The Love That Dare Not Sing It's Name: Lesbian, Gay and Bisexual Issues in Music Therapy Training and Education

7/30/2019 The Love That Dare Not Sing It's Name: Lesbian, Gay and Bisexual Issues in Music Therapy Training and Education

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THE LOVE THAT DARE NOT SING ITS NAME:

AN EXPLORATIVE INVESTIGATION INTO THE STATUS

OF LESBIAN, GAY AND BISEXUAL ISSUES IN MUSIC

THERAPY TRAINING AND EDUCATION

TRABAJO DE INVESTIGACIN

MASTER UNIVERSITARIO

DE MUSICOTERAPIA

Autor: Bill Thomas Ahessy

Fecha 28 Septiembre 2007

Facultad de Ciencias de la Educacin

Puerto Real, Cdiz - Espaa


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II

Abstract

This thesis investigates the status of lesbian, gay and bisexual (LGB) issues and perspectivesin the field of music therapy. It is divided into three parts. First, a comprehensive review of

lesbian, gay and bisexual issues in the music therapy literature and the related disciplinesof psychology and psychotherapy; second, a global survey of music therapy programswhich assesses the provision of lesbian, gay and bisexual issues in music therapy education;and finally, a global survey of music therapy associations which assesses guidelines andopportunities for continuing professional education regarding LGB issues. The provision ofLGB issues for both music therapy programs and associations is examined using quantitativeand qualitative perspectives. Although the data from both surveys indicate that the musictherapy community considers LGB issues important they are largely overlooked in casereports, journal articles and the music therapy literature. LGB issues are relatively neglectedin music therapy curricula, education and professional development.

An analysis of the data supplied by the surveyed music therapy programs indicates thatthese issues are receiving more attention now than they were in former years in musictherapy programs. Nevertheless, LGB issues are under addressed, in comparison with othermulticultural topics. Although many respondents thought LGB issues an important componentof music therapy education, less than half specifically addressed LGB issues in their trainingprograms. The majority of music therapy directors agreed that university music therapyprograms were the place to best address LGB issues, and there was support to addressthese issues in continuing professional education too, with a majority of the respondentsindicating that guidelines or further training opportunities in LGB issues from the musictherapy associations would be professionally beneficial for music therapists.

Analysis of the data supplied by the surveyed music therapy associations, reveal that only 1association out of those surveyed provided guidelines and further training opportunities forits member music therapists. A majority of the respondents also thought that training in LGBissues at university level would professionally benefit practicing music therapists. Many ofthe music therapy associations were also aware of members working with LGB clients or inLGB clinical settings. This paper is an exploration of this relatively untapped area of musictherapy. A comprehensive literature review together with descriptive research byquestionnaire-based survey was used to achieve the aims of developing and broadeningour understanding of the status of LGB issues and perspectives in music therapy.The implications of these findings from the literature review and the surveyed educationprograms and professional associations for music therapy training practice and futureresearch are discussed.

Key Words: Music therapy training and education, LGB issues, music therapy curriculum,


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Dedication

This thesis is dedicated to my grandfather Sean Kennedy andmy grandmother Angela McKeogh


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IV

Acknowledgements

Firstly I would like to thank my Professor, Patricia Sabbatella for inviting me to Spain to do

this Masters by research in Music Therapy. Patricia encouraged and supported me studying

in a new language and guided me in all aspects of this work.

I would like to thank my parents, Shay and June Ahessy and my brother Mark for their

encouragement. I would not have been able to undertake this project without them and I am

truly grateful.

Much gratitude to Professor Tom Hayden for his help with project design and revisions. He

was a constant support to me and his input was greatly valued throughout the year.

I would like to especially thank Maria Rey Piulestan for her patience and work on the

translation of the questionnaires.

I would also like to thank Mr. Alan Frisby, who was involved in reviewing the questionnaires

and his knowledge of statistics and survey research was of great help.

I wish to acknowledge Professor Celia Kitzinger (University of York) for advice and

guidance on LGB topics and terminology, and Dr. Gregory Herek (University of California

at Davis) for his advice on terminology. I would also like to thank Dr. Joanne Harrison

(University of South Australia) for sending articles and resources on LGB ageing issues.

Sincerest thanks to Carla Bongiorno for the editing and proof reading of the thesis and

Anya Gardiner for her online support and advice throughout the research.

Finally, I wish to express my sincere gratitude to all the music therapy programs and

associations, without whose participation, this study would not have been possible


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V

Table of Contents

Title page........

Abstract...Dedication...Acknowledgements..Table of contents.List of tables & figuresAuthors note....Prologue...........

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Introduction.......

Chapter I Theoretical Foundations .

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1.1: Music therapy practice and research

1.2: Emerging issues in music therapy and music therapy training....

1.2.1: Multicultural music therapy.1.2.2. LGB issues in music therapy1.2.3. Multicultural issues in music therapy training..1.2.4. LGB issues in music therapy and psychotherapy training...

Chapter II Literature review.

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2.1: LGB sexualities and therapy.

2.1.1: Historical perspectives....2.1.2: Homophobia and heterosexism..2.1.3: Societal and institutionalised forms.

2.1.3.1: Education.2.1.3.2: Media..

2.1.3.3: Health care..2.1.4: Internalised homophobia2.1.5: Mental health among LGB individuals

2.2: LGB lifespan issues

2.2.1: Youth and adolescence.

2.2.1.1: The coming out process2.2.1.2: Models of coming out2.2.1.3: Disclosure to parents...

2.2.1.4: Adopting a LGB identity..2.2.1.5: Conversion/reparative therapy.

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2.2.2: LGB midlife.

2.2.2.1: Prejudice against LGB families....2.2.2.2: Affirming LGB families

2.2.3: LGB ageing2.2.3.1: Aged care settings and fears..2.2.2.2: Affirming ageing LGB individuals...2.2.2.3: Ageing successfully......

