6 Lesbianism and mental health

Etymologically the adjective ‘lesbian’ is traced back to 1591 from ‘Lesbius’, emanating from the Greek conception ‘lesbios of Lesbos’. Lesbos is an island in the north-eastern Aegean Sea in Greece and was the great lyric poet Sappho’s home (born sometime between 630 and 612 BC). Sappho is famous for her erotic and romantic verses and is associated with homosexual relationships between women.

Adrienne Rich (1980), a feminist poet in the late 20^th century, outlined a continuum of lesbian intimacy ranging from sexual to platonic relationships. In the broadest definition of lesbianism, Rich proposed that the female who sidestepped traditional married life in order to combat male tyranny might be seen at one end of the continuum, usually connected with feminism. In the 1970s the radical lesbians declared, ‘A lesbian is the rage of all women condensed to the point of explosion’ (McCoy and Hicks 1979).

Henri de Toulouse-Lautrec, the prominent 19^th century French post-impressionist painter, injured as a young boy, became short, midget-like, and suffered from a sense of being an outsider. He empathized with prostitutes and represented them in his art. He became acquainted with lesbians and noted that these women often protectively turned to each other for love. His artistic inspiration emerged from their intense intimacy. When Toulouse-Lautrec observed two women sleeping entwined on a couch, he pronounced: ‘This is superior to everything. Nothing can compare to something so simple.’

Being a lesbian most often involves both romantic feelings and sexual attraction toward other women. Today the prevalence of female and male homosexuals plus bisexuals is estimated by the Stonewall organization to be between 5–7% among people in the United Kingdom. One crucial research observation of homosexual people relating to mental health seems to be whether they can openly stand for their homosexual identity or not. The identity process of ‘coming out’ is associated with healthier self-acceptance and self-esteem.

Richard von Krafft-Ebing considered homosexuality as pathological. In his book Psychopathia Sexualis (Krafft-Ebing 1886) homosexuality was registered as one of over 200 other sexual deviances. He postulated that this pathological phenomenon either emanated from birth or was acquired from the environment.

Sigmund Freud (1905) in a controversial book postulated that humans at birth are ‘polymorphous perverse’. Freud adopted a more accepting stance of diverse sexuality and did not regard this as immoral; on the contrary, he considered the infant was naturally open to all kinds of sexual orientations before her actual sexual orientation was formed by the resolution of the Oedipal complex occurring around the age of three to five years. In the ‘negative’ Oedipal complex (Freud 1924), where the child becomes homosexual, the child does not identify herself with the mother. The girl first tries to identify with her mother but abandons her search and turns towards her father. During this frustrating loss of female identification she experiences a ‘penis envy’ and incorporates the father’s gender identity and later turns her ‘masculine’ identity and love to the mother or other women.

Freud thought homosexuality should not be assessed as a form of pathology. In 1935 Freud wrote a letter to an American mother (Jones 1957, pp. 208–9):

Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness; we consider it to be a variation of the sexual function produced by a certain arrest of sexual development. Many highly respectable individuals of ancient and modern times have been homosexuals, several of the greatest men among them (Plato, Michelangelo, Leonardo da Vinci, etceteras). It is a great injustice to persecute homosexuality as a crime, and cruelty too …

If [your son] is unhappy, neurotic, torn by conflicts, inhibited in his social life, analysis may bring him harmony, peace of mind, full efficiency whether he remains a homosexual or not …

Although Freud was open-minded in efforts to investigate homosexuality, his theory has been criticized (Burch 1993) to be too one-dimensional, with an emphasis on masculinity, a unitary form of gender identity. It is not solely an over-identification with the ‘masculinity’ for the little girl, although many lesbians are considered as ‘tomboys’. Burch (1993) discusses that gender identity in human beings (both males and females, heterosexual and homosexual) might be fluid, more multifaceted, on a continuum from more or less masculinity to more or less femininity. Over time an individual may develop various dominating gender identity role patterns either in fantasy or in reality. According to Winnicott’s (1971) ‘potential space’ this fluidity might be understood as a psychological predicament for creativity and psychic expansiveness. This psychic play and reality within the lesbian personalities and between their relationships might turn to an enlarged sense of what is feminine.

Outcome from recent research (American Psychiatric Association 2000) has opposed earlier findings that sexual orientation would be innate and fixed. It suggests a maturational process across an individual’s lifetime. By 1973, empirical research had accumulated unmistakably that the American Psychiatric Association removed the diagnosis of homosexuality as a mental disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, homosexuals are still a focus of mental health research because they tend to be more vulnerable as compared to heterosexuals. One crucial parameter seems to be antigay attitudes, which undoubtedly affects homosexuals’ regulation of self-esteem. Even though research on lesbians started intensely in the late 1980s, there are still limitations in most of the studies. Outcome studies from empirical research have carefully investigated certain mental phenomena and accumulated a database supported by several studies in each phenomenon. The different phenomena are summarized in the following sections.

