Sexuality and disability

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Sexuality_and_disability

Caressing between people with Down syndrome

Sexuality and disability is a topic regarding the sexual behavior and practices of people with disabilities. Like the general population, these individuals exhibit a wide range of sexual desires and adopt diverse methods of expressing their sexuality. It is a widespread concern, however, that many people with disabilities do not receive comprehensive sex education, which could otherwise positively contribute to their sexual lives. This stems from the idea that people with disabilities are asexual in nature and are not sexually active. Although some people with disabilities identify as asexual, generalizing this label to all such individuals is a misconception. Many people with disabilities lack rights and privileges that would enable them to have intimacy and relationships. When it comes to sexuality and disability there is a sexual discourse that surrounds it. The intersection of sexuality and disability is often associated with victimization, abuse, and purity, although having a disability does not change someone's sexuality, nor does it change their desire to express it.

For physical disabilities that change a person's sexual functioning, such as spinal cord injury, there are methods that assist where needed. An individual with disabilities may enjoy sex with the help of and physical aids (such as bed modifications), by finding suitable sex positions, or through the services provided by a sex worker.

History

Much of the sexual biases in the United States are traced back to Puritan ethics. Issues on the acceptance of sexuality and disability root back to 2000 years. The review of history on sexuality in philosophy, religion, and science leads to the modern day views on sexuality and disability. Religious institutions were the first entities to combat sexuality. They believed that sex was a sin and should not be practiced unless it was done with intents of reproducing. Then doctors began developing medical views on sex. Sexual pleasure was deemed a sickness. The taboo around sexuality being a disease and sin restricted many people from expressing their sexuality, especially people with disabilities.

After much groundbreaking research, it was not until the 20th century that sex and pleasure became normalized. With the normalization of sex, pleasure became the main focus. Healthy sex meant a good performance that led into an orgasm. If a person was not able to orgasm during sex they were seen as inadequate for sexual intercourse. With this a sex therapist would help the individual explore oral sex, and clitoral orgasm. When a person with a disability is not able to achieve an orgasm it was not seen as problematic, because they did not have sexual desires. The neglect on the sexual lives of people with disabilities roots from the idea that they are child like and asexual. Because people with disabilities do not fall under the category of being sexual, there were no resources for them to seek sexual assistance.

Over the years sexually disenfranchised groups were working towards sexual acceptance for all people, including queer and disabled communities. The work of these groups began to open doors for people with disabilities to become more expressive of their sexuality. Even with these new found opportunities, sexual pleasure for people with disabilities remained unspoken of.

Self-image

Having a disability may sometimes create an emotional or psychological burden for the individual with disabilities. They may feel inhibition about pursuing relationships, fearing rejection on the basis that they have a disability. Self-image may suffer as a result of disfigurement, or lack of confidence. A New York disabled dating service manager explains, "Sexuality, travel, mobility, pain: Everything takes on a different dimension." In The Ultimate Guide to Sex and Disability, Miriam Kaufman points out that attempting to hide a disability or minimize its existence is ultimately an added burden, encouraging readers to "come out" to themselves as having a disability, to accept their disability.

There is often fear associated with the intersection of sexuality and disability. Many people with disabilities embody a fear of being rejected due to the way they look. This hypersensitivity causes the individual with disabilities to keep interactions platonic. Author of Sex and Disability Robert McRuer studied a man with disabilities. McRuer gave insight on the individuals sexual and non-sexual encounters. This man had a belief that crossing the line into sexual encounters meant it would cause severe bodily harm for him. During a sexual encounter, the man felt very uncomfortable and could not cross the sexual boundary. This was due to his fear of being judged. This is an issue common in some people with disabilities. The "evaluative gaze" coming from others causes people with disabilities to feel judged and uncomfortable in their own bodies.

It is a common misconception that people with disabilities are insecure and have a negative self-image. A study was done on 7 adolescents with cerebral palsy, to assess their self-image. Of the group there were 3 girls and 4 boys, ranging between 12 and 17 years old. A personality inventory was conducted and the results came out to be positive. The group of adolescents with disabilities viewed themselves very positively, rating their self-image higher than norm groups. After the inventory, the interviewer Lena Adamson wrote this conclusion in her "Brief report—Self-image, Adolescence and Disability", published in the American Journal of Occupational Therapy:

The following conclusions are made: Further studies on self-image and the psychosocial development of adolescents with disabilities should (a) focus on the social interaction outside their immediate families, and (b) continue to use and develop methods where these adolescents can give voice to their own experiences and opinions.

In contemporary society

Individuals with disabilities are rarely regarded in society as sexy or believed to be sexually active. When sex and disability are linked, it is common for marginalization to occur. Many people shy away from the idea that individuals with disabilities can have sex. This is due to a lack of information on the subject. Popular scholarly texts on disability rarely discuss sex, conversely disability is rarely discussed in the field of sexuality studies. Disability studies is a new field, it is just recently beginning to have a voice in the scholarly communities. Cultural theory on HIV and AIDS is one area of study that has broadly considered disability and sex. Since the AIDS epidemic, the queer community have been including physically and intellectually disabled individuals in their activist interventions. Even with these efforts, the correlation between sexuality and disability are not discussed in disability studies.

In society, it is widely believed that women with disabilities are asexual. One reason for this belief is that Individuals with disabilities are seen as eternal children. Others see the intertwine of sex and disability as an acrobatic act. It is difficult for many people to imagine an individual with a disability having sex, because of the restricting impairments. Viewing women with disabilities as asexual has issues. In contemporary United States, women with disabilities are not viewed as physically attractive because society does not view them as sexually desirable. This results in women with disabilities to be limited and constrained in their capacity to love and be loved.

In the United States, pleasure and sex have been largely ignored, especially when it comes to individuals with disabilities. Medical facilities, public schools, and religious groups have created a "don't ask don't tell" policy when it comes to sex education. The United States government has spent over 500 million dollars funding a program that restricts public schools from teaching sex in the classroom.

The idea that sex is meant for reproduction can be damaging to the sexual lives of individuals with disabilities. Because some disabilities restrict an individual from having children, the idea of this person having sex is eliminated. Additionally, the hereditary nature of certain disabilities may make caregivers of disabled adults uncomfortable allowing them to engage in sexual activity. There also exists a history of forced sterilization of disabled people, such as the Buck v. Bell case legalizing the practice in the US and the Law for the Prevention of Hereditarily Diseased Offspring mandating disabled people be sterilized in Nazi Germany.

Sexual activity

General

The mechanics of sex may be daunting, and communication, experimentation, medication and manual devices have been cited as important factors for sexual activity where disability is involved. Additionally, recognition of the pleasure that is derived from sexual activity beyond penetration and intercourse is also highlighted. For example, changes may take place in a person's sexuality after spinal cord injury; sensitivity to touch can increase above the lesion location in someone with a spinal injury. From research undertaken by the Christopher and Dana Reeve Foundation, orgasm was achievable for 79% of men with incomplete spinal cord injuries and 28% of men with complete injuries.