2.3: Gay affirmative therapy....

2.3.1: Critique.

2.4: Summary

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Chapter III Methodology.. 55

3.1: Justification for the Investigation....3.2: Investigative method..3.3: Participants3.4: Survey A

3.4.1: Participants in Survey A3.4.2: Structure of Questionnaire A

3.4.2.1: Introduction to Survey A...3.4.2.2: Professional and program contexts (questions 1-5)3.4.2.3: Provision of LGB issues (questions 6-13).3.4.2.4: LGB issues in music therapy (questions 14-17).....3.4.2.5: Final section (questions 19-21).....

3.5: Survey B...

3.5.1: Participants in Survey B..3.5.2: Structure of Questionnaire B...

3.5.2.1: Introduction to Survey B3.5.2.2: Association information (question 1)3.5.2.3: Provision of LGB issues (questions 2-4)3.5.2.4: LGB issues in music therapy (questions 5-7).

3.6: Ethical Implications.3.7: Method of Distribution...3.8: Procedure................3.9: Data Collection..3.10: Data Analysis.

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Chapter IV Results..79

4.1: Results of survey A Music Therapy University programs..

4.1.1: Professional and program contexts..

4.1.1.1: Characteristics of the respondents...4.1.1.2: Theoretical orientations of the respondents music therapy training4.1.1.3: Academic levels and duration of the music therapy programs...4.1.1.4: Theoretical orientations of the music therapy programs..

4.1.2: Provision of LGB issues in music therapy programs

4.1.2.1: Multicultural topics addressed in music therapy training.4.1.2.2: LGB topics in the music therapy programs...4.1.2.3: Reasons for not addressing LGB issues4.1.2.4: Manner in which LGB issues are addressed.4.1.2.5: LGB topics in music therapy curriculum4.1.2.6: The Importance of LGB issues in the music therapy programs.4.1.2.7: Preparation for working with LGB clients4.1.2.8: Clinical practicum with LGB clients...

4.1.3: LGB issues in music therapy education

4.1.3.1: Importance of LGB issues in music therapy education..4.1.3.2: Academic level for the provision of LGB issues...4.1.3.3: Most important LGB topics for music therapy curriculum.

4.1.3.4: Guidelines and training opportunities for working with LGB clients4.1.3.5: Provision of LGB issues in the respondents own music therapy training...

4.2: Results of survey B Music therapy Associations...

4.2.1: Association information...4.2.2: Provision of LGB Issues...

4.2.2.1: Provision of guidelines for working with LGB clients....4.2.2.2: Training opportunities in LGB issues.4.2.2.3: Music therapists working with LGB clients

4.2.3: LGB issues in music therapy

4.2.3.1: Training in LGB issues at university level..4.2.3.2: Importance of LGB issues for practicing music therapists.

4.3: Comparative results...

4.3.1: Guidelines and training opportunities in LGB issues....4.3.2: LGB issues in music therapy education

4.4: Main findings.

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Chapter V Discussion & Conclusion...................................................................................111

5.1: Discussion of results - Survey A..

5.1.1: Professional & program context.5.1.2: Provision of LGB issues...5.1.3: LGB issues in music therapy

5.2: Discussion of results - Survey B...

5.2.1: Association information...5.2.2: Provision of LGB issues...5.2.3: LGB issues in music therapy

5.3: Limitations..5.4: Recommendations and implications for music therapy...5.5: Directions for future research5.6: Conclusion..

References ..

Appendices.

Appendix 1 Music Therapy associations codes of ethics

Appendix 2 Survey A Introductory letter and debrief page...

Appendix 3 Survey A Questionnaire

Appendix 4 Survey B Introductory letter and debrief page.Appendix 5 Survey B Questionnaire

Appendix 6 Survey A Introductory letter (Spanish version)..

Appendix 7 Survey A Questionnaire (Spanish version)

Appendix 8 Survey B Introductory letter (Spanish version)...

Appendix 9 Survey B Questionnaire (Spanish version).

Appendix 10 Survey A Further comments...

Appendix 11 Survey B Further comments...

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List of Tables

Chapter I Theoretical foundations

Table 1.1: The range of music therapy settings and clientsTable 1.2: Professional Research Topics.Table 1.3: Implicit and active gay affirmative therapy.

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Chapter II Literature review

Table 2.1: Essential qualities of therapist working with LGB clients 51

Chapter III Methodology

Table 3.1: Survey research dealing with training and education in music therapy.Table 3.2: Music Therapy websites consulted.Table 3.3: Number of eligible participants for Survey A (by country)...Table 3.4: Eligible music therapy programs who received the surveyTable 3.5: Questionnaire A Dimensions...Table 3.6: Number of eligible participants for Survey B (by country)Table 3.7: Eligible music therapy associations who received the survey.Table 3.8: Dimensions of questionnaire B...

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Chapter IV Results

Table 4.1: Music Therapy Programs that respondedTable 4.2: Responses continent by continent.Table 4.3: Respondents years of clinical experienceTable 4.4: Association between experience and provision of LGB issues.Table 4.5: Theoretical Orientations of the respondents own music therapy trainingTable 4.6: Academic levels of music therapy programs...Table 4.7: Duration of music therapy programs...

Table 4.8: Theoretical orientations of the music therapy programs..Table 4.9: Multicultural topics addressed by the programs..Table 4.10: Programs that specifically address LGB issuesTable 4.11: Reasons for not addressing LGB issues in music therapy programs.Table 4.12: Where LGB issues were addressed in the programs...Table 4.13: LGB topics addressed..Table 4.14: Importance of LGB issues as a component of the music therapy programTable 4.15: Clinical practicum with LGB clients...Table 4.16: Importance of LGB issues as a component of music therapy...Table 4.17: The importance of LGB issues as a component of music therapy educationTable 4.18: Academic level for the provision of LGB issues...Table 4.19: Important LGB topics for music therapy education..Table 4.20: Guidelines and training opportunities in LGB issuesTable 4.21: Provision of LGB issues when the respondents trained as music therapists...Table 4.22: Respondents who received training in LGB issues in their own training...