The essential research of lesbianism and mental health is the prevalence of depression. It is up to several times higher in lesbians compared to women in general (Cochran 2001; Matthews et al. 2002). Lesbians have a higher prevalence of depression as compared to gay men and bisexual people. On the other hand, the two latter groups have other significant mental problems (e.g. anxiety) that lesbians do not experience as much.

Except for the uni- or bipolar manic–depressive mood disorders, which are partly genetic, depression exists on a psychological continuum, from mild to moderate depression, ultimately to severe melancholia. Important parameters are often seen in clinical work. For instance, a woman thinks: ‘people will welcome my lesbianism and I will try to come out’, in combination with not having worked through her gender identity enough. This constellation might lead to depression; firstly there is frustration, which to a certain degree results in aggression. Aggression that has no adequate channels might escalate to ‘intro-aggression’, i.e. the aggression turns inwards, which is typical for depression.

Gilman et al. (2001) investigated the probability of mental disorders in homosexuals. They used the representative household survey data from the National Comorbidity Survey. A total of 2.1% of men were homosexuals and 1.5% of women were lesbians. The DSM-III-R (American Psychiatric Association 1987) was applied to assess criteria for psychiatric disorders. The homosexuals experienced more prevalence of anxiety, mood difficulties, different substance use disorders, and suicidal thoughts, than compared to heterosexuals.

Cochran et al. (2007) found evidence that homosexuals experience elevated risk of mental health; the percentage of persons interviewed and assessed as homosexuals was about 4.8%. Lesbians and bisexual females had an increase of depressive disorders as compared to heterosexual females. This correlation was not found between gay men and heterosexual men.

There are several empirical studies showing that lesbians abuse drugs, like marijuana, tobacco, inhalants, cocaine, and analgesics more than the comparison groups of heterosexual women (Gilman et al. 2001; Cochran et al. 2004, 2007). A greater amount of studies show an increased significance of lesbians suffering from alcohol abuse or dependency in comparison to females in general. Female drug abusers report themselves more often as lesbians compared to women in general. Drug abuse and lesbianism constitute a phenomenon that ought to be more researched, while studies in problematic drinking are more prevalent.

In 1994, one national study in the United Kingdom, called the ‘Project of LSD’ (cited in Mullen 1998), embraced a sample of 287 persons at a Gay Pride festival. Fifty-six per cent were homosexual men and females and 8% were bisexual. Interesting results were documented as shown in Table 6.1.

It is clear in this study that lesbians suffer from using a broad range of substances, especially alcohol, tobacco, cannabis, and tranquilizers, as shown in many other research studies (e.g. Bux 1996). Fifty-two per cent of these substance users utilized two or more drugs during the same period.

In the United States, Cochran and coworkers (2004) investigated whether there were any differences in drug abuse or drug dependency between homosexuals and heterosexuals. From a sample of 194 homosexuals (98 men and 96 females) and 9714 heterosexuals (3922 men, 5792 women) they applied a cross-sectional national household interview investigation. The results showed consistent elevated drug abuse in homosexuals compared to the control group. Lesbians fulfilled criteria for both dysfunctional use and dependency of marijuana and analgesics.

In a Swedish study, Bergmark (1999) investigated the drinking patterns among Swedish homosexual men and

lesbians (n=1720) as compared to two nationally representative survey groups. She documented that alcohol constituted an important ‘core’ in the community of lesbians and gays. Furthermore it was shown that lesbians had higher-risk behaviour of alcohol level and addiction consequences. Lesbians were seldom abstainers and unfortunately the alcohol consumption did not decrease with aging, as it does in the general population.

Boehmer and colleagues conducted a recently published study (2007) examining whether lesbians suffer from a higher weight or obesity than women with other sexual orientations. Population estimates, from The National Survey of Family Growth (2002), of obesity across different groups of sexual orientation in 6000 women were compared. The statistical analysis resulted in lesbians having double the risk of both overweight and obesity compared to heterosexual women. Interestingly, bisexual women and those who were assessed as ‘something else’, i.e. besides heterosexual, lesbian, or bisexual women, did not show any risks of either being overweight or obese.

This up-to-date study confirms what previous research (e.g. Aaron et al. 2001) has indicated, i.e. lesbians do have higher risks of eating disorders that affect mental health. The consequences lead to morbidity—coronary heart disease, stroke, diabetes and certain forms of cancers. Ultimately mortality increases in lesbians as a secondary phenomenon to obesity.

