Homosexuality, as a specific category, was not described in the medical or psychiatric literature until the early 1870s. The fledgling psychoanalytic movement regarded homosexuality as a topic of special interest. Sigmund Freud believed a person’s sexual orientation, in and of itself, did not impair his or her judgment or cause problems, and Freud set a positive tone when he supported homosexual colleagues in medical and psychiatric societies. Even so, European psychoanalytic organizations did not welcome gay men and lesbians as members in the early years of psychiatry, and many American psychiatrists and psychoanalysts promoted the attitude that homosexuality was a mental disorder. Bieber and colleagues (1962) proposed that childhood influences and family upbringing were responsible for producing male homosexuality and described the classic combination of a distant, uninvolved father and an overinvolved mother. They did not consider biology or genetics as playing a role. Other psychoanalytic writing also refuted a biological component to female homosexuality, seeing it as caused primarily by early developmental disturbances. Alfred Kinsey introduced new perspectives on homosexuality with his studies of sexual behavior (Kinsey, Pomeron & Martin, 1948; Kinsey et al., 1953). Although his studies have been criticized for a variety of reasons, such as poor sampling methods, the studies greatly increased Americans’ awareness of sexuality and the range of sexual behavior. The psychologist Evelyn Hooker (1957) demonstrated that no discernible differences existed between the psychological profiles of gay men and those of heterosexual men, effectively beginning the debunking of the theory that homosexuality is a mental illness. Psychiatrist Judd Marmor (1980) recognized that homosexuality could not be explained in a single dimension and helped support exploring the biological, genetic, psychological, familial, and social factors involved in the formation and expression of a homosexual orientation. In 1973, the American Psychiatric Association, after extensive scientific review and debate, stopped classifying homosexuality as a mental illness. Homosexuality is now seen as a normal variation of human sexual and emotional expression, allowing, it is hoped, a nonpathological and nonprejudicial view of homosexuality as well as of LGBT people. LGBT people and homosexual and bisexual behavior are found in almost all societies and cultures in the world and throughout history (Herdt, 1996). But the degree of tolerance and acceptance of them has varied considerably in different periods of history and from country to country, culture to culture, and community to community. Anthropological studies that have observed homosexual behavior in other cultures may help put homosexuality in global perspective and may contribute to understanding some of the issues facing American LGBT individuals who are from ethnic or cultural minority groups, such as African Americans (Jones & Hill, 1996), Asian Americans (Nakajima, Chan & Lee, 1996), Latinos/ Latinas/Hispanics (Gonzalez & Espin, 1996), and Native Americans (Tafoya, 1996). The genetic and biological contributions to sexual orientation have been studied increasingly in recent years. Unfortunately, the biological studies often grow out of the confusion between sexual orientation and gender identity. Many studies have tried to demonstrate that physical traits in gay men resemble those of women or have tried to identify traits in lesbians that resemble those of males. These views are based on the belief that, if a man wishes to be with a man, he must somehow be like a woman, and a woman wishing to be with a woman must, in some way, be like a man. The Kinsey Institute has supported surveys and studies of both sexual behavior and sexual orientation and concluded that homosexuality must be innate, that is, inborn, and is not influenced developmentally by family upbringing (Bell & Weinberg, 1978; Bell, Weinberg & Hammersmith, 1981; Weinberg & Williams, 1974). The studies noted the diversity and variety of gay men and lesbians, recognizing that there was no uniform way to be or become gay or lesbian in our society. Lesbianism and female homosexuality have also been studied from a nonpathological perspective. Magee and Miller (1998) reviewed these efforts and found no psychodynamic etiologies to female homosexuality and that each lesbian is unique and without stereotypic characteristics. Studies of intersexual people, that is, people with sexually ambiguous genitalia or true hermaphrodites, are often analyzed. Hermaphrodites have both male and female reproductive organs. These studies ultimately are about gender role expectations and do not contribute to our understanding of homosexuality. The most promising areas of study involve genetics and familial patterns. Although the gene has not been identified, Hamer and Copeland (1994) have reported a linkage on the X chromosome that may influence homosexual orientation. The genetic and familial patterns studied by Pillard, Bailey, and Weinrich and their colleagues (Bailey et al., 1993; Bailey & Pillard, 1991; Pillard, 1996) have demonstrated the most consistent and verifiable data. Pillard found that gay men are much more likely to have gay or bisexual male siblings than heterosexual males—based on the incidence of homosexuality—but are not more likely to have lesbian sisters than are heterosexual males. Lesbians are more likely to have lesbian sisters but are not more likely to have gay brothers.

Combined with other twin and heritability studies, this research helps explain the probable genetic substrate of sexual orientation, with different genetic influences for male homosexuality, male heterosexuality, female homosexuality, female heterosexuality, and, possibly, bisexuality. Although the complex set of behaviors and feelings of homosexuality could not be explained by a single factor, a genetic basis seems to be the foundation on which other complex biological, familial, and societal influences work to shape the development and expression of sexual orientation (LeVay, 1996).

Perspectives on Bisexuality

Bisexuality has also existed throughout recorded history. Freud believed in innate bisexuality and that an individual evolves into a heterosexual or a homosexual, rarely a bisexual (Freud, 1963). Many bisexuals still find themselves contending with this lack of acknowledgment that a bisexual orientation can be an endpoint in itself and not just a step toward heterosexuality or homosexuality.

It is helpful for providers to know that the clinical issues facing bisexuals often are problems resulting from the difficulty of acknowledging and acting on a sexual orientation that is not accepted by the heterosexual majority but also not accepted by many gay men and lesbians.

Some people of color in the United States or people from different cultures may define themselves as bisexual, even if they focus exclusively on people of the same sex (Gonzalez & Espin, 1996). This perspective may be their way of coping with the stigma of homosexuality. Reviews that discuss theory and clinical issues include those by Weinberg, Williams, and Pryor (1994); Klein and Wolfe (1985); and Fox (1996).