, attitudes, and preferences?
Recent social-learning formulations assign a prominent role to observa-
tional learning or modeling processes in explaining the development of gender
identity and sex-typed attitudes and behaviors (Bandura, 1969; Bandura and
Waiters, 1963; Mischel, 1970). Bandura (1969) argues that the learning of identi-
ficatory sex-typed behaviors can mainly occur without any direct reinforcement
to the learner and primarily through the observation of other persons and events.
However, Bandura and other theorists (e.g., Mischel, 1966) also contend that
parents are actively indoctrinating the child to his appropriate sex role by such
actions as selective reinforcement of sex-appropriate behaviors, differential dres-
sing, selection of sex-appropriate toys and activities, and promotion of associa-
tions with same-sex playmates. Empirical support for this position has been
provided by several studies (e.g., Moss, 1967; Goldberg and Lewis, 1969).
Unlike Freud's (1938) identification theory, which insists on the presence
of a same-sex parent for appropriate development of a child's sex role, recent
social-learning theorists posit that the child can develop an adequate sex role
even in the absence of a same-sex parent by observing a variety of adult and peer
models (Bandura, 1969). But what are the variables which function to command
the child's motivation and attention to selectively imitate certain models and not
others? In recent years, a great deal of experimental and naturalistic research has
increasingly found that the model's power and status, nurturance, and similarity
18 Acosta

to the observer are factors which greatly influence imitation of both sex-typed
and non-sex-typed preferences and behaviors (Bandura et aL, 1963; Mischel and
Liebert, 1967; Hetherington, 1965; Mussen and Distler, 1959, 1960; Mussen,
1969; Payne and Mussen, 1956; Mischel, 1966). For example, in a naturalistic
study Hetherington (1965) found that sex-typed preferences and same-sex or
cross-sex imitation in boys and girls were significantly influenced by parental
dominance. Mussen and his associates (Mussen and Distler, 1959, 1960; Payne
and Mussen, 1956) in a series of empkical studies with young and adolescent
boys have consistently found that a father's nurturance and rewardingness do
facilitate the tendency of a son to imitate him and to prefer sex-appropriate
interests and behaviors.
Many of the sociaMearning explanatory assumptions for the development
of gender identity and sex-typed behaviors appear to be well buttressed by
experimental and naturalistic studies. The recent social-learning emphasis on
observational learning and the related implications for enhanced appropriate
sex-role learning and performance provide a strong explanatory and predictive
view of the development of sex typing. The importance of developing an
adequate gender identity and sex-typed behaviors for the preferential develop-
ment of heterosexual behaviors has been discussed earlier. Although these
social-learning hypotheses appear to have some support, social-learning theorists
have thus far fated to provide any first-hand empirical evidence which directly
links childhood learning of appropriate or inappropriate gender identity and
sex-typed behaviors to later adult homosexuality, except for Green and Money,
who report that six previously evaluated feminine boys are now homosexual
adults (Green, 1974).

TREATMENT AND ETHICAL ISSUES

Before initiating treatment of the homosexual, the therapist should ask

these basic questions: Does the patient desire to change his sexual orientation?
To what degree is he emotionally distressed? To what degree is he homosexual?
What is the therapist's attitude toward homosexuality? As will be seen in this
section, the individual answers to these questions can greatly affect the goals, the
course, and the outcome of any treatment of homosexuals.

Psychoanalytic Therapy

Psychoanalysts have traditionally maintained that homosexuality is a

pathological state in disturbed individuals who have either manifest or severe
underlying psychopathology (e.g., Bergler, 1956; Bieber et aL, 1962; Bieber,
1967). These therapists have attempted to help homosexuals resolve their
psychopathology and convert to exclusive heterosexuality through long and
costly hours of psychoanalytic therapy. Their principal efforts have been to
Etiology and Treatment of Homosexuality 19

