September 21, 2015

Is “Homophobia” A Mental Illness?

Posted at 5:24 pm (Pacific Time)

As I discussed in a previous post, the mental health establishment classified homosexuality as an illness until 1973. That year, the American Psychiatric Association removed it from their Diagnostic and Statistical Manual of Mental Disorders (DSM). The American Psychological Association soon followed suit.

The classification had always reflected value judgments and assumptions about homosexuality. There never was an empirical basis for it.

Another important event roughly coincided with the DSM change. In 1972, against the backdrop of a growing national gay rights movement, a new book was published, Society and the Healthy Homosexual. Its author, psychologist George Weinberg, began his first chapter with a provocative statement:

“I would never consider a patient healthy unless he had overcome his prejudice against homosexuality …. Even if he is heterosexual, his repugnance at homosexuality is certain to be harmful to him.”

A few pages later, Weinberg introduced a term he had coined during the late 1960s: homophobia, which he defined as heterosexuals’ “dread of being in close quarters with homosexuals” and homosexuals’ “self-loathing.”

Homophobia was a radical concept. It redirected society’s focus from what was then widely regarded as the “problem of homosexuality” to the problem of heterosexuals’ prejudice and hostility toward people who were gay. It communicated the idea that something was wrong with heterosexual people who dislike homosexuals.

To be sure, the legitimacy of anti-homosexual hostility had already been questioned by homophile activists after World War II in the United States and decades earlier in Europe. Those critiques, however, didn’t achieve widespread currency. With this new term, Weinberg gave the hostility a name and helped popularize the notion that it was a social problem that merited analysis and intervention.

The term homophobia soon became an important tool for lesbian and gay activists, advocates, and allies. Today, more than 40 years later, it’s more popular than ever.

And, in a 180-degree turn from the DSM’s classification of homosexuality, some people now argue that homophobia should be viewed as a form of mental illness.

It’s a proposal that follows logically from labeling sexual prejudice a phobia, which certainly invites people to think of it as a sickness. And it appeals to some (perhaps many) people.

But is it a good idea, one that could prove useful in eliminating prejudice against sexual minorities? Is homophobia, in fact, a form of psychopathology?

Are Homophobes Mentally Ill?

Labels and terminology can shape how we think about a phenomenon. For several reasons, I believe that embracing homophobia as a diagnostic label has negative effects on our ability to think clearly about sexual prejudice.

To begin, consider what constitutes a mental disorder. In 2001, the 4th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) provided this definition (I’ve emphasized some key phrases):

“a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.

Many – probably most – heterosexuals who harbor prejudice against sexual minorities don’t experience distress or obvious impairment from it. Nor does it put them at greater risk of death or other negative consequences.

And labeling homophobia “clinically significant” can blind us to the important fact that, in a society that still stigmatizes homosexuality, prejudice against sexual minorities isn’t a maladaptive pathology restricted to a small portion of the population. Rather, it’s part of the routine socialization that — at least until fairly recently — nearly everyone has undergone in the course of growing up.

Ironically, labeling homophobia a mental disorder has something in common with the erroneous classification of homosexuality as a sickness prior to 1973. In both cases, a diagnostic label is used to stigmatize a disliked pattern of thought and behavior. Using the label misrepresents what really is a subjective value judgment as a scientific, empirically grounded conclusion.

Moreover, by equating psychopathology with evil, it also reinforces the stigma that historically has been attached to mental illness.

Yet another problem with labeling homophobia a clinical disorder is that doing so frames heterosexuals’ hostility toward homosexuality as a purely individual phenomenon. This limits our ability to understand the social processes through which sexual prejudice develops and is reinforced. It encourages us to focus on the prejudiced individual while ignoring the larger culture that stigmatizes homosexuality.

This is not to deny that sexual prejudice (like other form of prejudice) is observed in some people with severe psychological problems. But that doesn’t mean homophobia is itself a pathology.

But What About the Newest Scientific Data?

Web and media coverage of a recently published research study by Dr. Giacomo Ciocca and his colleagues from several Italian universities could lead you to believe that we now have evidence that homophobia is linked to mental illness.