Oral sex and manual sex are other alternatives where penetration is not possible or not wanted, and wedge devices can be used to aid with positioning—wedges can be used as an aid in sex generally. Sex toys may be used as assistive devices as well; for example, vibrators can be used to provide extra stimulation and in circumstances where hand mobility is impaired. Other supportive devices include manual stimulation pumps, for erection promotion and maintenance, and "sex furniture", whereby rail or clamp enhancements, or specialised designs facilitate sexual activity.

Writer Faiza Siddiqui sustained a serious brain injury that led to a decrease in her sexual drive and the loss of her ability to orgasm, with the latter most likely the result of damage to Siddiqui's hypothalamus. Siddiqui explained her learning process in relation to sexual activity following the accident in a 2013 article:

I had to clear away all the thoughts I had about my imperfect body ... Since then, I've started to feel less shame about my unresponsive body ... My brain can't concentrate on as many things anymore, so I have to focus more on every little twinge and the lightest of touches. Surely that's going to mean better sex? I can't say that the sex is exactly better – I can't be on top anymore – but I'm learning that it doesn't really matter ... I had to grow up. Growing up is something that we're all having to do.

Some people with a spinal cord injury are able to "transfer their orgasm" using sexual energy to any part of the body that has sensation. For example, Rafe Biggs acquired a spinal cord injury in 2004. Through his work with a sexologist he discovered during a massage that when his thumb was being massaged; it felt very similar to his penis. It was through this experience that he learned that he could transfer his orgasm, using tantric energy, to his penis. Kenneth Ray Stubbs also has a spinal cord injury and is able to use tantric bodywork to obtain an "orgasmic feeling".^[16] If a person is able to use sexual energy correctly then they would be able to experience an orgasm in any part of the body that is capable of feeling sensation.

Fetishes and BDSM

Sexuality for people with disabilities is often linked to fetishes and "freakish excess".

• Abasiophilia is when an individual's sexual arousal is dependent on a sexual partner with a disability. The obsession is most common for people with disabilities who wear leg braces.
• Apotemnophilia is self demanded amputation.

Apotemnophilia is when an individual amputates their own limb for sexual pleasure. A case research done in the Journal of Sex Research states "Apotemnophillia is related to erotization of the stump and to overachievement despite a handicap." Little is known about the relationship between sexual pleasure and amputated limbs. This is due to the fetish being fairly new. Apotemnophilia was first introduced to the public in the magazine Penthouse in late 1972. The fetish was brought up by a young man with a disability who practices this fetish. After reading his accounts some editors of the magazine related with this feelings and published his story.

Some individuals who have this fetish, have made successful amputation attempts. For those who want to be amputated but do not have the means or strength to do so, are able to get professional assistance.

• Devotism is the sexual attraction someone has for a person with disabilities

Sex and disability does not only have an unattractive connotation. Sex and Disability writer Robert McRuer found that Devotism had renewed self-assurance in a group of women with disabilities. He writes "Women who had felt profound shame about their bodies reported significant gains in their self-confidence after discovering devotees." This empowerment has led to positive changes in the women's behavior. It has been reported by Robert McRuer that because of this some women with disabilities are more confident in their self-image and do not hide their disabilities as they previously have.

People who have a devotism fetish are referred to as Devotees. Robert McRuer argues that devoteeism relies on disgust and desire. The description of the devotees' desire come from an ableist assumption that disabled bodies are disgusting. It is typical for a devotees to view themselves as the only people who are sexually attracted to amputees. This belief establishes a ground for Devotees exceptionalism.

BDSM is a topic in the sex and disability culture. It has been described as empowering for people with disabilities because of their acceptance of non-normative bodies. BDSM could be used as a way to control pain for people with chronic pain. Bob Flanagan used BDSM to help him cope with his Cystic Fibrosis. His ability to control his own pain excited him as he was known to push himself as far as he could. "I was making a mockery out of something serious that had happened to me," said Flanagan when making light of his pain related to Cystic Fibrosis. Flanagan was an artist. He was a writer, an actor, and also created a traveling museum exhibit called "Visiting Hours" that showed the intersectionality of Cystic Fibrosis and sadism and masochism. In the exhibit, "Visiting Hours", museumgoers would experience an environment that was a combination of a children's residential hospital and a BDSM torture chamber. The purpose of this exhibit was to portray Flanagan's pain through a pleasurable lens showing that BDSM could offer some sexual healing.

Women and girls with disabilities are a common focus in fetishism due to their immobility. This makes them especially vulnerable to sexual abuse.

Sex work

In February 2013, it was reported that citizens with disabilities in the Netherlands were eligible for a government-funded scheme that provided funds to cover up to 12 occasions of sexual service per year. During the same period, Chris Fulton, a campaigner in the UK with cerebral palsy and muscular dystrophy, called upon the UK government to also provide financial support for sexual services for people with disabilities. Fulton explained:

The idea is to give people with disabilities more of a choice. There's still a lot of stigma attached [to people with disabilities having relationships] from research I've done and experiences I've had. I think it would be good to bring the Dutch scheme over here to take away that stigma about people with disabilities having sex. But it's not just about that. It's about people with disabilities being accepted when they have relationships ... It needs to be brought out into the open in a managed and constructive way.

In early 2013, former brothel owner Becky Adams spoke with the media about her intention to open a non-profit brothel exclusively for people with disabilities in the UK, which, if launched in 2014, will be the nation's first legal initiative of this nature. Adams stated that she will invest £60,000 into the brothel following a stroke in 2009—Adams explained that after the stroke, her "eyes were suddenly opened. I was utterly unaware that such a big group was suffering so enormously." If she is approved for a permit, Adams plans to open a two-room service in Milton Keynes, near London, that will be staffed by sex workers and assistants.

Adams also founded the Para-Doxies service in 2012, which connects people with disabilities throughout the UK with sex workers—at the time, Adams ran the service on a completely voluntary, non-profit basis. In April 2013, the service was receiving over 500 enquiries a week from men, women and couples, and was struggling to cope with the demand.

A 2011 Australian documentary directed by Catherine Scott, Scarlet Road, explores another aspect of sexuality and disabilities through the life of a sex worker who has specialized for 18 years in a clientele who have disabilities. In 2012, the topic was highlighted in a fictional film based on the real life experience of writer Mark O'Brien. The Sessions portrays the relationship between O'Brien, who survived polio as a child, and a "sexual surrogate" to whom he loses his virginity. A member of the British Polio Fellowship states that post-polio syndrome, which affects polio survivors later in life, is a little-known condition that could have been explored in the film.