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Table 4.23: Respondents by continentTable 4.24: Music therapy associations that responded to the survey...Table 4.25: Establishment of associations..Table 4.26: Provision of guidelines on LGB issues...Table 4.27: Further training opportunities in LGB issues.

Table 4.28: Members working in LGB area...Table 4.29: Would training in LGB issues professionally benefit music therapists..Table 4.30: Importance of LGB issues for music therapists in your country.Table 4.31: Guidelines and training opportunities in LGB issuesTable 4.32: Provision of guidelines and training opportunities in LGB issues..Table 4.33: Would training in LGB issues professionally benefit music therapists..Table 4.34: Programs that specifically address LGB issues

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Chapter V Discussion & Conclusion

Table 5.1: Important topics for working with LGB clients 126

List of Figures

Chapter III Methodology

Box 3.1: Introductory letter.Box 3.2: Debrief page... 6370

Chapter IV ResultsFigure 4.1: Continental response: Survey AFigure 4.2: Duration of experience of directors of music therapy programs..Figure 4.3: Duration of experience in relation to provision of LGB issues...Figure 4.4: Theoretical orientations of the programs respondents attended/direct...Figure 4.5: Duration of programs...Figure 4.6: Multicultural topics addressed by the music therapy programs

Figure 4.7: Reasons why LGB topics were not addressed...Figure 4.8: The manner in which LGB issues are addressedFigure 4.9: The importance of LGB issues in the programs.Figure 4.10: The importance of LGB issues (LGB+/LGB-)...Figure 4.11: LGB topics which respondents addressed and rated important.Figure 4.12: Correlation between important LGB topics between LGB+ and LGB .Figure 4.13: Continental response: Survey B...

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Authors Note

Throughout the course of this thesis the acronym LGB is used rather than the termhomosexual or homosexuals, to refer to lesbian, gay and/or bisexual persons/individuals.

The word homosexual has several problems of designation. First, it may perpetrate negativestereotypes because of its historical associations with pathology and criminal behaviour; second, it isambiguous in reference because it is often assumed to refer exclusively to men and thus renders lesbiansinvisible. Third, it is often unclear (American Psychological Association, 1991).

The researcher contacted two leading professors in the field of LGB psychologies to ensurethe wording for this thesis is politically correct and up to date. 1Both professors approved that the title for this thesis and reported that usage of the term LGB wasin line with what is in common use in both scholarly and activist context.

The term heterosexual will be used in the course of this thesis as an adjective for those whodo not engage in sexual relations with people of the same gender. The AmericanPsychological Association (1991) suggests that heterosexual as an adjective is acceptable forpeople who have male-female affectional/sexual relationships.

The term sexual orientation is used rather than sexual preference inline with theguidelines of the American Psychological Association, due to the word preferencesuggesting an element of voluntary choice that is not necessarily reported by lesbians andgay men, and that has not been demonstrated in psychological research (AmericanPsychological Association, 1991).

The American Psychological Association defines sexual orientation as an enduringemotional, romantic sexual or affectionate attraction to individuals of a certain gender

(Fordham, 1998:14).

Although transgender and intersex issues are not addressed in this thesis, they arementioned by other authors.

Glossary

LGB lesbian, gay and/or bisexualLGBT lesbian, gay, bisexual and/or transgenderedLGBTI lesbian, gay, bisexual, transgendered and/or intersex

1Prof. Celia Kitzinger Department of Sociology, University of York... She is author of the book Social

Construction of Lesbianism (1987) and co-author of the books Heterosexuality: a Feminism & PsychologyReader (1993), Changing Our Minds (1993), Feminism & Discourse: Psychological Perspectives 1996), andLesbian & Gay Psychology: New perspectives (2002) as well as many scholarly articles.Dr. Gregory M. Herek Professor of Psychology at the University of California at Davis, editor of the Journalof Sex Research, the Journal of Homosexuality and Applied Social Psychology. His edited and co-editedbooks include Hate Crimes: Confronting violence against lesbians & gay men (1992), AIDS Identity &Community: HIV & Lesbians & Gay Men (1995), Out in Force: Sexual Orientation & the Military (1996), andStigma & Sexual Orientation (1998).


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Prologue

Two LovesI dreamed I stood upon a little hill,

And at my feet there lay a ground, that seemedLike a waste garden, flowering at its will

With buds and blossoms. There were pools that dreamedBlack and unruffled; there were white lilies

A few, and crocuses, and violetsPurple or pale, snake-like fritillaries

Scarce seen for the rank grass, and through green netsBlue eyes of shy peryenche winked in the sun.

And there were curious flowers, before unknown,Flowers that were stained with moonlight, or with shades

Of Nature's willful moods; and here a oneThat had drunk in the transitory tone

Of one brief moment in a sunset; bladesOf grass that in an hundred springs had beenSlowly but exquisitely nurtured by the stars,

And watered with the scented dew long cuppedIn lilies, that for rays of sun had seen

Only God's glory, for never a sunrise marsThe luminous air of Heaven. Beyond, abrupt,A grey stone wall. o'ergrown with velvet mossUprose; and gazing I stood long, all mazedTo see a place so strange, so sweet, so fair.

And as I stood and marvelled, lo! across

The garden came a youth; one hand he raisedTo shield him from the sun, his wind-tossed hairWas twined with flowers, and in his hand he bore

A purple bunch of bursting grapes, his eyesWere clear as crystal, naked all was he,

White as the snow on pathless mountains frore,Red were his lips as red wine-spilith that dyes

A marble floor, his brow chalcedony.And he came near me, with his lips uncurled

And kind, and caught my hand and kissed my mouth,And gave me grapes to eat, and said, 'Sweet friend,

Come I will show thee shadows of the worldAnd images of life. See from the South

Comes the pale pageant that hath never an end.'