uncover early childhood conflicts in disturbed parental relationships and in so

doing to reduce the patient's neurotic fear of heterosexuality. In general, the
results reported have been poor. Curran and Parr (1957) and Woodward (1958)
report meager changes in large groups of male homosexual patients. Curran and
Parr found practivally no increased heterosexuality among their exclusive homo-
sexual patients, and Woodward, in an inadequate follow-up study, found changes
in only a few of his bisexual patients. In a study with both male and female
homosexuals, Mayerson and Lief (1965) found that a follow-up conducted 4½
years after termination of psychoanalytic treatment showed about half of their
19 patients to have become exclusive heterosexuals. These authors were careful
to point out that most of the successfully treated patients had initially been
bisexual. Again, little change had occurred with the exclusive homosexuals.
In the comprehensive psychoanalytic treatment and research study
conducted by Bieber et al. (1962), 29 of their 106 (27%) male homosexuals
showed a significant shift to exclusive heterosexuality at the time of their last
reported therapy session. These results are less impressive when one considers
that these changed patients were all in therapy from 150 hr to more than 350 hr.
In addition, these "cured" patients were not representative of the exclusive
homosexuals who constituted the major part of the treatment group. More
specifically, only 18% of the exclusive homosexuals, in contrast to 50% of the
bisexuals, showed a significant change. Based on the results of their study,
Bieber et al. noted that the homosexual was more likely to convert to hetero-
sexuality if he were relatively young, if his homosexuality were not exclusive,
long-lasting, and deeply rooted in childhood familial disturbances, and if he had
not developed effeminate mannerisms during childhood.
Churchill (1967) and Taylor (1965)have recently attacked the optimistic
"cure" claims of the Bieber et al. study for its failure to provide a systematic
follow-up. However, Bieber (1967) has reported that in a 5-year follow-up it was
found that 15 of the 29 cured patients had kept "contact" with their psycho-
analyst. "Of these cured cases, 12 had remained exclusively heterosexual; the
other 3 cases remained predominantly heterosexual..." (1967, p. 972).
Unfortunately, Bieber did not provide an adequate report. He failed, for exam-
ple, to specify (1) whether or not these 15 follow-up patients had continued
with their psychoanalysis and for how long, (2) how many of the 15 patients
were from which pretreatment group, and (3) what the follow-up status was of
the remaining 14 cured patients.
A serious ethical issue arises when one considers whether or not a change
to heterosexuality is the most desirable therapeutic goal for a homosexual. It is a
tenuous argument which the psychoanalysts (e.g., Bergler, 1956; Bieber, 1967)
posit: that homosexuals are disturbed psychopathological individuals whose
"cure" can involve only a complete change to heterosexuality. First of all, these
theorists have generalized from a highly select and motivated population who
voluntarily sought treatment. Whether or not clinical patients all want to change
their sexual orientation is another matter. What does appear to be evident is that
20 Acosta

patients who voluntarily seek therapeutic intervention are in some form of

distress. Churchill (1967) and West (1967) both contend that it is highly inap-
propriate to postulate that all homosexuals experience the same degree of emo-
tional problems which clinicians may encounter in their homosexual patients.
A substantial number of investigators have in fact found that nonpatient
groups of male and female homosexuals do not presem a picture of pathology
(e.g., Siegelman, 1972; Saghir et al.. 1969, 1970a,b; Schofield, 1965: Hooker,
1957, 1958; Dean and Richardson, 1964: Hopkins, 1969). In a series of studies,
Saghir et al. (1969, 1970a,b) used structured interviews to investigate the
personality profiles and sexual activities of large groups of volunteer nonpatient
male and female homosexuals. Both male and female homosexuals were primar-
ily exclusive. These investigators compared their target subjects to matched
groups of heterosexual males and females. No significant differences in manifest
psychopathology were found between the male homosexuals and heterosexuals.
The female homosexuals, however, did show significant differences from the
heterosexuals in suicide attempts, alcohol abuse, and drug abuse. But Saghir et
al. assert that these female homosexuals were able to work productively, advance
economically, and live in a "more or less normal condition" (1970b, p. 153).
Hopkins (1969) has provided further illustration that homosexuals are not
necessarily suffering from psychopathology. Her questionnaire study revealed
that neither a group of primarily exclusive lesbians nor a group of matched
heterosexual females fit into a "neurotic profile."
The same objections to Bieber's generalizations apply to Saghir's and
Hopkins' findings and conclusions. The homosexual groups sampled cannot be
recognized as random samples of the homosexual population. The homo-
sexual subjects were all members of various kinds of homophile clubs and were
all unpaid volunteers. The difficulty of acquiring a truly representative sample of
the homosexual population is clearly a major research handicap (Hooker. 1965b).
Returning to the ethical issue raised earlier of determining goals in the
treatment of the homosexual, it can be seen that in spite of methodological
limitations the profile which emerges from personality investigations of the non-
patient homosexual is n o t necessarily one of a very psychologically disturbed
individual. Willis (1967), West (1967), and Churchill (1967) contend that the
ethical obligation of the therapist should be to determine whether or not a
change to heterosexuality for a patient who desires such a change would lead to
a better adjustment. If no better adjustment is anticipated, a therapist would do
the patient a disservice to try to alter sexual orientation. In such a situation, the
therapist could do the patient a better service by helping him o~ her accept
sexuality per se. Beyond an individual approach, Schofield (1965), from an
extensive study of different types of homosexuals, has cogently advocated a
positive change in public attitudes and legal systems which are punitive to the
homosexual. He argues that such a change would significantly reduce the
number of homosexuals who seek treatment.
Etiologyand Treatment of Homosexuality 21