A survey conducted by the Disability Now magazine in 2005 found that 19% of female participants would see trained sex workers, compared with 63% of the male respondents. Tuppy Owens, sex therapist and disability professional, explained in 2013 that disabled women "don't trust male sex workers to be honourable".

LGBT

Main article: Disability and LGBT identities

LGBT people with disabilities face double marginalization. Individuals with disabilities are often either viewed as nonsexual or hypersexual. Because of these misconceptions it is hard to find queer people with disabilities portrayed in healthy sexual lives. During the recent decades, scholars have been working to include disabilities studies into queer theory, with the intentions of normalizing disability in queer and LGBT spaces. Queer and disabled liberation starts with the rejection of historic ideas on sexuality and disability.

It is also rare to have a queer person with disabilities portrayed in media. Some movies and literature do exist for the queer disabled communities such as:

• Akers, Michael D. (director). 2012. Morgan (film). United Gay Network

This movie is about a bicyclist who gets in an accident and becomes paraplegic. After the bicyclist recovers from his injuries, he comes to terms with his sexuality and falls in love with a man.

• Alland, Sandra (filmmaker). 2013–2014. I'm Not Your Inspiration (documentary film series)

This is a short documentary series documenting the lives of queer and trans people with disabilities.

• Bose, Shonali (director). 2014. Margarita, With a Straw (film).

This is a film about a young Indian woman with cerebral palsy who relocates to America for her undergraduate education. The movie follows her complex romantic relationship with a blind woman.

Relationships

Individuals with disabilities access to sexual and emotional partners is restricted by societies de-eroticization of their sexuality. The experiences of individuals with disabilities has shown that the basic human need to form close relationships is as relevant for individuals with disabilities as it is for humans without a disability. Furthermore, the social networks of people with disabilities can be small and this restricts the ability to form new relationships. Society's view of disability also puts pressure of individuals with disabilities in finding relationships. Even though our society has made great strides with creating a more accepting world, individuals with disabilities are still seen as outsiders. Parents prevent their children from asking individuals with disabilities questions which results in them viewing people with disabilities as "other". While the majority of non-disabled people meet other people in public spaces there are many physical and social barriers. The lack of access to public spaces, whether it be stairs; an absence of menus written in braille; or no ASL interpreters; could make it difficult and almost impossible for an individual with disabilities to go out. Individuals with disabilities also participate in online dating. Not only are there websites that are for online dating, but there are also websites that are solely for people with disabilities finding someone that is also disabled or someone that wants to date an individual with disabilities.

Disability stereotypes add to the difficulty and stigma experienced by individuals with disabilities. The following myths about individuals with disabilities have been identified:

• Individuals with disabilities do not need sex to be happy.
• Individuals with disabilities are not sexually attractive.
• Individuals with disabilities are "oversexed".
• Individuals with disabilities have more important needs than sex.
• Individuals with disabilities do not need sex education.
• Individuals with disabilities cannot have real sex.
• Individuals with disabilities, particularly those with intellectual disabilities, should not have children and should not be allowed to have children.

According to one survey, up to 50% of adults with disabilities are not in any sexual relationship at all. Online dating sites specifically aimed at individuals with disabilities have been founded to fill this void.

Misperceptions from the broader community has been raised as a prominent issue for individuals with disabilities in terms of their own relationships. The head of a disabled dating service explained in 2010: "Like anyone else, people with disabilities have different preferences. Someone with good mobility may prefer someone also mobile; others don't limit at all." In a 2012 Sydney Morning Herald, the mother of a man with cerebral palsy explained, "It's hard being a parent and this [sexuality] comes up. People see them sitting in their wheelchair think, that's it. They don't see what's going on in their lives and Mark [son] would dearly love a relationship."

Oppression

There is a long history of seclusion and segregation that has affected society's view of people with disabilities. For years people with disabilities have been segregated from society. People with disabilities were often put in institutions against their will because they were deemed "weak" and "feeble minded". While they were in the institutions they would often experience compulsory sterilization a.k.a. forced sterilization. The types of sterilization would include vasectomies, salpingectomy, and other types as well. None of these were considered dangerous to the person in the institution. In 1927, the United States Supreme Court case of Buck v. Bell stated that it was permissible to sterilize some people with disabilities against their will. It also stated in the decision that that did not violate the Fourteenth Amendment to the United States Constitution. However, in Olmstead v. L.C., 527 U.S. 581 (1999), the Supreme Court of the United States held that under the Americans with Disabilities Act, individuals with mental disabilities have the right to live in the community rather than in institutions if, in the words of the opinion of the Court, "the State's treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the affected individual, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities."

According to a series of interviews taken place in Malta investigating the sexual lives of men and women with intellectual disabilities, most individuals reported that they felt oppressed by the expectations from families and caretakers to not engage in sexual activity or a relationship. As a result of the study, almost all individuals expressed a desire to be able to talk openly about their relationships and spend more time away from the family. And while all people's sexualities are controlled and limited by social norms, people with disabilities feel that they are limited by further factors. Another study in Texas explored the beliefs of the families and caretakers of people with intellectual disabilities on their sexualities. The results revealed that the majority of families and caretakers of those with intellectual disabilities believed that those with disabilities should not engage in sexual activity because of the fear that they will be taken advantage of. A resolution to the oppression that people with disabilities face when it comes to sexuality is educating families on these findings and educating disabled people on their own sexualities and life options.

Sexual harassment, assault, and domestic violence

People with disabilities are no less vulnerable than people without disabilities to harassment, assault, and domestic violence. People with disabilities are more vulnerable to sexual assault than the general public, being targeted due to the physical or mental impairments that they have. The American Journal of Preventive Medicine has published results of a survey that found that males with disabilities are 4 times more likely to be sexually abused. Other studies have shown that for women with disabilities, "regardless of age, race, ethnicity, sexual orientation, or class [they] are assaulted, raped, and abused at a rate two times greater than women without disabilities [... the] risk of being physically assaulted for an adult with developmental disabilities is 4–10 times higher than for other adults".

It is estimated that 25% of both girls and boys with disabilities will experience sexual abuse before the age of 18. It is also estimated that 20% of these incidents are reported. These rates are much higher than sexual abuse incidents pertaining to nondisabled children. There is a 1 in 4 chance that a girl with developmental disabilities will be molested before the age of 18. This is 10 times higher than the nondisabled population. During the California Committee on Abuse of Person with Disabilities, national statistics estimate the sexual abuse on people with disabilities as such:

By combining national statistics with specific studies, estimate ranges are as follows: between 39% and 83% of girls with developmental disabilities, and between 16% and 32% of boys with developmental disabilities will be subjected to sexual abuse before the age of 18 years. Incidence of sexual abuse among the population of persons with developmental disabilities was estimated in 1985 by the California State Department of Developmental Services to be 70%.

