Pathologising alternate sexuality: shifting psychiatric practices and a need for ethical norms and reforms

Section 377 of the Indian Penal Code, criminalising consensual sexual activity between adults of the same sex, was framed during the British Raj and continued to govern Indian sexual relations until very recently. This law seems to reflect societal attitudes towards alternate sexualities. Such attitudes can affect the self-esteem and quality of life of people in the lesbian, gay, bisexual, transgender (LGBT) community who may then seek help from mental health professionals. Unfortunately, psychiatry has a history of pathologising homosexuality.

Recently, I was consulted by Mr A, a 26-year-old man, who identified himself as gay. A year earlier, when he had been questioning his own sexual orientation, he contacted a reputed psychiatric institute where the psychiatrist told him that his attraction towards men could be controlled, and that he could feel sexually attracted to women, by just completing a course of medicines. The patient quoted the psychiatrist as saying: “I guarantee that you can marry a woman after this treatment.” Mr A agreed to take the medications and also started attending weekly therapy sessions at the same institute, but with a different psychiatrist.

Mr A said that for almost six months, his therapy sessions discussed every aspect of his life except sexuality. After six months when he insisted that they discuss his sexuality, the psychiatrist suggested that the medications would have started to work and he should “try out” the effect by “going and having sex with a girl.” When the patient said that he did not know any girl who would agree to this, the psychiatrist suggested that he can go and “try out” with a commercial sex worker. Mr A did as advised but did not succeed. At the next consultation, the psychiatrist encouraged a “retrial since one cannot infer anything from a single encounter.” Mr A “tried” three more times, unsuccessfully. At this point, he realised three things: that he did not get sexually aroused by women, and that his sexual arousal for men had gone down. However, his sexual attraction for men remained unaffected, which was contrary to what the first psychiatrist had “guaranteed” a year earlier. When he went back to the first psychiatrist, he was asked: “Is marriage all about sex?” and advised a combined consultation along with the second psychiatrist. The patient did not go back to see either of them.

I read the prescription and saw that Mr A had been prescribed amisulpiride, escitalopram, amoxapine, lamotrigine and zolpidem for a full year. Amisulpiride, an atypical antipsychotic is used in the treatment of psychotic disorders. Escitalopram and amoxapine are antidepressants. Lamotrigine is a mood stabiliser used in bipolar depression. The patient denied having any history that could suggest depression, psychosis, or bipolar disorder at any time in his life. He stated repeatedly that the only reason for his consultation with the psychiatrists was the dilemma about his sexual orientation.

This case draws our attention to what some psychiatrists still practise today, thus making it difficult to draw a line on what they can treat and what they cannot or rather should not treat! Anecdotal reports suggest that many psychiatrists now use these classes of drugs under the pretext of helping the patient’s depression or stress, possibly with the intention of reducing their overall sexual desire. This is a paradigm shift from the earlier behaviour modification techniques that were claimed to ‘cure’ homosexuality (1, 2).

A common side-effect of all these medications (except lamotrigine) is sexual dysfunction that may include decreased libido, erectile dysfunction and ejaculatory disturbances in men (3, 4,5,6). Although these medications reduced Mr A’s sexual arousal for men, they could do nothing as far as his innate attraction to the same sex was concerned, highlighting the fact that an individual’s sexual arousal and sexual attraction towards another individual are governed neuro-biologically through different circuitry.

This case raises the issue of giving false assurances “guaranteeing a cure” when there is no evidence to support such a cure (7). It also highlights how a psychiatrist can breach therapeutic boundaries and suggest that the patient visit a CSW in order to see if the treatment is working. This case could just be the tip of the iceberg and there could be many more such LGBT patients who are misguided about a possibility of curing themselves of their natural sexual preferences?

Such incidents call for urgent reforms in the mental healthcare system, as well as in the wider healthcare system, to make them more LGBT-friendly. Redefining the role of healthcare professionals in these cases is urgently needed (8). An initiative on this front can be taken by national bodies and societies, individual institutes and healthcare providers. This would not only increase clients’ trust in the healthcare system but also reduce the burden of their mental health problems.