Behavior Therapy

Behavior therapists have attempted to modify homosexual behaviors by

the application of such varied techniques as classical conditioning (James, 1962;
Freund, 1960; McConaghy, 1971), instrumental conditioning (MacCulloch and
Feldman, 1967; Bancroft, 1969; Birk et al., 1971; Tanner, 1973), systematic
desensitization (Stevenson and Wolpe, 1960; Kraft, 1967; Haynes, 1970;
Bancroft, 1970), and covert sensitization (Cautela, 1967; Gold and Neufeld,
1965; Callahan and Leitenberg, 1973). These therapists have worked primarily
with the male homosexual and have attempted to reduce his responses to homo-
sexual stimuli and/or to increase his responsiveness and approach to heterosexual
stimuli. Typically, the behavioral treatment program is completed within several
months. It has been hypothesized that the effect achieved in the laboratory will
generalize over the whole range of the patient's real-life sexual responses.
Although much disagreement exists among these therapists about the efficacy of
their approaches, the majority do reject traditional psychoanalytic therapy. In
general, however, the results of behavior therapy with male homosexuals have
not been much better than those reported by psychoanalysts.
Using injections of an emetic such as apomorphine, some therapists have
attempted to change homosexuality by associating anxiety or fear with previ-
ously attractive homosexual stimuli (Freund, 1960; James, 1962; McConaghy,
1971). In the study by Freund (1960) of a large group of male homosexual
patients, a classical conditioning paradigm was used in which subjects were
shown slides of nude and seminude men while feeling highly nauseous from an
emetic. In addition, the patients were shown films of nude or seminude women
several hours after receiving injections of testosterone propionate. At termina-
tion of treatment, one-fourth of the patients had shown heterosexual adapta-
tion. However, in a 5-year follow-up Freund found that all of the "recovered"
patients had homosexual desires and only one-eighth refrained from overt homo-
sexual behavior. Rachman (1965)has argued against the use of chemical aversion
because of its severe unpleasantness and imprecision of timing. He suggests the
use of electrical aversion as a safer, more precise and manipulable tool in any
aversive therapy.
Treatments which have involved electrical aversion in a classical condition-
ing paradigm have in general resulted in failures with homosexuals (e.g., Thorpe
et aI., 1963; Thorpe and Schmidt, 1964). In a critical review of studies which
used electrical aversion in a classical conditioning paradigm to treat homo-
sexuals, Feldman (1966) has argued that the results point to the futility of such
a learning technique. Instead, Feldman contends that the application of an
instrumental conditioning paradigm would increase the probabilities of a long-
term change in sexual orientation. He further maintains that, besides reduction
of responses to homosexual stimuli, positive responses to heterosexual stimuli
must be conditioned.
22 Acosta