And lo! within the garden of my dreamI saw two walking on a shining plain

Of golden light. The one did joyous seemAnd fair and blooming, and a sweet refrainCame from his lips; he sang of pretty maids

And joyous love of comely girl and boy,His eyes were bright, and 'mid the dancing blades

Of golden grass his feet did trip for joy;

And in his hand he held an ivory luteWith strings of gold that were as maidens' hair,

And sang with voice as tuneful as a flute,


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And round his neck three chains of roses were.But he that was his comrade walked aside;

He was full sad and sweet, and his large eyesWere strange with wondrous brightness, staring wide

With gazing; and he sighed with many sighs

That moved me, and his cheeks were wan and whiteLike pallid lilies, and his lips were redLike poppies, and his hands he clenched tight,

And yet again unclenched, and his headWas wreathed with moon-flowers pale as lips of death.

A purple robe he wore, o'erwrought in goldWith the device of a great snake, whose breath

Was fiery flame: which when I did beholdI fell a-weeping, and I cried, 'Sweet youth,

Tell me why, sad and sighing, thou dost roveThese pleasant realms? I pray thee speak me sooth

What is thy name?' He said, 'My name is Love.'

Then straight the first did turn himself to meAnd cried, 'He lieth, for his name is Shame,

But I am Love, and I was wont to beAlone in this fair garden, till he cameUnasked by night; I am true Love, I fill

The hearts of boy and girl with mutual flame.'Then sighing, said the other, 'Have thy will,I am the love that dare not speak its name.'

(Douglas, A. 1896)


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Introduction

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1.1. Introduction

Lord Alfred Douglass prose was used by the prosecution in the famous trial of Oscar

Wilde, the Irish playwright, novelist and poet in 1895 that lead to him being imprisoned

and sentenced to two years hard labour for his sexual orientation. The trial resulted inpublic attitudes towards same-sex sexualities becoming increasingly harsher and less

tolerant. Over one hundred years later, sexual minority rights have improved greatly in

many countries around the world and there are many anti-discrimination laws are in place

to ensure equality for sexual minorities and to enforce the protection of LGB individuals.

Unfortunately widespread prejudice and intolerance exists in many countries and in others,

blatant oppression and sanctioned discrimination of sexual minorities.

Despite the improvements in societal acceptance of LGB individuals, we LGB individuals are one of the

only minority groups that are met with continued legalised discrimination (Safren, 2005: 29).

in recent years the President of the United States attempted to make a constitutional

amendment to ban same-sex marriage;

the Prime Minister of Australia initiated an adoption bill prohibiting same-sex couples

from adopting babies from outside the Australian jurisdiction;

participants in the LGB pride parade in Warsaw this year were repeatedly attacked

during their improvised march after the Mayor of the city refused the participants apermit to hold the parade; and then issued a permit for a normality parade, which in

reality was preaching hate and intolerance against sexual minorities; and

currently around 85 member states of the United Nations consider LGB sexual

relations to be a criminal act and some of these countries impose the death penalty

(Flamer-Caldera & Kahramanoglu, 2007; Joint United Nations Program, 2007).

Since the late 1800s activists have long taken up the cause for LGB rights. However it has

only been since the late 1960s, after the Stonewall riots, and the beginning of the gay

liberation movement in the 1970s, that activists came to prominence in their fight for equal

rights, benefits and protections for the LGB community. A momentous occasion for the LGB

community was the declassification of homosexuality as pathology, and its removal from the

list of mental illnesses in the American Psychiatric Associations (APA) Diagnostic Statistical

Manual (DSM) III (Davies & Neal, 1996). Although music has been used therapeutically in

many cultures for centuries, the specific discipline of music therapy is a middle-to-late

twentieth century development (Bunt, 1997: 249). The first training courses were initiated

after the Second World War, but as with LGB activism it was only from the beginning of


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Introduction

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the 1970s that the profession became established internationally. During this decade music

therapy associations in Australia, Canada, Norway and the United States were established

and more music therapy programs were initiated in the Australia, Denmark, the United

Kingdom and other countries (Bunt, 1997:249). By this decade the music therapy community

and had two peer-reviewed journals in the United States and Canada and pioneers such as

Juliet Alvin, Mary Priestley, Helen Bonny, Rolando Benenzon, Serafina Poch Blasco, and

Clive and Carol Robbins were paving the way forward and solidifying the growing

profession. The World Congress of Music Therapy was also initiated in this decade and the

seeds for the development of a World Federation of Music Therapy were sown (World

Federation of Music Therapy, 2007).

It can be seen from this brief summary that the 1970s was a decade in which both the musictherapy profession and the gay liberation movement were both gaining strength, maturing

and making themselves heard in the world. Since music therapy as a profession was just

establishing itself at this time, it is perhaps understandable that LGB issues and gay

affirmative approaches were not incorporated into the field to the extent they were in the

longer established disciplines of psychology and psychotherapy. Over thirty years later,

LGB issues and perspectives have still not been sufficiently explored or addressed in music

therapy. There was a development of multicultural music therapy literature in the 1990s

(Moreno, 1988 1989 1995; Toppozada, 1995; Sloss, 1996; Brandt, 1997; Darrow and

Molloy 1998; Ruud, 1998; Estrella, 2001; Brown, 2002; Stige, 2002; Chase, 2003),

resulting in more attention being given to this area in music therapy in regard to education,

training and supervision. Nevertheless LGB issues were not specifically addressed in this

domain and as consequence they have been largely neglected by all but by a few authors.