A majority of the predators are documented to be the father or stepfather of the victim. This is especially true for females with developmental disabilities. It is estimated that 10% of girls with intellectual disabilities are victims of incest. Females are most likely to be victims of sexual abuse. Studies show 50% of disabled females have experience multiple incidents of sexual abuse and 80% of disabled males experienced 1 incident. The numbers for sexual abuse are so high because the perpetrators are well known to the individual, such as a parent, uncle, aunt, cousin, friend, caretaker or sibling.

The statistics on sexual abuse for people with disabilities are also high because staff and dependent parents are not adequately trained in identifying sexual abuse. Many staff believe that sexual abuse must be proven before it is reported. The issue with this is that certain disabilities restrict the individual from expressing the experience. Adults with training in identifying abuse are more effective in protecting the child. Most programs focus on "stranger danger", which is not effective because most sexual abuse assaults come from the individual's inner circle.

Prevention

Several prevention programs against sexual abuse for people with disabilities exist in the United States.

• Seattle

In Seattle, United States a program called Seattle Project trains individuals with developmental disabilities to prevent sexual assault.

• Minnesota

In Minnesota, the Department of Corrections created a prevention program where children and adults with disabilities are trained in all aspects of abuse prevention.

• California

In California, there is the Waters Child Abuse Prevention Training Act (WCBTA). This program attempts to provide all children with abuse prevention. Each program caters to the child's age and learning level. In Contra Costa County, California, the WCBTA focuses on the needs of various disabilities and sexual abuse prevention. In Los Angeles County Office of Education they have created a Preschool Abuse Prevention Program for Children with disabilities. In this, teachers are instructed to train students with disabilities on physical, emotional, and sexual abuse.

Organizations

Australia

The subject of the Scarlet Road documentary, Rachel Wotton, also co-founded and helps run Touching Base, an organization based in New South Wales, Australia that provides information, education and support for clients with disabilities, sex workers and Disability Service Providers. The organization has been active since October 2000 following the formation of the founding committee that consisted of disability and health organization representatives. Wotton explains, "I am a sex worker and I make my money from clients seeing me. Some clients just happen to have a disability." Initially, the organization was receiving around one weekly phone call, but by 2012, inquiries were daily.

In March 2014, former Australian High Court judge Michael Kirby became a patron of the organization, joining four other inaugural patrons: Eva Cox, Professor Basil Donovan, Associate Professor Helen Meekosha, and NSW Local Government elder statesman Peter Woods. Following his appointment, Kirby stated: "If you deny sexual expression to human beings, cut them off from that aspect of their personalities and of their happiness, then you end up with a lot of very frustrated and very unhappy people", and he praised Touching Base for recognising that people with disabilities need "to have opportunities for sexual expression".

People with Disability Australia has developed a sex and relationship education workshop for people with intellectual disabilities.

United Kingdom

• TLC Trust

The TLC Trust provides a web-based service that facilitates the provision of sexual services—sex workers, therapists, and teachers—for people with disabilities, including a phone call appointment-booking service for those people with speech impairments or care workers who are unable to organize such services for clients due to the policy of their employer. The TLC Trust was founded in 2000 at a Sexual Freedom Coalition Conference and the website was initially run by James Palmer, a man with disabilities. The organization has garnered praise from sex educator and performance artist Annie Sprinkle, and academic and writer A.C. Grayling.

• Outsiders

Founded by Owens, Outsiders is primarily an international social club for people with disabilities, but the organization also runs the Sex and Disability Helpline, a telephone support service for people with disabilities that is staffed by both people with disabilities and health professionals. Outsiders is supported by the Outsiders Trust, which consists of a board of trustees that assists with the management of matters such as finances and projects.

• Sexual Health and Disability Alliance (SHADA)

The Sexual Health and Disability Alliance, also founded by Owens, was first started to provide a forum in which all of the UK's disability helpline operators, and others, could meet and discuss their work. The individuals who were initially involved state that they were "eager to improve the sex-positive work we do" and the Alliance was eventually formalized in 2008 with a mission to "bring together health professionals who work with people with disabilities to empower and support them in their sex and relationship needs." The Alliance does not charge a fee for those interested in becoming members and meets biannually in London. It held its first conference in 2009 at the Royal Society of Medicine.

• The Disabilities Trust

The Disabilities Trust is over 30 years old and is a leading charitable organization in the UK. It states that it provides "residential and day services to meet the needs of individuals with Autism, Brain Injury, Physical Disability and Learning Disability", as well as helping people to live at home in the community. The Trust has produced written information on sexuality and disability, which are freely available on the Internet.

United States

• Reach Out USA

Reach out USA is an advocacy organization that focuses on the relationship between disability and LGBT (gay, lesbian, bisexual, and transgender) concerns. The group's goal is to influence disabled communities to be more aware of the LGBT communities, and LGBT communities and organizations to be more accountable and welcoming of disabled communities. Reach Out USA also helps out with other topics such as mental illness, suicide, depression and much more.

• Queerability

Queerability is an LGBT and disabled rights advocacy group that is run by LGBT people with disabilities who hope to increase visibility to the community. The goal of this group is to ensure that the voices of LGBT people with disabilities are heard. The organization gives them a large social platform to express themselves. Queerability does not only advocate for the rights of LGBT disabled communities, but also provides educational sources pertaining to the individuals sexuality and disability. Some of the sources they provide include: How to Meet, Date, and Have Sex When You're Disabled, Practical Sex Tips for people with disabilities, Good Sex Positions for Disabled Sex, Talking About Sensitive Topics and more.

France

The idea of sexual support emerged in 2007, when a conference on "Physical dependence: intimacy and sexuality" was organised by Marcel Nuss. The Strasbourg conference is co-organised by Handicap International, the Association des Paralyés de France (APF), the French Muscular Dystrophy Association (AFM) and the Coordination Handicap et Autonomie (CHA).

In France there are several structures that now provide training for sex assistants: the Swiss association Sexualité et Handicap Pluriels (SEHP), the Association for the Promotion of Sexual Support (APPAS), founded by Marcel Nuss, which is organising its first training cycle in 2015, and the association Corps Solidaires, which brings together certified sex assistants.