In a series of studies, Feldman and MacCulloch (1964, 1965; MacCulloch

and Feldman, 1967; Feldman et al., 1969) treated a group of 43 homosexuals,
mostly males. These investigators used an anticipatory avoidance technique in
which patients were allowed to avoid electrical shock under a variable interval
and reinforcement schedule when viewing slides of homosexual stimuli. In
addition, the patients were randomly exposed to heterosexual slides which
appeared at the offset of the male slides and always in the absence of electrical
shock. These investigators report a 58% rate of improvemem even after more
than 2 years of follow-up! Close to the prognostic signs found by the Bieber
group (1962), Feldman and MacCulloch found that the most likely patients to
show significant improvement were those who were under 30, whose Kinsey
rating was not high, and who had some history of heterosexual interest and
experience.
Bancroft (1969) has sharply criticized MacCulloch and Feldman (1967)
for failing to explain how the patient's acquisition of an avoidance response to
specific homosexual stimuli affected his sexual behavior outside of treatment. In
his own aversion treatment of ten male homosexuals, Bancroft (1969) attempted
to make the learning procedure more relevant to the patient's actual subjective
states of sexual arousal and thus to increase generalization to situations outside
the laboratory. He therefore measured the patient's penile erections to homo-
sexual stimuli by means of a penis plethysmograph (see Bancroft et al.. 1966,
1971). Electrical shocks were administered to the patient only at the occurrence
of certain minimal levels of measured penile erection. At the end of treatment,
the desired suppression of penile erection was not evident in most cases. Surpris-
ingly, Bancroft found that most subjects did show some positive change in their
sexual interests and behaviors. However, only three patients showed significant
improvement, this number dropping to one in a l- to 2-year follow-up. Bancroft
concluded that change in patients' attitudes, apparently more important than
conditioned suppression of penile erection, was short-lived. It should be noted
that most of those patients who did show some trend toward longer-lasting
change in attitudes had also received follow-up supportive psychotherapy.
The wlue of instrumental conditioning of homosexuality through elec-
trical aversion seems uncertain. Tanner's (1973) finding, for example, that
homosexuals showed greater avoidance learning and change in heterosexual
direction at higher shock intensities directly contradicts MacCulloch et aL's
(1971) prediction that effective learning can be gained with only minimal aver-
sion. Bancroft (1970), with matched groups of primarily bisexual males, com-
pared electrical aversion to homosexual stimuli with systematic desensitization
to heterosexual situations. He found that over half of both groups showed some
clinical improvements but did not differ much from each other. In a 6-month
follow-up, however, Bancroft found that the desensitization group had signifi-
cantly better attitudes toward heterosexuality than the aversion group.
Etiology and Treatment of Homosexuality 23

Birk e t al. (1971) compared the effects of avoidance conditioning (modi-

fied aversion paradigm of Feldman and MacCulloch, 1965) with those of placebo
conditioning (subject saw a light instead of receiving shock) between two groups
of mostly exclusive homosexuals. All subjects also participated in psychodynam-
ic-oriented group therapy in both pre- and postconditioning periods of 1 year.
Birk found that the aversion group showed more immediate improvement.
However, in a 1-year follow-up the two groups were no longer different on
generally high Kinsey ratings. This latter finding was difficult to interpret since
the aversion group reported significantly more reduction of homosexual behav-
iors in spite of their increased Kinsey ratings.
Callahan and Leitenberg (1973) have compared aversion therapy and
covert sensitization in the treatment of two male homosexuals. They modified
Bancroft's (1969) procedures for the aversion condition. For the sensitization
condition, they modified Cautela's (1967) technique of pairing an imagined
aversive event with an imagined homosexual behavior. It was found that covert
sensitization led to more suppression of self-reported homosexual interests in
both cases. However, the within-subject design of this study may have led to an
overlap of treatment effects, which would make any conclusions from this work
questionable.
One should be cautious against placing too much credence on the behav-
ioral techniques alone in those studies which have shown some success. It is
important to note that some of the behavioral studies do include more tradi-
tional psychotherapeutic intervention along with the behavioral therapy and/or
in continued follow-up treatment (e.g., MacCulloch and Feldman, 1967;
Bancroft, 1969; Birk et al., 1971). The principal focus of this adjunctive psycho-
therapy has been to assist the patients in their adjustment to heterosexual activi-
ties. It thus seems that some behavior therapists acknowledge the potential
usefulness of traditional psychotherapy in their treatment of homosexuality.
It appears that some of the behavioral techniques do have some merit in
effecting changes in sexual orientation within a relatively brief time period.
However, the lack of conclusive evidence for the effectiveness of these proce-
dures militates against their widespread application. Continued refinement of
research is thus needed in order to better answer the question: what technique
or combination of approaches works best, and for what kind of homosexual
with what kind of presenting problems?