Chase (2004) reviewed LGB psychotherapy literature on working with LGB clients and

provided implications for music therapists. Lee (1996) and Bruscia (1998b) published case

studies on gay men living with HIV/AIDS, and Hedigan (2005) presented a paper on

working with a chemically dependent gay male. There have been no music therapy case

studies, which focus on LGB lifespan issues, nor research on the provision of LGB issues in

training programs or professional development. This is the reason that this researcher

wanted to explore LGB issues and perspectives in music therapy and to evaluate

developments in the literature, and music therapy education and professional development.


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Introduction

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Questions that were of interest to the researcher included:

where and how have LGB issues been addressed in the music therapy literature?

what are the central topics regarding therapy with LGB clients? And LGB individuals

topics the lifespan?

are LGB topics being addressed in music therapy training programs?

which LGB topics do the music therapy programs address? And what format does the

provision of LGB issues take?

do music therapy associations provide any guidelines or opportunities for continuing

professional education regarding LGB issues?

are music therapists working with LGB clients? and

how important do music therapy programs and associations view LGB issues as acomponent of music therapy education and the field at large?

This project aimed to answer these questions and explore LGB issues in music therapy by

a. a comprehensive review of LGB issues in the music therapy literature and related

disciplines of psychology and psychotherapy, to identify the central LGB topics across

the lifespan;

b. a global survey of music therapy programs investigating the provision of LGB issues in

music therapy education; and

c. a global survey of music therapy associations investigating the provision of guidelines

or training opportunities in LGB issues.

Chapter 1 sets out the theoretical orientations of the project. It examines music therapy

practice and research; multicultural issues and LGB issues in music therapy. It also explores,

multicultural training in music therapy, as well as LGB issues in music therapy training and

psychology and psychotherapy training. Chapter 2 sets out a review of the LGB psychology

and psychotherapy literature, with the aim of identifying central LGB topics relevant for

music therapists and music therapy educators. The literature that has formed the subject of

this review has been divided into 3 main sections for the purpose of this discussion (1) an

inquiry into LGB issues that have direct impacts on healthcare and therapy, (2) an

exploration of LGB issues over the lifespan, and (3) an exploration of gay affirmative

therapy. Chapter 3 contains a detailed explanation of the methodology used in the

execution of the surveys. After a justification for the study, both questionnaires for thesurvey of music therapy programs and the music therapy associations are presented. There


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Introduction

4

is an explanation of the method of distribution, the procedure and ethical implications of the

surveys, as well as a discussion of the data collection process, data analysis. Chapter 4 sets

out the results for each question in the surveys. There is a final section, in which comparative

results between the two surveys are presented, finishing with a summary of the main

findings. Chapter 5 is a discussion of the survey results, presented by theme. The limitations

of the study are discussed, as well as applications and implications for music therapy.

Finally recommendations and possibilities for future research are discussed.

Because there is more visibility and acceptance of LGB individuals than ever before, it is

urgent that music therapists explore and become familiar with LGB issues and perspectives.

Music therapists will encounter more opportunities to work with LGB clients and families and

therapists need to be certain that they possess the knowledge, skills, and sensitivity to provide

competent care to this population (Eubanks-Carter et al. 2005, p. 1). Many LGB individuals

will present for therapy at some point in their lives, perhaps more so than the general

population. So it is imperative that music therapists have been exposed to, and addressed

LGB issues in their music therapy training, and have opportunities for continuing professional

development regarding working with LGB clients (Bradford et al. 1994; Jones & Gabriel,

1999. In. Safren, 2005).

This thesis deals only with LGB issues. It does not include transgender or intersex issues. Theresearcher felt that although sharing some common issues with LGB individuals,

transgendered and intersex individuals have very specific issues related to their gender

identity and for that reason they have not been included in this work. Although bisexual

individuals have distinctive issues too, they also share many issues with gay men and lesbian

women, and so perhaps it is easier to speak about LGB issues than LGBTI2 issues. If there

were no discrimination and sexual orientation was as insignificant as the colour of a persons

eyes or hair, then there would be no need to focus on and highlight on LGB issues; however

sexual minorities are stigmatised and still very much discriminated against. Discrimination on

the basis of sexual orientation can in turn lead to important LGB issues being hidden, by

LGB individuals, health-care workers and larger communities. As the literature reveals,

attention to and discourse on LGB issues in music therapy is long overdue. This thesis is the

first study in the field of music therapy to assess the provision of LGB issues in music therapy

training programs and the provision of guidelines and opportunities for continuing

professional education in LGB related matters.

2 LGBTI Lesbian, Gay, Bisexual, Transgendered, Inter-sex


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Theoretical Orientations

5

Chapter I



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1.1. Music therapy practice and research

Music was perhaps the first art form to be employed therapeutically. There is evidence of

this in Egyptian medical papyri, biblical passages, Greek medical practice, as well as

creation stories, magic and mythology and tribal medicine (Bunt, 1997).Ruud (1998, p. 53)defines music therapy as

The use of music and/or its elements (sound, rhythm, melody, and harmony) by a musictherapist, and client or group, in a process designed to facilitate and promotecommunication, relationship, learning, mobilization, expression and organization(physical, emotional, mental, social and cognitive) in order to develop potentials anddevelop or restore functions of the individual so that he or she can achieve better intra-and interpersonal integration and, consequently a better quality of life.

Music therapy its application is varied and holistic. Educational, recreational, rehabilitative,

preventive, or psychotherapeutic goals can be addressed and physical, psychological,

emotional, intellectual, social and spiritual needs can be met(Bruscia, 1998a, p. 11). Music

therapy is thus a unique fusion between science and art, and can work effectively as a

treatment intervention with clients in medical, psychoanalytical, behavioural and humanistic

domains. Music therapy today is employed in many settings and for the benefit of a great

variety of clients, as illustrated in table 1.1 below.

