Factors Associated With the Outcome of Psychoanalysis of Homosexual Patients

Houston MacIntosh, M.D.

This study examines the response of 287 psychoanalysts to a survey regarding their work in psychoanalysis with 1222 homosexual patients. It is a continuation of a previous study of attitudes and experiences of psychoanalysts in analyzing homosexual patients (MacIntosh, 1994). In that paper I reported the results of psychoanalysts' opinions regarding whether a homosexual patient in analysis, for whatever reason, can and should change to heterosexuality. I further made a statistical comparison of those analysts who had changed their minds in the last 10 years versus those who had not, and of those analysts who believe most of their colleagues think a homosexual patient can and should change to heterosexuality versus those analysts who do not hold such an opinion of their colleagues.

In this paper I will focus on other analyst variables as they relate to the outcome of psychoanalysis with homosexual patients in regards to reported change to heterosexuality and receiving of significant therapeutic benefit.

Method

A questionnaire (Appendix 1) and cover letter (Appendix 2) were sent to 400 graduate analysts and 22 advanced candidates in various parts of the country. The sample consisted of all members of the Washington Psychoanalytic Society (39%) who practice in Washington, D.C. and its Maryland suburbs. The remainder of the sample was drawn from equal size groups from the rest of the Northeast, South, Midwest, and Far West. This second group was chosen from the roster of the American Psychoanalytic Association in a semi-random manner which gave greater emphasis to analysts who have published, who have a national reputation, and who are female. The sampling method has been described in greater detail elsewhere (Maclntosh, 1994).

The database was divided into male and female patients. A regression analysis of this data was done for both male and female patients in which reported change to heterosexuality and having received significant therapeutic benefit were treated as dependent variables. The independent variables were the analyst's expectation that a homosexual patient in analysis may be able to change to heterosexuality, years since graduation, status, number of homosexual patients analyzed, and average length of analysis per patient. When change to heterosexuality was the dependent variable, receiving of significant therapeutic benefit was included as an independent variable and vice versa. ("Significant therapeutic benefit" in this context refers to "substantial" or "meaningful," not statistical.) The database was also subdivided into male patients of male analysts, female patients of male analysts, male patients of female analysts, and female patients of female analysts. For these subdivided groups, a regression analysis was done using length of analysis as the dependent variable.

Charts were also constructed to demonstrate patterns and trends which might otherwise not be noticed.

In order to perform statistical tests, some variables were translated into numbers. Thus, those analysts who expect a homosexual patient will never change to heterosexuality in analysis were represented by a # 1; those who expect this happens rarely by a #2, sometimes by a #3, and frequently by a #4. Similarly, in regards to status, #1 represented a candidate, #2 represented a non-certified graduate, #3 represented a certified graduate, and #4 represented a training analyst. Regarding analyst gender, #1 represented male and #0 represented female. Candidates were arbitrarily assigned a minus two years since graduation. Non-numerical responses were excluded from statistical analysis. Records which lacked complete numerical data for each variable were excluded from regression analysis.

Results

Two additional questionnaires were received after the previous report (MacIntosh, 1994) was written and were included in the database of the present study (they in no way significantly changed the statistical results of the first study).

Two hundred eighty-seven psychoanalysts reported their work with 1222 patients (828 male and 394 female). Overall, 23 percent of patients were reported to change to- heterosexuality (male 24 percent, female 20 percent) and 84 percent received significant therapeutic benefit (male 85 percent, female 81 percent).

Thirty-nine percent of the respondents were from the Washington, D.C. area, and 15 percent each from the rest of the Northeast, South, Midwest, and far West respectively. Fifteen identified themselves as candidates, 78 as non-certified graduates, 76 as certified graduates, and 116 as training analysts. Two believed that a homosexual patient in psychoanalysis can never change to a heterosexual orientation, 81 rarely, 180 sometimes, 12 frequently, and I I had no opinion. Two hundred nineteen were men and 67 were women.

Change to heterosexuality was strongly associated with both the analyst's expectation of change and reported significant therapeutic benefit for both male patients (Table 1) and female patients (Table 2). The expectation factor was stronger for male patients (p=<.0001) than for female patients (p=.001). Association with significant therapeutic benefit was similar for both male and female patients.