CONCLUSION
It seems that neither behavior therapy nor psychoanalytic therapy has
convincingly proven to be effective in the treatment of either male or female
homosexuals. What is clear is that both methods have had minimal successes and
an overwhelming number of failures.
24 Acosta

It has been evident throughout this discussion that homosexuals present

highly diversified profiles. Their developmental histories, degrees of homosex-
uality, psychological disturbances, and motivation for changing their sexual
orientations vary greatly. It is critical, then, to determine the present state,
desires, and possible alternatives for the homosexual before deciding on the
direction of therapy. Since the homosexual who voluntarily seeks therapy Js
probably in some emotional conflict and distress (e.g., Bieber et aL, 1962), the
use of some form of psychodynamic therapy would seem appropriate. If the
homosexual desires to change his sexual orientation, then the adjunctive applica-
tion of learning techniques such as aversive avoidance conditioning (e.g.,
MacCulloch and Feldman, 1967) may be productive for effecting specific behav-
ioral changes.
At present, the available prospects for completely changing the homo-
sexual's sexual orientation are poor. Better prospects, however, seem to exist for
the usefulness of a therapist's intervention in assisting the disturbed homosexual
patient to fully accept sexuality and to better adjust to his homosexuality ha a
heterosexual society (Churchill, 1967). Furthermore, as Schofietd (1965) has
argued, the therapist could significantly assist the homosexual patient through
professional efforts to reeducate public views and thus reduce societal and legal
condemnation of homosexuality.
From the implications of both retrospective findings (e.go, Bieber et aL,
1962; Evans, 1969; Bene, 1965a,b) and social-learning experimental findings
(Bandura and Waiters, 1963; Mischel, 1970), it would seem that the best inter-
vention in homosexuality would be at level of the potentially homosexual child.
As discussed earlier, disturbed parental relationships and parental-child relation-
ships, together with inadequate or inappropriate patterns of social reinforce-
ment, seem to contribute greatly to the childhood development of inappropriate
or inferior sex-typed behaviors and attitudes and to later adult homosexuality.
A few studies which have recently attempted to identity the potentially
homosexual child have evaluated the relationship between effeminate behavior
in the childhood years of boys and later adolescent homosexuality (Zuger. 1966;
Zuger and Taylor, 1969; Green, 1974). In the study by Zuger (1966), the
majority of a group of boys who showed marked effeminate behaviors in their
childhood years were found in follow-up evaluations to be homosexuals in late
adolescence. Zuger's findings imply that patterns of marked effeminate behav-
iors in boys are distinct from noneffeminate boys' behaviors and that these
effeminate behaviors do indicate later development of homosexuality. However,
Zuger's (1966) findings are questionable if one considers the methodological
deficiencies of his study. First of all, an experimenter bias may have easily
confounded the results since Zuger himself conducted all initial and follow-up
examinations. Second, Zuger's failure to systematically gather the data on the
 Etiology and Treatment of Homosexuality 25

individual boys' effeminate behaviors resulted in data which varied widely from
a sole reliance on parental interviews to observations recorded by teachers.
Green and his colleagues (Green, 1969b; Green and Money, 1966; Stoller,
1969) have initiated some promising longitudinal studies in their psychological
treatment of boys who manifest cross-gender identifications in their childhood
years. These investigators have thus far found that the boys' marked effeminate
behaviors are like those which adult male transsexuals state they had as children.
Interestingly, these effeminate behaviors include those identified by Zuger
(1966) in his prehomosexual group of boys. Stoller (1969) has further argued
that unique patterns of parental-child relationships and disturbed parental
relationships appear to be specific for the development of transsexualism. As
Green (1969b) and Stoller (1969) have both maintained, long-term follow-up
studies are needed to determine exactly what childhood cross-gender behaviors
are precursors of what adult behaviors and attitudes, e.g., transsexual, homo-
sexual, or heterosexual. In addition, long-term studies which include both treat-
ment and nontreatment control groups of boys would help to indicate if early
treatment can lead to long-lasting changes in boys with marked effeminate
behaviors and cross-gender identifications.
Clearly, more refined and representative longitudinal studies which
identify childhood factors of homosexuality and trace the development of target
children through adolescence and adulthood need to be conducted. This is a
challenge that must be met before any definitive understanding of the homo-
sexual's development and possible treatment can be achieved.

ACKNOWLEDGMENTS

Sincere gratitude is expressed to the author's colleague, John E. Bates, for

his critical reading of this manuscript. Appreciation is also extended to Professor
Michael J. Goldstein for his encouragement during the preparation of this paper.

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