Employment of Music TherapyRange of clients Range of settingsAutistic children and adultsEmotionally disturbed children and adultsAdults with psychiatric disordersCognitively disabled children and adultsIndividuals with visual, hearing, speech andmotor impairmentLearning disabled children and adultsAbused children, and abuse survivorsSex offendersIndividuals with behavioural, language andcommunication disordersPrisonersSubstance abusers

Medical patientsAgeing individuals,Terminally ill children and adultsAdopted childrenFamiliesRefugees and asylum seekersBereaved individualsNeonates

SchoolsClinicsHospitalsResidential centresGroup homesNursing homesDay-care centresHospicesPrisonsCommunity centresInstitutesPrivate practices

Table 1.1: The range of music therapy settings and clients (Bruscia, 1998a, p. 11).

The range of clients with whom music therapists work with is constantly growing, and

therapists can now be found working with communities as well as individuals for lifeenhancement, stress management, personal growth, spiritual development and a range of

other problems (Bruscia, 1998a, p. 11).


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Bruscia (1987) has identified two types of music therapy; music in therapy and music as

therapy.

Music in therapy: Music as a form of relaxation to support verbally-based psychotherapy

or in dentistry and surgery (Bunt, 1997, p. 251).

Music as therapy: Music is the central ingredient, changes in the music often being

mirrored in changes within the client-therapist relationship (Bunt, 1997, p. 251).

The clinical practice of music therapy straddles many disciplines. Every music therapistbrings to the profession a unique blend of musical and personal skills and experiences,applied practically in the service of children and adults with wide-ranging physical andmental health care needs. Effective clinical practice also requires awareness of the relevantpsychological and therapeutic processes and knowledge of the appropriate medicalbackground (Bunt, 1997, p. 249).

Research is a vital aspect of the discipline and profession of music therapy. Research, theory

and practice depend on each other, likened to a tripod by Gaston (1968) each necessary in

order for the other to stand (Wheeler, 2005a: 5). Wheeler (2005) differentiates between

basic research and applied research as follows

1) Basic research is conducted with the aim of increasing knowledge. The application of

research findings is not the central aim, but rather knowledge for its own sake

which may ultimately lead to changes in practice.

2) Applied research on the other hand is conducted with the aim of solving a practicalproblem, to test a hypothesis or model in a real situation of interest or to expand

our understanding of an actual situation. The author notes how basic research can

become applied research once the results are applied to real problems

Wheeler (2005a, p. 11)

Bruscia (1998a) divides music therapy research topics into two distinct categories; topics on

the discipline and topics on the profession. In research topics on the discipline of music

therapy, he observes three broad topical areas: assessment, treatment and evaluation.

Research of the profession of music therapy is any systematic, self monitored inquiry which

leads to a discovery regarding music therapists, professional standards, education and

training, employment, history, and public relations and conditions affecting the discipline of

music therapy (Bruscia, 1998a, p. 253). For research to be discipline orientated the topic

must include four elements: the client, the therapist, the musical experience and the

therapeutic process (Bruscia, 1998a, p. 253). Research on the profession of music therapy

covers a broad scope of interrelated topics (Table 1.2: Bruscia, 1998a, p. 251).


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Professional Research Topics ThemesEmployment practices Work settings, job titles, salaries, job duties, music therapys place in

health care settings and institutions, music therapy policies andprocedures and accountability

Music therapists Demographics, profession related stress and burn-out, personality

profiles, levels of education, attitudes and opinions regarding clinicalwork, and employmentProfessional education and training Teaching and supervision methods, student experiences and

personality profiles, curricula, and academic requirementsProfessional standards Ethics in music therapy clinical work, competency standards and

registration procedures and issues, academic and clinical trainingprogram standards

Legislation and public relations Effects of laws and regulation on music therapy, licensing issues,relationships between music therapy and other disciplines, politicaland cultural factors in the advancement of music therapy

History and culture Historical narratives of the discipline and profession of music therapyand music therapy associations and organisations, biographies, meta-analysis and descriptions of research literature

Table 1.2 Professional Research Topics (Bruscia, 1998a, p. 251)

Research in music therapy has been growing steadily over the past four decades and

Edwards (2005) observes that for the last 10 years there have been music therapy journals

produced in English in six countries compared with 1 journal in the 1970s and two in the

1980s. Six categories of research in music therapy were identified in a survey of nine

journals: quantitative, qualitative, clinical reports, philosophical and theoretical research,

historical research and professional articles, (Brooks, 2003). Quantitative articles and

clinical reports were found to be the most common, making up two thirds of the articles

analysed, Qualitative, philosophical/theoretical and professional research were equally

represented, while historical research received the lowest attention (Edwards, 2005). More

recently, there has been an increase in qualitative designs in music therapy such as;

hermeneutic, phenomenological and naturalistic inquiry, art-based research, participatory

action-research, first-person research and ethnographically informed research inquiry as

well as mixed designs. After a relatively brief history of research when compared with

other disciplines, music therapy has an effectual, developed and comprehensive body of

research with a variety of designs and we are poised in this new century to use this body

of knowledge to consolidate, refine and further develop our approaches to research

(Edwards, 2005, p. 20).


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1.2. Emerging Issues in music therapy and music therapy training

Music therapy is an ever-evolving and expanding discipline both in clinical practice and

research. Although music therapists still work in the traditional clinical areas, the 2005

World Music Therapy Conference in Brisbane, Australia presented some more recent and

emerging client groups with whom music therapists work, such as:

women survivors of violence,

adopted children;

mother and infant asylum seekers,

indigenous families;

sexually abused children;children from war-torn countries; and

offenders from ethnic minorities.

More recent and emerging themes in music therapy theory, practice and research were also

highlighted, such as:

music therapy and spirituality,

cultural competency in music therapy;

community music therapy; and

multicultural music therapy.