Table 2
Female Patients Change to Heterosexuality

Significant therapeutic benefit was strongly associated for male patients (Table 3) with length of analysis and change to heterosexuality. Significant therapeutic benefit for female patients (Table 4) was less associated with length of analysis, but level of association with change to heterosexuality was similar for both male and female patients. For female patients analyst gender was an important variable relating to therapeutic benefit.

Table 3
Male Patients Significant Therapeutic Benefit

Table 4
Female Patients Significant Therapeutic Benefit

Selected variables relating to analyst gender are compared in Table 5. Male and female analysts have a similar number of female patients, but male analysts have significantly more male patients (4.35 patients vs. 1.84 patients). Male and female analysts analyze male patients a similar length of time (4.03 years vs. 4.22 years), but female analysts analyze female patients longer than male analysts analyze female patients (5.20 years vs. 3.83 years). Male and female analysts report a similar rate of significant therapeutic benefit for male patients (86 percent vs. 93 percent), but female analysts report a significantly higher rate of therapeutic benefit for female patients than do male analysts (95 percent vs. 79 percent).

Table 5
Analyst Gender

For male analysts, the length of analysis was strongly associated with significant therapeutic benefit and the analyst's expectation of change. This was true for both male (Table 6) and female (Table 7) patients. On the other hand, with female analysts, no variable was associated with length of analysis for both male and female patients.

Table 6
Length of Analysis
Male Analyst / Male Patients

Male analysts in this study were longer graduated (20.81 years) compared to female analysts (9.80 years) and of higher average status (3.13 vs. 2.61).

Chart 1 describes the distribution of analysts reporting on change to heterosexuality.

Chart 2 describes the distribution of length of analysis.

Chart 3 compares length of analysis with change to heterosexuality.

Chart 4 describes the distribution of analysts reporting significant therapeutic benefit.

Chart 5 compares significant therapeutic benefit to length of analysis.

Chart 6 describes the number of patients changed to heterosexuality per analyst.

Chart 7 describes the number of patients per analyst.

Discussion

Overall, 23 percent of patients (male percent 24 and female 20 percent) in analysis were reported to have changed to heterosexuality. These results are comparable to an informal unpublished 1956 report of members of the American Psychoanalytic Association: Of 32 homosexual patients who completed analysis, eight or 25 percent were reported to have changed to heterosexuality (Socarides, 1978). Bieber et al., reported on 106 male homosexual patients in analysis, of whom 27 percent changed to heterosexuality. Socarides (1978, pp. 404-406) reported that from 1967 to 1977 he treated 45 homosexual patients (44 male, one female) in psychoanalytic therapy all of whom were "strongly motivated for therapy." Twenty patients or 44 percent "developed full heterosexual functioning, and were able to develop love feelings for their heterosexual partners." He has further reported (Socarides, 1994) that from 1977 to 1993 he has treated over 50 homosexual patients with similar results.

Siegel (1988) described, in considerable detail, her psychoanalytic work with 12 female homosexual patients: "The analyses on the whole reached satisfactory conclusions. As conflicts were resolved and distanced from, anxiety was reduced and life became more joyful and productive for all these analysands. With the attaininent of firmer inner structures, interpersonal relationships also solidified and became more permanent. Although I never interpreted homosexuality as an illness, more than half of the women became fully heterosexual" (pp. xi-xii).

These results contrast with the views of Isay (1985, 1989, 1992a, 1992b, 1993), who has written and lectured widely on male homosexuality and has described his experience as a gay psychoanalyst (Isay, 1991). He believes that "traditionally trained" psychoanalysts cannot be helpful to homosexual patients and may, in fact, harm them (Isay, 1985, 1992a, pp.3-17,1992b). He has further stated (Isay, 1993) that since the conclusion of his analysis in 1972, he has not believed homosexuality can be changed. Isay supports his views with anecdotal data based on his personal experience.