Homosexuality and psychology

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The field of psychology has extensively studied homosexuality as a human sexual orientation. The American Psychiatric Association listed homosexuality in the DSM-I in 1952 as a "sociopathic personality disturbance,"^[1] but that classification came under scrutiny in research funded by the National Institute of Mental Health. That research and subsequent studies consistently failed to produce any empirical or scientific basis for regarding homosexuality as anything other than a natural and normal sexual orientation that is a healthy and positive expression of human sexuality.^[2] As a result of this scientific research, the American Psychiatric Association removed homosexuality from the DSM-II in 1973. Upon a thorough review of the scientific data, the American Psychological Association followed in 1975 and also called on all mental health professionals to take the lead in "removing the stigma of mental illness that has long been associated" with homosexuality. In 1993, the National Association of Social Workers adopted the same position as the American Psychiatric Association and the American Psychological Association, in recognition of scientific evidence.^[2] The World Health Organization, which listed homosexuality in the ICD-9 in 1977, removed homosexuality from the ICD-10 which was endorsed by the 43rd World Health Assembly on 17 May 1990.^[3]

The consensus of scientific research and clinical literature demonstrate that same-sex attractions, feelings, and behaviors are normal and positive variations of human sexuality.^[4] There is now a large body of scientific evidence that indicates that being gay, lesbian, or bisexual is compatible with normal mental health and social adjustment.^[5]

Historical background

The view of homosexuality as a psychological disorder has been seen in literature since research on homosexuality first began; however, psychology as a discipline has evolved over the years in its position on homosexuality. Current attitudes have their roots in religious, legal, and cultural underpinnings. Some Ancient Near Eastern communities, such as the Israelites, had strict codes forbidding homosexual activity, and when Christianity began, it adopted their Jewish predecessors attitudes surrounding homosexual activities. Among the New Testament authors Paul in particular is notable for his affirmation and reinforcement of such texts in his letters to nascent churches. Later, the Apostolic Fathers and their successors continued to speak against homosexual activity whenever they mentioned it in their writings. In the early Middle Ages the Christian Church ignored homosexuality in secular society; however, by the end of the 12th century, hostility towards homosexuality began to emerge and spread through Europe's secular and religious institutions. There were official expressions condemning the "unnatural" nature of homosexual behavior in the works of Thomas Aquinas and others. Until the 19th century, homosexual activity was referred to as "unnatural, crimes against nature", sodomy or buggery and was punishable by law, sometimes by death.^[6]

As people became more interested in discovering the causes of homosexuality, medicine and psychiatry began competing with the law and religion for jurisdiction. In the beginning of the 19th century, people began studying homosexuality scientifically. At this time, most theories regarded homosexuality as a disease, which had a great influence on how it was viewed culturally.^[7] There was a paradigm shift in the mid 20th century in psychiatric science in regards to theories of homosexuality. Psychiatrists began to believe homosexuality could be cured through therapy and freedom of self, and other theories about the genetic and hormonal origin of homosexuality were becoming accepted. There were variations of how homosexuality was viewed as pathological.^[6] Some early psychiatrists such as Sigmund Freud and Havelock Ellis adopted more tolerant stances on homosexuality. Freud and Ellis believed that homosexuality was not normal, but was "unavoidable" for some people. Alfred Kinsey's research and publications about homosexuality began the social and cultural shift away from viewing homosexuality as an abnormal condition. These shifting viewpoints in the psychological studies of homosexuality are evident in its placement in the first version of the Diagnostic Statistical Manual (DSM) in 1952, and subsequent change in 1973, in which the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance".^[7] However, it was not until 1987 in DSM-III-R that it was entirely dropped as a mental disorder.^[8]

A 2016 survey of the European Union Agency for Fundamental Rights found that many medical professionals in countries such as Bulgaria, Hungary, Italy, Latvia, Poland, Romania and Slovakia believe that homosexuality is a disease and that such interpretations continue to exist in professional materials. This goes against Council of Europe Recommendation 2010(5) which recommends that homosexuality not be treated as a disease.^[9] As of 2018, homosexuality was popularly considered a disease in Lebanon.^[10]

Freud and psychoanalysis

Sigmund Freud's views on homosexuality were complex. In his attempts to understand the causes and development of homosexuality, he first explained bisexuality as an "original libido endowment",^[11] by which he meant that all humans are born bisexual. He believed that the libido has a homosexual portion and a heterosexual portion, and through the course of development one wins out over the other.

Some other causes of homosexuality for which he advocated included an inverted Oedipus complex where individuals begin to identify with their mother and take themselves as a love object. This love of one's self is defined as narcissism, and Freud thought that people who were high in the trait of narcissism would be more likely to develop homosexuality because loving the same sex is like an extension of loving oneself.^[12]

Freud believed treatment of homosexuality was not successful because the individual does not want to give up their homosexual identity because it brings them pleasure. He used psychoanalysis and hypnotic suggestion as treatments, but showed little success.^[13] It was through this that Freud arrived at the conclusion that homosexuality was "nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness, but a variation of sexual function".^[14] He further stated that psychoanalysts "should not promise to abolish homosexuality and make normal heterosexuality take its place",^[11] as he had concluded in his own practice that attempts to change homosexual orientations were likely to be unsuccessful. While Freud himself may have come to a more accepting view of homosexuality, his legacy in the field of psychoanalysis, especially in the United States viewed homosexuality as negative, abnormal and caused by family and developmental issues. It was these views that significantly impacted the rationale for putting homosexuality in the first and second publications of the American Psychiatric Association's DSM, conceptualizing it as a mental disorder and further stigmatizing homosexuality in society.^[7]

Havelock Ellis

Havelock Ellis (1859–1939) was working as a teacher in Australia, when he had a revelation that he wanted to dedicate his life to exploring the issue of sexuality. He returned to London in 1879 and enrolled in St. Thomas's Hospital Medical School. He began to write, and in 1896 he co-authored Sexual Inversion with John Addington Symonds. The book was first published in German, and a year later it was translated into English. Their book explored homosexual relationships, and in a progressive approach for their time they refused to criminalize or pathologize the acts and emotions that were present in homosexual relationships.^[15]

Ellis disagreed with Freud on a few points regarding homosexuality, especially regarding its development. He argued that homosexuals do not have a clear cut Oedipus complex but they do have strong feelings of inadequacy, born of fears of failure, and may also be afraid of relations with women.^[16] Ellis argued that the restrictions of society contributed to the development of same-sex love. He believed that homosexuality is not something people are born with, but that at some point humans are all sexually indiscriminate, and then narrow down and choose which sex acts to stick with. According to Ellis, some people choose to engage in homosexuality, while others will choose heterosexuality.^[16] He proposed that being "exclusively homosexual"^[17] is to be deviant because the person is a member of a minority and therefore statistically unusual, but that society should accept that deviations from the "normal" were harmless, and maybe even valuable.^[15] Ellis believed that psychological problems arose not from homosexual acts alone, but when someone "psychologically harms himself by fearfully limiting his own sex behavior".^[16]

Ellis is often credited with coining the term homosexuality but in reality he despised the word because it conflated Latin and Greek roots and instead used the term invert in his published works. Soon after Sexual Inversion was published in England, it was banned as lewd and scandalous. Ellis argued that homosexuality was a characteristic of a minority, and was not acquired or a vice and was not curable. He advocated changing the laws to leave those who chose to practice homosexuality at peace, because at the time it was a punishable crime. He believed societal reform could occur, but only after the public was educated. His book became a landmark in the understanding of homosexuality.^[15]