Music therapists have always worked in communities to some extent. In recent years there

has been more of a focus on community based music therapy and systems theory. From this

perspective ill-health is seen within a totality as a part of social systems and embedded in

material processes (Ruud, 2004, p. 11). Music therapy in some of these contexts hasbecome more socio-political, dealing with whole communities, focusing on systemic

interventions, network building, and providing symbolic means for underprivileged

individuals or being used to empower subordinate groups (Ruud, 2004, p. 13).

Today, music therapy is used alongside other therapies in many conflict zones and deprived

areas. There have been music therapists working with Tsunami victims in Thailand and music

therapy projects in other disaster areas (Fachner, 2007). At the Brisbane World Conferencein 2007 the World Federation of Music Therapy initiated a new commission called Global


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in music therapy programs and multicultural approaches in music therapy supervision. The

practice of culturally-sensitive music therapy is intertwined with personal awareness and

requires a music therapist to take another step towards this awareness. It calls for

examination and sensitivity to ones own worldview and a willingness to be open to others,

recognising that both differences and similarities exist (Brown, 2002: 85).

Sue (1996) highlights the fact that the Eurocentric or Euro-American view has been the

standard to judge normality, abnormality and characteristics of good counseling within the

psychotherapeutic tradition (Estrella, 2001, p. 44). The multicultural music therapy literature

has emphasised the need for music therapists to examine their own worldviews, while

becoming more familiar with cultural differences (Chase, 2003). Familiarity with world

musics and the role they play within cultures is also seen as a therapeutic asset for musictherapists (Moreno, 1995). Therapists need to be aware of differences in attitudes and

value-systems of their culturally diverse clients. Lack of attention to these cultural differences

may lead to misdiagnosis and hinder effective therapeutic results (Brandt, 1997).

1.2.2. LGB Issues in music therapy

In music therapy LGB issues are not covered sufficiently in any of the discourse on

multicultural issues, and nor are they addressed in other contexts including: music therapy

case studies, clinical reports and research. There have been some case studies of music

therapy with gay men, but only in relation to having HIV/AIDS or substance addiction.

Bruscia (1998b) has two guided imagery through music (GIM) case studies with two gay

men suffering from AIDS and Colin Lees (1996) Music at the Edge: The Music Therapy

Experiences of a Musician with AIDS describes the journey of a gay man who eventually

dies from the disease. More recentlyat the 10th World Music Therapy Congress (2005) in

Brisbane, Australia, music therapist John Hedigan presented his work on Using music therapy

to explore sexual orientation with a heroin- dependent male. They are all extremely valuablecase studies, but none of them examine the complex spectrum of issues specific to LGB

clients presenting for therapy. The case studies are mainly in relation to HIV/AIDS, and do

not sufficiently explore the multitude of LGB specific lifespan and societal issues.

Furthermore the focus of such case studies has been on gay males, excluding lesbian and

bisexual experiences.

The only exception is an article, which focuses more directly on lesbian and gay issues in

therapy with implications for music therapists by Kristin Chase (2004). Chase reviewing the

literature on therapy with gay and lesbian clients identified four areas relevant to music


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therapists. These were (i) general issues and approaches, (ii) attitudes towards therapists,

(iii) choice of therapist, and (iv) heterosexual therapists working with gay lesbian and gay

clients. She highlights some key issues for music therapy

music therapists must feel confident to refer a client if they are not comfortable or

experienced in this area, rather than risking culturally incompetent care;

music therapists may not work directly with lesbian and gay clients, but may encounter

lesbian and gay parents, family members across many settings and be aware of the

effects of negative attitudes in these circumstances and their effects on therapeutic

outcomes. Music therapists may also take on the role of a family advocate to their

lesbian or gay client; and

It is important to have an understanding of transference and counter-transference, aswell as issues such as: the effects of oppression and heterosexism and loss and

mourning of the heterosexual self, or of family and friends.

Chase (2004) also recommends that music therapists engage in rigorous self reflection by

means of a complete cultural self-assessment or reflective journal writing, and that we

become familiar with lesbian and gay culture through literature, films and LGB networks

finally. She also recommends that therapists adapt the clinical practice of music therapy to

be more inclusive by using inclusive terminology, a wider variety of music and adopting a

cultural assessment tool as part of clinical assessment. This author also reviews how lesbian

and gay clients bring a diversity of typical and atypical issues to therapy and that music

therapy is a valuable treatment modality for these clients music therapy has been effective

with grieving persons, hospitalised patients, persons with psychiatric illness, adolescents with

emotional issues and well adults seeking therapy (Austin, 1996; Bednarz & Nickkel, 1992;

Frish, 1990; Heaney, 1992; OCallaghan, 1997; O Callaghan & Cosgrove 1998 in Chase,

2004, p. 37). Chase does not consider bisexual individuals in this article.

Music therapy in its integration of multiculturalism traditionally looked to the disciplines of

psychology and psychotherapy, with their larger bodies of research to inform and

familiarise itself with multiculturalism, thus evolving the field and encouraging multicultural

music therapy literature and research to grow. LGB issues have not sufficiently been dealt

with in the music therapy literature so it seems appropriate to look to the psychology and

psychotherapeutic literature to investigate LGB issues and perspectives further in Chapter 2.


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1.2.3. Multicultural issues in music therapy training

In Toppozadas (1995) study of music therapists attitudes toward multicultural issues, she

found that although the issue was perceived to be important for music therapy, training in

this area was taking place in professional contexts, rather than in training programs andthere was a need for music therapy students to do more coursework in the areas of

multicultural psychotherapy and ethical issues. It has been emphasised that multicultural

issues need to find their foundation in music therapy training courses (Brandt, 1997) and

that training courses need to prepare students for working with diverse populations

How can music therapists be aware of possible ethical issues when working with culturallydifferent clients? if they were never taught so during the training programs (Brandt,1997, p. 140).