Although contemporary psychoanalysts do not expect their homosexual patients to change to heterosexuality (Maclntosh, 1994), most believe a homosexual patient in analysis may be able to change to heterosexuality sometimes (62 percent) or frequently (four percent). This is the case even though psychoanalysts as a group have had relatively modest experience working with homosexual patients in psychoanalysis. Of course, experience derived from consultations, psychotherapies, and supervisions may contribute to forming opinions, but those data were not part of this survey. A majority of analysts (53 percent) report they have not worked in analysis with a homosexual patient who changed to heterosexuality. Seventy-one percent have never had a male patient change to heterosexuality and 82 percent have never had a female patient change to heterosexuality. Twentythree percent have never worked with a male patient in analysis. Forty-four percent have never worked with a female patient in analysis. Eighteen percent have never worked with a homosexual patient in analysis at all. Only ten percent had more than one male patient change to heterosexuality, and only five percent had more than one female patient change (Charts 6 & 7). Given this relative lack of experience with patients who have changed, it is not surprising that only four percent of analysts believe that homosexual patients frequently may be able, through psychoanalysis, to change to heterosexuality.

The most important variable associated with greater reported change to heterosexuality is the analyst's expectation that such change will occur. Although this expectation could be based on actual experience in working with patients, it seems likely other factors are also important. Those factors do not appear to be years since graduation, status, or gender (although male analysts do seem to have a stronger expectation). It is also possible this expectation could influence actual or reported results. Nevertheless, I think it is likely the most important factor in forming a psychoanalyst's belief that he or she can be helpful to a homosexual patient, or that a homosexual patient in analysis may be able to change to heterosexuality, is shaped by the analyst's personal experience, both as an analysand and in analyzing homosexual patients. This personal experience factor has been described by Siegel (1988, p. xiii), "Some assert that homosexuality needs to be 'normalized,' a view I myself held for some years until the patients described in this book taught me otherwise ... I have never met a homosexual person, either male or female, who did not appear internally driven toward homosexuality. Most often the homosexuality is ego-syntonic, but so are many other symptoms. It is during analytic investigation that the patient, not the analyst, decides what is 'good' for him or her and what he or she wishes to change, what to retain."

The relative inexperience of many analysts in actually having worked with a homosexual patient who changed to heterosexuality could possibly make such analysts more subject to personal biases, as well as more susceptible to influences from popular and professional media (Isay, 1992a) which declare that homosexuality is unchangeable, or which emphasize the biologic origin of homosexuality and its equivalent nonnality with heterosexuality (Friedman & Downey, 1993). There is some suggestion that such an influence may be occurring (Maclntosh, 1994).

A greater expectation of change to heterosexuality could lead some analysts to analyze their patients longer. The data of this survey are insufficient to forin a firm conclusion whether increasing the length of analysis beyond eight or nine years increases the probability of an analysand's changing to heterosexuality. Although such a trend may be seen in Chart 3, it should be interpreted cautiously, as only 16 percent of male patients and 22 percent of female patients, and two percent of male patients and three percent of female patients, were treated longer than five and seven years, respectively. Furthermore, the regression analysis shows that change to heterosexuality is not related to length of analysis. This is an area where we need more data. Overall, 84 percent of analysts reported their patients received significant therapeutic benefit (85 percent for male patients and 81 percent for female patients).

Although increasing the length of analysis may have an uncertain effect on a patient's changing to heterosexuality, it is certainly justified for therapeutic reasons. Increasing length of analysis is strongly associated with reported significant therapeutic benefit (Chart 5, ). This is consistent with other psychoanalytic outcome studies (Bachrach, et al., 199 1). Reported significant benefit increases steadily, reaching a 90 percent average at five years, and 100 percent at eight to nine years. This should not be construed to mean maximal therapeutic benefit is reached after eight to nine years of analysis, only that 100 percent of patients analyzed this long received significant therapeutic benefit. Longer analysis may, indeed, provide even greater benefit.