So could the study’s title, Psychoticism, Immature Defense Mechanisms and a Fearful Attachment Style are Associated with a Higher Homophobic Attitude.”

And so could remarks by the study’s senior author, Dr. Emmanuele Jannini, who was quoted as saying “The study is opening a new research avenue, where the real disease to study is homophobia” and “we have the final proof that [homophobia] for sure is” a disease.

Published in the Journal of Sexual Medicine, the study involved administering a measure called the Homophobia Scale (HS) and several other questionnaires to a sample of Italian college students, and then assessing whether and how the scores were intercorrelated.

In brief, the researchers found that HS scores were significantly associated with scores on two checklists  of psychological symptoms — “psychoticism” and “depression.” Overall, students with higher HS scores (more prejudice) tended to score higher on a Psychoticism scale, whereas students with lower HS scores (less prejudice) tended to score higher on a Depression scale.

Students with higher HS scores also tended to respond differently from low HS scorers on a questionnaire designed to reveal the types of psychological defense mechanisms a person is likely to use when experiencing anxiety. The high HS scorers tended toward a cluster of defenses that are often labeled “immature,” while the low HS students tended toward “neurotic” defenses.

Finally, when responses to another questionnaire were used to categorize students according to their attachment style — a general psychological pattern that characterizes an individual’s close relationships with others  — the students classified as having a “fearful” attachment style had higher HS scores, on average, than those whose attachment style was categorized as “secure.”

A Closer Look

Many Web and media reports accepted the study’s findings at face-value. Here’s a sampling of headlines:

Examining the study’s methodology, however, makes clear that it doesn’t provide support for thinking about prejudice against lesbian, gay, and bisexual people as a disease.

Let’s begin with the sample.

The study participants were 551 psychology students, mostly female (about 71%) and Catholic (74%). The sample wasn’t representative of a larger population so there’s no way of knowing whether the findings can be generalized to anyone else.

Perhaps more importantly, none of the students could be considered mentally ill. Prior to the study, a team of clinical psychologists screened potential participants for severe psychological problems, a procedure that led to the exclusion of nine students who had been diagnosed and treated for a psychiatric disorder.

Consequently, although the students’ scores on the various psychological measures differed (as is routinely the case), the variation presumably was, as psychologists often phrase it, within normal limits.

And the sample may have included few students, if any, who would be considered “homophobic.”

Homophobia was measured using a questionnaire called the Homophobia Scale (HS), which asks respondents how much they agree or disagree with each of 25 statements such as “Gay people make me nervous” and “Homosexuality is immoral” and “Homosexual behavior should not be against the law.”

Here again, there was normal variation among the students in HS scores. But overall, the sample was very low in sexual prejudice. HS scores can range from zero to 100, with higher scores indicating less prejudice. The average score in this study was about 26. Given that the scale consists of 25 items, a substantial portion of participants must have given a “low-prejudice” response (i.e., a 1 or 2 on a 5-point scale) to all 25 items.

So the participants weren’t mentally ill and few, if any, could be labeled homophobic.

Now let’s consider each of the study’s main findings.

Psychoticism and Depression. In addition to the HS scale, the students also completed the Symptom Check List (SCL-90), a widely used questionnaire on which respondents use a 5-point scale (ranging from Not at all to Extremely) to report how much they’ve been bothered or distressed during the previous week by each of 90 problems and complaints, e.g., “Heart pounding or racing,” “Feeling that most people cannot be trusted.”

The SCL-90 can be scored to indicate the extent to which a respondent reports symptoms and feelings that are commonly associated with various psychological problems. Here again, scores vary. Two people with different scores can both be within the “normal” range, i.e., not reporting symptoms to a degree that would warrant a clinical diagnosis.

Using a statistical procedure called multiple regression analysis, the researchers found that scores on the SCL-90 Psychoticism and Depression scales were significantly associated with Homophobia Scale scores, as noted above. This doesn’t mean that students with high HS scores were psychotic or that those with low HS scores were clinically depressed. It simply means that responses to the SCL-90 varied in a way that corresponded to variations in HS scores.