The mental phenomenon of violence in lesbian relationships challenges stereotypes of traditional women as related to non-domestic violence. Fortunata and Kohn (2003) investigated psychosocial characteristics and personality traits of lesbian batterers and factors connected with domestic violence in lesbian relationships. The subjects in this study consisted of 100 lesbians in current relationships, where 33 were assessed as batterers and 67 non-batterers. The lesbian batterers reported experiences of sexual abuse, childhood physical abuse, and greater risks of alcohol abuse. Batterers were assessed as having personality traits of being aggressive, antisocial, borderline, and paranoid. They also showed more alcohol-dependency, drug-dependency, and delusional clinical symptoms compared to non-batterers.

To comprehend the various forms of violence in lesbian relationships, especially the batterers, Coleman (1994) emphasized an understanding from a multidimensional theory of partner abuse; crucially, it must build upon individual personality dynamics. The psychodynamics in this article were related to the borderline and narcissistic personality disorders. In relation to drugs and alcohol these disorders and also similar traits as Fortunata and Kohn (2003) discovered, irrespective of lesbianism, homosexuality, or heterosexuality, are always connected to difficulties in handling aggressive affects (Aleman 2007). However, in the empirical research field of lesbianism and mental health, there should be several more such studies conducted before pointing to the prevalence of borderline and narcissistic personality disorders in lesbians and particularly the batterers.

Another form of experiencing violence is witnessing violence and perpetrating violence against others. Russell et al. (2001) examined hate crimes committed against lesbians, gay, and bisexual youths compared to heterosexual youths. They applied representative data from the National Longitudinal Study of Adolescent Health. Lesbian (and gay men plus bisexual) youths did experience extreme forms of violence compared to heterosexual youths. The same groups of youths also reported experiences of witnessing violence. These findings provide strong evidence that lesbian youths have to handle very complex situations and affects that certainly influence their mental states of mind.

During adolescence, lesbians (and gay men plus bisexual persons) attempt suicide up to six times more than heterosexuals. Lesbians’ vulnerability to depression, substance abuse, and experience of violence are known risk factors for attempted and completed suicide. Historically, research about gay men and suicide has been far more studied than in lesbians. Still, it seems probable that there are greater attempts of suicide among young lesbians, because young gay men, who ‘come out’ with their gender identity are consistently more prevalent, as compared to young lesbians, who tend to come out later or never. Therefore, it is most possible that a major proportion of young lesbians who attempt suicide are disguised within the general numbers of young females who attempt suicide.

The highest prevalence of suicide is among lesbians who are isolated from help or support. Those who identify their sexuality early on, run a particularly high risk of attempted suicidal. Even young lesbians (and gays) who identify themselves as ‘tomboys’ (and ‘sissies’), i.e. developing an atypical gender stereotype, are more at suicidal risk.

Lesbians suffer far more from suicidal attempts, depression, and also from dependency on substances than heterosexual women and heterosexual men or homosexual men (Saghir and Robins 1973; Bell and Weinberg 1978; Lewis et al. 1982; Blume 1985; McKirnan and Peterson 1989; Schilit et al. 1990). In a recent published study (Silenzio et al. 2007), the authors analysed current data from the National Longitudinal Study of Adolescent Health. Again, results showed that lesbians (and gay men plus bisexuals) suffered from more suicidal ideation and suicide attempts as compared to heterosexual respondents.

Lesbians (and gay men plus bisexuals) have greater prevalence of deliberate self-harm and say that physical harm gives them a sense of relief. Lesbians and gay men are more likely than bisexuals to refer to their gender identity as a reason for harming themselves. Empirical research suggests that self-harm might be connected to difficulties in being out in society (King and McKeown 2003) or having experienced rejection from other people. Self-harm is associated with low self-esteem and high anxiety. A greater number of homophobic incidents are reported among self-harming lesbians as compared to those without a history of self-harm. Bisexual people are reported having higher prevalence of self-harm than either lesbians or gay men (Bennett 2004).

In general, among people who are homosexual or bisexual, being the victim of a homophobic incident is commonly reported. Female homosexuals more commonly report verbal abuse, while male homosexuals more likely report experience of physical assault. Hate crimes have a serious effect on the quality of life of victims—many of them alter their behaviour in public spaces by not openly displaying affection. One study in the United Kingdom conducted by Wake et al. (1999) found that 82% of all incidents are not reported.

Empirical studies use many different definitions of lesbianism as lesbianism, i.e. from people who solely fantasize about it to those who act it out, making it difficult to make meaningful comparisons. Lesbianism is often assessed as both behavioural, i.e. desire or attraction, and cognitive, i.e. sense of identity. Lesbians therefore constitute subgroups of females whose mental health and risk behaviours have not been well researched. Interestingly, lesbians are found among all subpopulations of females and are represented in all socioeconomic strata, and all ages in ethnic and racial groups. There is no clear assessment of demographic category characteristics and neither a clear lesbian single type of family, community, or culture. Since the view of sexual identity and sexual behaviour varies with culture, race and ethnicity, assessment of lesbianism must take these factors into account.