Alfred Kinsey

Alfred Charles Kinsey (1894–1956) was a sexologist who founded the Institute for Sex Research, which is now known as the Kinsey Institute for Research in Sex, Gender and Reproduction. His explorations into different sexual practices originated from his study of the variations in mating practices among wasps. He developed the Kinsey Scale, which measures sexual orientation in ranges from 0 to 6 with 0 being exclusively heterosexual and 6 being exclusively homosexual.^[18] His findings indicated that there was great variability in sexual orientations. Kinsey published the books Sexual Behavior in the Human Male and Sexual Behavior in the Human Female, which brought him both fame and controversy. The prevailing approach to homosexuality at the time was to pathologize and attempt to change homosexuals. Kinsey's book demonstrated that homosexuality was more common than was assumed, suggesting that these behaviors are normal and part of a continuum of sexual behaviors.^[7]

The Diagnostic and Statistical Manual

See also: Homosexuality in the DSM

The social, medical, and legal approach to homosexuality ultimately led to its inclusion in the first and second publications of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). This served to conceptualize homosexuality as a mental disorder and further stigmatize homosexuality in society. However, the evolution in scientific study and empirical data from Kinsey, Evelyn Hooker, and others confronted these beliefs, and by the 1970s psychiatrists and psychologists were radically altering their views on homosexuality. Tests such as the Rorschach, Thematic Apperception Test (TAT), and the Minnesota Multiphasic Personality Inventory (MMPI) indicated that homosexual men and women were not distinguishable from heterosexual men and women in functioning. These studies failed to support the previous assumptions that family dynamics, trauma, and gender identity were factors in the development of sexual orientation. Many psychologists have differing opinions about same-sex relationships. Some think that it is not healthy at all, some support it, and some cannot support it because of their own personal religious beliefs.^[19] Due to lack of supporting data, as well as exponentially increasing pressure from gay rights advocates, the board of directors for the American Psychiatric Association voted to declassify homosexuality as a mental disorder from the DSM-II in 1973, but the DSM retained a diagnosis that could be used for distress due to one's sexual orientation until the DSM-5 (2013).^[20]

Major areas of psychological research

Major psychological research into homosexuality is divided into five categories:^[21]

1. What causes some people to be attracted to his or her own sex?
2. What causes discrimination against people with a homosexual orientation and how can this be influenced?^[22]
3. Does having a homosexual orientation affect one's health status, psychological functioning or general well-being?
4. What determines successful adaptation to rejecting social climates? Why is homosexuality central to the identity of some people, but peripheral to the identity of others?^[23]
5. How do the children of homosexual people develop?

Psychological research in these areas has always been important to counteracting prejudicial attitudes and actions, and to the gay and lesbian rights movement generally.^[21]

Causes of homosexuality

See also: Biology and sexual orientation and Environment and sexual orientation

Although no single theory on the cause of sexual orientation has yet gained widespread support, scientists favor biologically based theories.^[24] There is considerably more evidence supporting nonsocial, biological causes of sexual orientation than social ones, especially for males.^[25][26][27]

Discrimination

This section needs expansion. You can help by adding to it. (May 2008)

See also: Societal attitudes toward homosexuality

Anti-gay attitudes and behaviors (sometimes called homophobia or heterosexism) have been objects of psychological research. Such research usually focuses on attitudes hostile to gay men, rather than attitudes hostile to lesbians.^[21] Anti-gay attitudes are often found in those who do not know gay people on a personal basis.^[28] There is also a high risk for anti-gay bias in psychotherapy with lesbian, gay, and bisexual clients.^[29] One study found that nearly half of its sample had been the victim of verbal or physical violence because of their sexual orientation, usually committed by men. Such victimization is related to higher levels of depression, anxiety, anger, and symptoms of post-traumatic stress.^{[30][full citation needed]} Through the 2015 U.S. Transgender Survey, which was conducted by the National Center for Transgender Equality, transgender people of color were found to face disproportionate discrimination because of their overlapping identities. These forms of discrimination included violence, unreasonable unemployment, unfair policing, and unfair medical treatment.^[31]

Research suggests that parents who respond negatively to their child's sexual orientation tended to have lower self-esteem and negative attitudes toward women, and that "negative feelings about homosexuality in parents - decreased the longer they were aware of their child's homosexuality".^[32]

In addition, while research has suggested that "families with a strong emphasis on traditional values implying the importance of religion, an emphasis on marriage and having children – were less accepting of homosexuality than were low-tradition families",^[33] emerging research suggests that this may not be universal. For example, recent^[when?] research published in APA's Psychology of Religion & Spirituality journal by Chana Etengoff and Colette Daiute^[34] suggests that religious family members can alternatively use religious values and texts in support of their sexual minority relative. For example, a Catholic mother of a gay man shared that she focuses on "the greatest commandment of all, which is, love". Similarly, a Methodist mother referenced Jesus in her discussion of loving her gay son, as she said, "I look at Jesus' message of love and forgiveness and that we're friends by the blood, that I don't feel that people are condemned by the actions they have done." These religious values were similarly expressed by a father who is a member of the Church of Jesus Christ of Latter-day Saints who shared the following during his discussion of the biblical prohibition against homosexuality: "Your goal, your reason for being, should be to accept and to love and to lift up ... those in need no matter who they are".^[22]

Mental health issues

Psychological research in this area includes examining mental health issues (including stress, depression, or addictive behavior) faced by gay and lesbian people as a result of the difficulties they experience because of their sexual orientation, physical appearance issues, eating disorders, or gender atypical behavior.

• Psychiatric disorders: in a Dutch study, gay men reported significantly higher rates of mood and anxiety disorders than straight men, and lesbians were significantly more likely to experience depression (but not other mood or anxiety disorders) than straight women.^[21] A research paper from the American Journal of Community Psychology states that individuals who face multiple forms of oppression tend to find their hardships more difficult to manage. In this study, it is noted that LGBTQ+ people who are disabled have reported struggling more with their oppressed statuses.^[35]
• Physical appearance and eating disorders: gay men tend to be more concerned about their physical appearance than straight men.^{[36][full citation needed]} Lesbian women are at a lower risk for eating disorders than heterosexual women.^[37]
• Gender atypical behavior: while this is not a disorder, gay men may face difficulties due to being more likely to display gender atypical behavior than heterosexual men.^[38] The difference is less pronounced between lesbians and straight women.^[39]
• Minority stress: stress caused from a sexual stigma, manifested as prejudice and discrimination, is a major source of stress for people with a homosexual orientation. Sexual-minority affirming groups and gay peer groups help counteract and buffer minority stress.^[7]
• Ego-dystonic sexual orientation: conflict between religious identity and sexual orientation can cause severe stress, causing some people to want to change their sexual orientation. Sexual orientation identity exploration can help individuals evaluate the reasons behind the desire to change and help them resolve the conflict between their religious and sexual identity, either through sexual orientation identity reconstruction or affirmation therapies.^[7] Ego-dystonic sexual orientation is a disorder where a person wishes their sexual orientation were different because of associated psychological and behavioral disorders.
• Sexual relationship disorder: people with a homosexual orientation in mixed-orientation marriages may struggle with the fear of the loss of their marriage.^[7] Sexual relationship disorder is a disorder where the gender identity or sexual orientation of one of the partners interferes with maintaining or forming of a relationship.