To make sense of this pattern, it’s instructive to examine the symptoms included in the SCL-90. For example, the Psychoticism scale includes “The idea that you should be punished for your sins” and “Having thoughts about sex that bother you a lot.”

It’s easy to imagine the most religious college students in this predominantly Catholic sample being more bothered than their peers by thoughts about sex and believing that they (and all people) should be punished for their sins.

Highly religious students are also more likely than others to score high on the HS scale. Many empirical studies (including my own) have shown that conservative religious beliefs are strongly associated with higher levels of sexual prejudice.

Thus, there’s ample reason — having nothing to do with psychoticism — to expect that students with higher HS scores would also report more distress from thoughts about sex and sin. Responses to these two SCL-90 items alone may well account for the correlation observed between HS and Psychoticism scores. Unfortunately, the researchers’ statistical analysis didn’t take differences in religious belief into account.

Defense Mechanisms. The concept of defense mechanisms derives mainly from psychoanalytic theory, which posits that they are unconscious strategies for avoiding anxiety. Psychoanalysts have developed a long list of them which includes, for example, projection and reaction formation.

In the extreme, they can be associated with psychopathology. Most of them, however, are also used by psychologically healthy people, at least occasionally.

Students in the Ciocca et al. study completed the Defense Style Questionnaire (DSQ), which consists of 40 statements, each of which is intended to indicate a tendency to use one of 20 different defenses. For example, agreeing that “People tend to mistreat me” is supposed to indicate a tendency to use projection. Agreeing that “If someone mugged me and stole my money, I’d rather he be helped than punished” is supposed to be consistent with using reaction formation.

Of course, there are many reasons — having nothing to do with defense — why a person might agree with one or more of these statements.

DSQ scores for individual defenses can be combined into larger categories. Using one of the most common categorization systems, the researchers found that students with higher HS scores tended to score somewhat higher on “immature” defenses (a group that includes projection), while low HS scorers tended to score higher on “neurotic” defenses (which includes reaction formation). In this system, using neurotic defenses to excess is considered less pathological than using immature defenses.

As noted above, however, most of the defenses are used by mentally healthy people (like the students in this sample). Minor variations within a healthy group don’t indicate pathology.

Attachment. Finally, the researchers categorized students according to their predominant attachment style, as assessed by the Relationships Questionnaire (RQ). Respondents to the RQ rate the extent to which their own patterns of relating to others correspond to each of four descriptions.

In the Ciocca et al. study, students in one attachment category (“Fearful”) scored significantly higher on the Homophobia Scale than students in another category (“Secure”). HS scores for students in the other two attachment categories (“Preoccupied” and “Dismissing”) didn’t differ significantly from each other or from the Fearful or Secure groups.

For at least three reasons, no conclusions about homophobia and mental illness can be drawn from this finding.

First, the Relationships Questionnaire isn’t a measure of psychopathology. Mentally healthy people can (and do) occupy any of the four categories.

Second, some research has suggested that high levels of attachment anxiety may be linked to derogation of all outgroups. So the findings of Ciocci et al. may reflect this more general tendency.

Third, results from other published studies that have looked for links between attachment style and homophobia have been inconsistent and contradictory. Like Ciocca et al., none of these studies used a representative sample. The safest conclusion to draw about homophobia and attachment style is that the jury is still out.

Beyond Homophobia

In summary, the Ciocca et al., study doesn’t provide evidence that would justify categorizing homophobia as a mental illness. Nor does any other empirical research.

Labeling homophobia a form of psychopathology may score rhetorical points but is inaccurate. And doing so distracts us from achieving a better understanding of the phenomena encompassed by the term homophobia.

As readers of my empirical and theoretical papers know, I’ve been arguing for much of my professional career that scientific research must move beyond homophobia in order to yield insights about cultural stigma and individual prejudice based on sexual orientation.

To facilitate that shift, I’ve developed a conceptual framework for thinking about and studying these phenomena.

I’ll discuss that framework and relevant empirical research in future posts.

Copyright © 2015 by Gregory M. Herek. All rights reserved.