Generally, the majority of lesbian, gay, and bisexual people together do not experience mental health problems, although research suggests that lesbians are at higher risk of mental disorder (particularly depression), suicidal behaviour, substance abuse, eating disorders, and experiencing violence. Returning to the concept of the borderline syndrome (and narcissism) that is not yet documented in lesbians from several empirical studies, in fact, all aforementioned psychological phenomena usually occur in one or other way in the borderline syndrome. Within this syndrome one might say that individuals do not solely abuse substances but also food or intimate emotions because of their primary identity diffusion (Kernberg 1975). However, evidence indicates that the increased risk of mental disorder in lesbians is linked to experiences of discrimination (Mays and Cochran 2001). They are more likely to report both daily and lifetime discrimination than heterosexual people. Lesbians more commonly experience verbal and physical intimidation than heterosexual women (King and McKeown 2003). Antigay stigma has been linked to an increase in deliberate self-harm in lesbians.

It should be recognized that mental distress can be caused by many factors unconnected with sexuality. Homosexual people do face particular psychological pressures living in a discriminatory and heterosexist society. Furthermore internalized homophobia, with associated feelings of low self-esteem and self-hatred, can lead to emotional distress. Being homosexual is not in itself a mental health problem, but coping with the consequences of discrimination can be highly detrimental to lesbian mental health. A Health Education Authority mental health promotion on ‘sexual identity’ states that: ‘some studies have suggested that internalized homophobia is a risk factor for alcohol and drug dependency. Anxiety, depression, self-harm, suicide and attempted suicide have all been linked with the combined effects of the experience of prejudice and discrimination and internalized negative feelings’. A Department of Health leaflet states that those at increased risk of suicide include people ‘whose sexual orientation brings them into conflict with their family or others’.

There is a real problem of awareness of alcohol and drug misuse in lesbians. The following description of the United States in the 1970s (O’Donnell et al. 1978) could be written of the United Kingdom in 2002:

One in every three gay persons abuses alcohol and is either an alcoholic or is rapidly heading towards that destination. This is more than three times the estimate of problem drinkers in the general population. Alcoholism is not talked about very much in the lesbian community. Some of us think we don’t know anyone who drinks heavily. But most of us do know women who drink heavily—we just do not recognize the extent of the problem.

The difference between the United States and the United Kingdom is that the former has been discussing and debating alcohol use and recovery for several decades to the extent where now there are many lesbian and gay Alcoholics Anonymous (AA) groups and ‘clean and sober’ social events, which provide some of the social functions previously provided by the lesbian/gay bar subculture. This is not the case in the United Kingdom. Reasons suggested for this include the problems of dealing with societal oppression, using alcohol and drugs as a means of coping with depression, and the pivotal role of ‘bar culture’ in homosexual social networks.

Lesbians (gay men and bisexuals) use mental health services more frequently than their heterosexual counterparts. Over 40% of lesbians reported negative or mixed reactions from mental health professionals when they disclosed their sexual orientation. One in five lesbians and gay men and a third of bisexual men stated that a mental health professional made a causal link between their sexual orientation and their mental health problem (King and McKeown 2003). Lesbians reported not being confident about accessing mental health services (Mitchell et al. 2001). Reports of problems are observed in their encounters with mental health professionals, ranging from lack of empathy about sexual orientation to incidents of homophobia. There are acknowledged difficulties for mental health professionals in getting the balance right.

Morris et al. (2001) documented that ‘coming out’ with gender identity is evidently beneficial to mental health. Self-esteem is associated with good mental health. Lesbians (and gay men) were more confident with their sexual identity and more likely to have parents and siblings to whom they had disclosed their sexual identity than their bisexual counterparts. Lesbians were more likely to communicate that their sexual orientation was important to their identity than heterosexual women (Bennett 2004).

It seems that lesbians (gay men and bisexuals) are overlooked in mental health policy making. Lesbians are at increased risk of both attempted and completed suicide. Despite this, their needs have not been addressed in the series of Annual Reports from National Suicide Prevention Strategy for England. Current government policy focuses on the importance of choice in mental health services. However, there is not much available information on appropriate service provision which could give lesbians’ choice. A report documented by the mental health charity of homosexuals and bisexuals, PACE, listed several recommendations for including these people in the National Service Framework for Mental Health (McFarlane 1998). These involved promoting mental health for homosexuals and bisexuals in public exposures and positive imagery, preventing suicide, improvements of contact with services, and ensuring needs are addressed within the Care Programme Approach.