Suicide

See also: Suicide and Suicide among LGBT youth

The likelihood of suicide attempts is higher in both gay males and lesbians, as well as bisexual individuals of both sexes, when compared to their heterosexual counterparts.^[40][41][42] The trend of having a higher incident rate among females encompasses lesbians or bisexual females; when compared with homosexual or bisexual males, lesbians are more likely to attempt suicide.^[43]

Studies dispute the exact difference in suicide rate compared to heterosexuals with a minimum of 0.8–1.1 times more likely for females^[44] and 1.5–2.5 times more likely for males.^[45][46] The higher figures reach 4.6 times more likely in females^[47] and 14.6 times more likely in males.^[21]

Race and age play a factor in the increased risk. The highest ratios for males are attributed to young Caucasians. By the age of 25, their risk is more than halved; however, the risk for black gay males at that age steadily increases to 8.6 times more likely. Over a lifetime, the increased likelihoods are 5.7 times for white and 12.8 for black gay and bisexual males. Lesbian and bisexual females have the opposite trend, with fewer attempts during the teenager years compared to heterosexual females. Through a lifetime, the likelihood for Caucasian females is nearly triple that of their heterosexual counterparts; however, for black females there is minimal change (less than 0.1 to 0.3 difference), with heterosexual black females having a slightly higher risk throughout most of the age-based study.^[21]

Gay and lesbian youth who attempt suicide are disproportionately subject to anti-gay attitudes, often have fewer skills for coping with discrimination, isolation, and loneliness,^[21][48][49] and were more likely to experience family rejection^[50] than those who do not attempt suicide. Another study found that gay and bisexual youth who attempted suicide had more feminine gender roles,^[51] adopted a non-heterosexual identity at a young age and were more likely than peers to report sexual abuse, drug abuse, and arrests for misconduct.^[51] One study found that same-sex sexual behavior, but not homosexual attraction or homosexual identity, was significantly predictive of suicide among Norwegian adolescents.^[52]

Government policies have been found to mediate this relationship by legislating structural stigma. One study using cross-country data from 1991 to 2017 for 36 OECD countries established that same-sex marriage legalization is associated with a decline in youth suicide of 1.191 deaths per 100,000 youth, with the impact more pronounced for male youth relative to female youth.^[53] Another study of nationwide data from across the United States from January 1999 to December 2015 revealed that same-sex marriage is associated with a significant reduction in the rate of attempted suicide among children, with the effect being concentrated among children of a minority sexual orientation, resulting in about 134,000 fewer children attempting suicide each year in the United States.^[54]

Sexual orientation identity development

Main article: Sexual orientation identity

• Coming out: many gay, lesbian and bisexual people go through a "coming out" experience at some point in their lives. Psychologists often say this process includes several stages "in which there is an awareness of being different from peers ('sensitization'), and in which people start to question their sexual identity ('identity confusion'). Subsequently, they start to explore practically the option of being gay, lesbian or bisexual and learn to deal with the stigma ('identity assumption'). In the final stage, they integrate their sexual desires into a positive understanding of self ('commitment')."^[21] However, the process is not always linear^[55] and it may differ for lesbians, gay men and bisexual individuals.^[56]
• Different degrees of coming out: one study found that gay men are more likely to be out to friends and siblings than to co-workers, parents, and more distant relatives.^[57]
• Coming out and well-being: same-sex couples who are openly gay are more satisfied in their relationships.^[58] For women who self-identify as lesbian, the more people know about her sexual orientation, the less anxiety, more positive affectivity, and greater self-esteem she has.^[59]
• Rejection of gay identity: various studies report that for some religious people, rejecting a gay identity appears to relieve the distress caused by conflicts between religious values and sexual orientation.^{[7][60][61][62][63]} After reviewing the research, Judith Glassgold, chair of the American Psychological Association sexuality task force, said some people are content in denying a gay identity and "there is no clear evidence of harm".^[64]

Fluidity of sexual orientation

Main article: Sexual fluidity

Often, sexual orientation and sexual orientation identity are not distinguished, which can impact accurately assessing sexual identity and whether or not sexual orientation is able to change; sexual orientation identity can change throughout an individual's life, and may or may not align with biological sex, sexual behavior or actual sexual orientation.^[65][66][67] Sexual orientation is stable and unlikely to change for the vast majority of people, but some research indicates that some people may experience change in their sexual orientation, and this is more likely for women than for men.^[68] The American Psychological Association distinguishes between sexual orientation (an innate attraction) and sexual orientation identity (which may change at any point in a person's life).^[69]

In a statement issued jointly with other major American medical organizations, the American Psychological Association states that "different people realize at different points in their lives that they are heterosexual, gay, lesbian, or bisexual".^[70] A 2007 report from the Centre for Addiction and Mental Health states that, "For some people, sexual orientation is continuous and fixed throughout their lives. For others, sexual orientation may be fluid and change over time".^[71] Lisa Diamond's study "Female bisexuality from adolescence to adulthood" suggests that there is "considerable fluidity in bisexual, unlabeled, and lesbian women's attractions, behaviors, and identities".^[72][73]

Parenting

See also: LGBT parenting

LGBT parenting is the parenting of children by lesbian, gay, bisexual, and transgender (LGBT) people, as either biological or non-biological parents. Gay men have options which include "foster care, variations of domestic and international adoption, diverse forms of surrogacy (whether "traditional" or gestational), and kinship arrangements, wherein they might coparent with a woman or women with whom they are intimately but not sexually involved".^{[74][75][76][77][78]} LGBT parents can also include single parents; to a lesser extent, the term sometimes refers to parents of LGBT children.