Male analysts who analyze their patients longer, have a greater expectation that a patient may be able to change to heterosexuality through analysis. Thus, having such a belief may in some cases, indirectly contribute to a greater degree of therapeutic benefit if it increases the length of analysis, even though a change to heterosexuality may not result. However, since in this database the analyst's expectation of change to heterosexuality is not directly related to the degree of reported therapeutic benefit, a possible irony could develop. If for the reasons mentioned above, an analyst's expectation that change to heterosexuality may be possible, decreases, this could lead to shorter analyses and consequently, to diminished therapeutic benefits.

A greater length of analysis is associated with a higher analyst status, but not significantly. Higher status in itself is not associated with higher reported benefit rates. One possible explanation could be that higher status analysts are more conservative in assessing benefit, or it could mean that status is simply not that important in the ability to provide therapeutic benefit to patients.

A further caution should be mentioned when interpreting data regarding length of analysis. This data reflects the average experience of psychoanalysts for various lengths of time, up to over 40 years. Longer periods of analysis may be indicated and beneficial for many patients based on individual circumstances. Contemporary psychoanalysts appear to be analyzing patients longer than they have in the past, frequently leading to enhanced patient benefit (Abend, 1992). More research is needed in this area.

Change to heterosexuality is strongly associated with receiving significant therapeutic benefit and vice versa. Such an association may reflect a judgment on the analyst's part that a change to heterosexuality reflects therapeutic benefit or that a change to heterosexuality may be just one factor in a total package of improved functioning. Neither possibility is, of course, mutually exclusive. It is also important to note that nearly two thirds of the patients (61.4 percent) who did not change to heterosexuality, nevertheless received significant therapeutic benefit by report of their analysts.

Analyst experience does not seem to be an important factor relating to outcome, at least in regards to years since graduation or status. One exception is for female analysts analyzing male patients, where longer years since graduation may be related (p = .06, by regression analysis) to change to heterosexuality. This could also indicate that younger female analysts have a different style or perspective in working with male homosexual patients, which results in fewer changing to heterosexuality.

There also is some suggestion that for male patients, a greater number of patients is associated with a greater degree of reported benefit (but not reported change to heterosexuality). Although the regression analysis does not demonstrate this, it can be seen when comparing analysts who report more than 50 percent of their male patients having received significant therapeutic benefit with those who have reported 50 percent or less of their male patients having received such benefit. The greater than 50 percent group has an average of 4.0 patients, and the 50 percent or less group has an average of 2.6 patients (p = .05, two-tail t - test)). On the other hand, this difference with female patients is not observed (2.0 patients and 2.6 patients, p = .20). Although one might intuitively expect that greater experience and working with a particular type of patient would lead to greater therapeutic success, such an expectation should be guarded. More research would be useful.

An interesting and complex relationship to therapeutic outcome relates to the analyst's gender. Female analysts report a significantly higher rate of significant therapeutic benefit for their female patients than male analysts report for their female patients (95 percent vs. 79 percent). The difference in benefit rate for male patients, however, is not significant (93 percent vs. 86 percent.) Bieber (1962) also noted similar outcome results for male and female analysts with male patients.

Are the differences in reported received benefit due to analyst gender or are other factors at work? The female analysts in this database are younger than male analysts (20.81 years vs. 9.80 years since graduation). This difference is probably a reflection of the changing demographics of psychoanalysts (Brauer, 1992). However it could also mean that more experienced analysts are more conservative in assessing therapeutic change, or it could mean that younger analysts are more effective therapeutically with female patients. When male and female analysts who have graduated more than ten years are compared, similar differences regarding female patients remain, and the female analysts have still graduated more recently (25.48 years vs. 19.04 years). This difference is probably not meaningful. In addition, regression analysis of the measured variables indicates that no variable associated with therapeutic benefit is significant for female analysts working with female patients. On the other hand, two variables are significant for male analysts. The first is the statistical association between reported benefit and reported change to heterosexuality. It is possible that female analysts are somewhat more relaxed about whether or not their female patients change to heterosexuality which could possibly give them an edge over male analysts. The second variable is length of analysis. As female analysts report nearly all of their female patients receive significant benefit, it means that they also analyze almost all of them longer.