In the 2000 U.S. Census, 33% of female same-sex couple households and 22% of male same-sex couple households reported at least one child under eighteen living in their home.^[79] Some children do not know they have an LGBT parent; coming out issues vary and some parents may never come out to their children.^[80][81] Adoption by LGBT couples and LGBT parenting in general may be controversial in some countries. In January 2008, the European Court of Human Rights ruled that same-sex couples have the right to adopt a child.^[82][83] In the U.S., LGBT people can legally adopt, as individuals, in all fifty states.^[84]

Although it is sometimes asserted in policy debates that heterosexual couples are inherently better parents than same-sex couples, or that the children of lesbian or gay parents fare worse than children raised by heterosexual parents, those assertions are not supported by scientific research literature.^[2][85] There is ample evidence to show that children raised by same-gender parents fare as well as those raised by heterosexual parents. Much research has documented the lack of correlation between parents' sexual orientation and any measure of a child's emotional, psychosocial, and behavioral adjustment. These data have demonstrated no risk to children as a result of growing up in a family with one or more gay parents.^[86] No research supports the widely held conviction that the gender of parents influences the well-being of the child.^[87] If gay, lesbian, or bisexual parents were inherently less capable than otherwise comparable heterosexual parents, their children would present more poorly regardless of the type of sample; this pattern has not been observed.^[88]

Professor Judith Stacey of New York University, stated: "Rarely is there as much consensus in any area of social science as in the case of gay parenting, which is why the American Academy of Pediatrics and all of the major professional organizations with expertise in child welfare have issued reports and resolutions in support of gay and lesbian parental rights".^[89] These organizations include the American Academy of Pediatrics,^[86] the American Academy of Child and Adolescent Psychiatry,^[90] the American Psychiatric Association,^[91] the American Psychological Association,^[92] the American Psychoanalytic Association,^[93] the National Association of Social Workers,^[2] the Child Welfare League of America,^[94] the North American Council on Adoptable Children,^[95] and the Canadian Psychological Association (CPA). The CPA is concerned that some persons and institutions are misinterpreting the findings of psychological research to support their positions, when their positions are more accurately based on other systems of belief or values.^[96]

The vast majority of families in the United States today are not the "middle-class family with a bread-winning father and a stay-at-home mother, married to each other and raising their biological children" that has been viewed as the norm. Since the end of the 1980s, it has been well established that children and adolescents can adjust just as well in nontraditional settings as in traditional settings.^[97]

Psychotherapy

Most people with a homosexual orientation who seek psychotherapy do so for the same reasons as straight people (stress, relationship difficulties, difficulty adjusting to social or work situations, etc.); their sexual orientation may be of primary, incidental, or no importance to their issues and treatment. Regardless of the issue for which psychotherapy is sought, there is a high risk of anti-gay bias being directed at non-heterosexual clients.^[29]

Relationship counseling

See also: Relationship counseling

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Most relationship issues are shared equally among couples regardless of sexual orientation, but LGBT clients additionally have to deal with homophobia, heterosexism, and other societal oppressions. Individuals may also be at different stages in the coming out process. Often, same-sex couples do not have as many role models for successful relationships as opposite-sex couples. There may be issues with gender-role socialization that does not affect opposite-sex couples.^[98]

A significant number of men and women experience conflict surrounding homosexual expression within a mixed-orientation marriage.^[99] Therapy may include helping the client feel more comfortable and accepting of same-sex feelings and to explore ways of incorporating same-sex and opposite-sex feelings into life patterns.^[100] Although a strong homosexual identity was associated with difficulties in marital satisfaction, viewing the same-sex activities as compulsive facilitated commitment to the marriage and to monogamy.^[101]

Gay affirmative psychotherapy

Main article: Gay affirmative psychotherapy

Gay affirmative psychotherapy is a form of psychotherapy for gay, lesbian, and bisexual clients which encourages them to accept their sexual orientation, and does not attempt to change their sexual orientation to heterosexual, or to eliminate or diminish their same-sex desires and behaviors. The American Psychological Association (APA) and the British Psychological Society offer guidelines and materials for gay affirmative psychotherapy.^[102][103] Practitioners of gay affirmative psychotherapy state that homosexuality or bisexuality is not a mental illness, and that embracing and affirming gay identity can be a key component to recovery from other mental illnesses or substance abuse.^[102] Some people may find neither gay affirmative therapy nor conversion therapy appropriate, however. Clients whose religious beliefs are inconsistent with homosexual behavior may require some other method of integrating their conflicting religious and sexual selves.^[104]

Sexual orientation identity exploration

See also: Ego-dystonic sexual orientation

The American Psychological Association recommends that if a client wants treatment to change their sexual orientation, the therapist should explore the reasons behind the desire, without favoring any particular outcome. The therapist should neither promote nor reject the idea of celibacy, but help the client come to their own decisions by evaluating the reasons behind the patient's goals.^[105] One example of sexual orientation identity exploration is sexual identity therapy.^[7]

After exploration, a patient may proceed with sexual orientation identity reconstruction, which helps a patient reconstruct sexual orientation identity. Psychotherapy, support groups, and life events can influence identity development; similarly, self-awareness, self-conception, and identity may evolve during treatment.^[7] It can change sexual orientation identity (private and public identification, and group belonging), emotional adjustment (self-stigma and shame reduction), and personal beliefs, values and norms (change of religious and moral belief, behavior and motivation).^[7] Some therapies include "gender wholeness therapy".^[106]

The American Psychiatric Association states in their official statement release on the matter: "The potential risks of 'reparative therapy' are great and include depression, anxiety, and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient. Many patients who have undergone 'reparative therapy' relate that they were inaccurately told that homosexuals are lonely, unhappy individuals who never achieve acceptance or satisfaction. The possibility that the person might achieve happiness and satisfying interpersonal relationships as a gay man or lesbian are not presented, nor are alternative approaches to dealing with the effects of societal stigmatization discussed. APA recognizes that in the course of ongoing psychiatric treatment, there may be appropriate clinical indications for attempting to change sexual behaviors."^[107]

The American Psychological Association aligns with this in a resolution: it "urges all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientation"^[108] and "Therefore be it further resolved that the American Psychological Association opposes portrayals of lesbian, gay, and bisexual youth and adults as mentally ill due to their sexual orientation and supports the dissemination of accurate information about sexual orientation, and mental health, and appropriate interventions in order to counteract bias that is based in ignorance or unfounded beliefs about sexual orientation."^[109]

The American Academy of Pediatrics advises lesbian, gay, gynandromorphophilic, and bisexual teenagers struggling with their sexuality: "Homosexuality is not a mental disorder. All of the major medical organizations, including The American Psychiatric Association, The American Psychological Association, and the American Academy of Pediatrics agree that homosexuality is not an illness or disorder, but a form of sexual expression. No one knows what causes a person to be gay, bisexual, or straight. There probably are a number of factors. Some may be biological. Others may be psychological. The reasons can vary from one person to another. The fact is, you do not choose to be gay, bisexual, or straight."^[110]

Developments in individual psychology

In contemporary Adlerian thought, homosexuals are not considered within the problematic discourse of the "failures of life". Christopher Shelley, an Adlerian psychotherapist, published a volume of essays in 1998 that feature Freudian, (post)Jungian and Adlerian contributions that demonstrate affirmative shifts in the depth psychologies.^[111] These shifts show how depth psychology can be utilized to support rather than pathologize gay and lesbian psychotherapy clients. The Journal of Individual Psychology, the English language flagship publication of Adlerian psychology, released a volume in the summer of 2008 that reviews and corrects Adler's previously held beliefs on the homosexual community.