Thus, the reason for the higher benefit rates reported by female analysts, most likely, is that they analyze their female patients longer than do male analysts. The difference (3.83 years vs. 5.20 years) is significant. When male and female analysts who analyze their female patients the same length of time are compared, female analysts still report somewhat higher benefit rates. However, the small numbers of female analysts in this group make statistical comparisons of the results unreliable. Thus, length of analysis is probably the most important variable, but female analysts may still, on average, be slightly more skillful with female homosexual patients than are male analysts. A larger statistical sample would help clarify this question.

Another question: What factors in the transference/countertransference interaction lead female analysts to analyze their female patients longer, but not their male patients? Freud (1920) was concerned that he could not successfully analyze his female patient because of the intensity of negative paternal transference. Accordingly, he stopped the analysis and recommended a transfer to a female analyst. In a more contemporary formulation, some analysts (Jacobs, 1990; Siegel, 1988, 1991) have suggested that because of traumatic experiences in early relations with her mother a woman who is homosexual has been unable to identify with her mother's femininity and femaleness. Through a benign psychoanalytic process which includes patient/analyst interactions (Dorpat, 1988, 1990), the patient may be able to identify with her analyst's femaleness, and thus repair her own female identity. This process requires time, and perhaps the female analyst senses this, resulting in the non-nal course of an analysis with a female homosexual patient becoming longer for a female analyst, than it is for a male analyst. This is not to say that a skillful male analyst can not be helpful to a female patient. These differences are statistical and not terribly large. More research is needed to clarify whether this is a general phenomenon or just limited to homosexual patients.

A further interesting finding in these data concern the relative case loads of male and female patients as related to analyst gender. Male analysts have more male patients than do female analysts (4-35 patients vs. 1.84 patients). On the other hand, the average number of female patients is similar (2.63 vs. 2.3 1). These data are consistent with the findings of Mayer and de Maineffe (1992) which indicate a male patient is more likely to be referred to a male analyst. A similar difference in case loads is also seen if only male and female analysts, who have graduated more than ten years, are compared. Thus, the difference is not explained by the male analysts having been in practice a longer time.

In the results of regression analysis, years since graduation, status, and number of patients are not significantly related to outcome. Male analysts have analyzed significantly more male patients than have female analysts, yet the outcomes are similar. The female analysts who reported significantly higher benefit rates for their female patients had less experience than their male counterparts (20.81 years vs. 9.80 years since graduation). Although experience may have some importance, length of treatment seems to carry more weight.

There are limitations with this data. It is based on the judgment and memory of the treating analysts. There is extremely limited and only anecdotal follow-up. There are neither reports from patients themselves nor from third party evaluators. There are also problems associated with defining the terms being studied here: homosexuality, heterosexuality, change in sexual orientation, and significant therapeutic benefit. I have assumed that although there may be some degree of general agreement, every psychoanalyst probably has his or her own unique operational definition of these terms. Given a sufficient number of responses, differences will average out, and a psychoanalytic consensus will emerge. Although more observations (particularly with female analysts) might clarify some of the questions raised here, nevertheless, I believe the observations of 287 psychoanalysts over many years deserve serious consideration.

Summary

In a survey of 422 psychoanalysts, 287 or 68 percent of those surveyed responded, reporting data regarding their experience analyzing 1222 homosexual patients. These psychoanalysts reported 23 percent of their patients changed to heterosexuality and 84 percent received significant therapeutic benefit. The database was analyzed for both male and female patients in regard to eight analyst variables, in order to find out how such variables might relate to the outcome of analysis.

The most important variable associated with change to heterosexuality is the analyst's expectation such change will occur. The clearest and strongest factor associated with higher rates of significant therapeutic benefit is length of analysis. Longer analysis leads to greater therapeutic benefit. Nearly two-thirds of patients received significant therapeutic benefit without changing to heterosexuality. Further rates of change are associated with higher rates of benefit for both male and female patients. Analysts who analyze their patients longer have a greater expectation that change to heterosexuality is possible, but increasing length of analysis is not related to greater change to heterosexuality. Greater analyst experience sometimes may also be important. Female analysts report a higher benefit rate for female patients than do male analysts, but this is mostly accounted.

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