In a survey of music therapists, Darrow and Molloy (1998, p. 30), found that while musictherapy programs in the United States were incorporating multicultural issues into their

curricula and viewed them important, often there is was little attention given to these issues

in course work or central modules in comparison with music education programs. They also

found that the majority of music therapists felt their training programs did not adequately

prepare them to work in multicultural settings. Brown (2002) argues that training in

multicultural issues should work on Iveys (1997) first and second order skills. These are:

1) The therapists ability to communicate culturally, effectively and sensitively within thetherapeutic relationship

2) The therapists ability to appropriately apply therapeutic interventions within in the

cultural context (Brown, 2002: 88).

Furthermore, the skills needed to practice within culturally-centred music therapy will be

learned through training, but also with time and experience. Practicing within a culture-

centred framework is to be seen as an ongoing and incremental process (Brown, 2002).

Stone (1997) defines two approaches in multiculturalism:

1) Inclusive: A broad and international definition of cultural groups; race, ethnicity,

nationality, social class, religion, gender, sexual orientation, age, disability

2) Exclusive: Visible ethnic and racial groups; Native Americans, Australian aboriginal

peoples, Hispanic (Estrella, 2001, p. 47).


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Culture is a complex concept, and an individual may belong to one or multiple cultures

simultaneously, especially if culture is defined inclusive terms. In the majority of the music

therapy, psychology and psychotherapy literature on multicultural therapy, the definition of

culture has been somewhere in between inclusive and exclusive, however there has been

primarily a focus on nationality, ethnicity, race and religion in relation to culture, exclusive

to sexual orientation.

1.2.4. LGB issues in music therapy and psychotherapy training

There have been no specific studies in music therapy regarding LGB issues in music therapy

training, curricula and continuing professional education. This study being the first in the

field to assess this area, the researcher reviewed the psychotherapy and psychology

literature, to assess the current situation regarding training in LGB issues and highlight keypoints in relation to LGB issues in curricula and education. Educational institutions can be

vehicles for communicating heterosexual bias, and this bias has often served as an integral

part of the underpinnings of theoretical and research paradigms (Greene, 1994, p. 17).

This may explain the dearth of LGB content in psychology and psychotherapy literature and

training courses (Rodolfa & Davis, 2003).

Milton, Coyle and Legg (2002) interviewed 14 gay affirmative therapists and found that

many of these stated that there was limited coverage of LGB issues in training courses and

as a result there was difficulty discussing these issues openly. Participants emphasised the

limited coverage of LGB issues in their own training and also how the provision of these

issues were presented in a highly medicalised context, as opposed to a sociological context

and as a result there was difficulty discussing these issues openly. They were also of the

opinion that the professional literature holds either absent or limited and stagnant views

of therapy with LGB individuals and LGB issues in general (Milton, Coyle & Legg, 2002, p.

16). This was highlighted by Rodolfa & Davis (2003), who surveyed eight major psychologyjournals published during the 1990s and found there were only 2.11% of articles in these

publications addressing LGB issues a haunting and abysmal number and a challenge for

psychology (Rodolfa & Davis, 2003, p. 70). The Guidelines by the American Psychological

Association for working with LGB clients state that even though there has been an addition

of diversity training in graduate education, students often report a lack of education and

training in LGB issues and that graduate students and novice therapists feel unprepared to

work effectively with LGB clients (Garnets & Kimmel, 2003, p. 773). This means that the

lacunae of LGB issues in graduate training and the psychological literature will mean that

most therapists will lack valuable tools for working with LGB clients, including knowledge


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about LGB experiences over the lifespan. This knowledge could naturally enhance

therapeutic skills and provide a more effective service to clients (Eubanks-Carter, 2005).

The promotion of LGB affirmative practice relies heavily on the provision of LGB issues in

therapeutic training courses. Adequate space needs to be created within the curriculum to

address LGB issues and educators need to promote competence in LGB affirmative practice

among trainees. This will entail staff developing and refining their own competence in this

domain and becoming skilled in disseminating it to trainees (Milton & Coyle, 1999, p. 56).

The American Psychological Association encourages faculty members and supervisors to

integrate LGB issues throughout training for professional practice. This could be achieved by

providing guest lecturers who have expertise in LGB issues or by faculty members seeking

out continuing education in LGB matters (American Psychological Association, 1998). This is

important for music therapy educators to consider.

In A Delphi study (Godfrey et al. 2006) examining essential components in curricula for

preparing therapists for work with LGB clients, panellists reached consensus on five

important in classroom learning experiences for students , which might prove useful for music

therapy educators:

listening to an LGB panel and guest speakers, including LGB people of colour;

providing therapy to LGB clients with supervision;

doing role plays of coming out scenarios with unaccepting parents, at work, with

friends;

observing therapy with LGB clients; and

writing papers on students own journeys around sexual orientation and goals for

development in reducing heterosexism in their own lives/families/work

settings/schools (Godfrey et al. 2006, p. 498).

It is important that up-to-date information and current research is used in the provision of

LGB topics at all levels in professional development, undergraduate, post-graduate,

continuing education and in-service training (Garnets et al. 1991). Which LGB topics should

be included in program curricula? There may obviously be core topics, which deserve more

attention, and others, which could be followed up through private guided reading. Rodolfa

& Davis (2003) list some core topics that should be minimally known by psychology trainees

if they are to be adequately prepared to work with LGB clients. These include: sexual

minority development, oppression and discrimination, coming out & identity development,

HIV/AIDS, bisexuality, assessment of sexual orientation and sexual identity, dual-minority


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status, and LGB parenting. Homophobia, including its internalised and institutionalised forms,

was the topic picked by respondents as the most important LGB topic to address in another

study on components of curricula (Godfrey el al. 2006).

In the treatment of LGB issues, there could be a specific module or part thereof so

designated to address these issues in isolation. However, it has been found that addressing

diversity issues across the curriculum has lead to higher student satisfaction and

understanding as opposed to isolated seminars or classes (Rodolfa & Davies, 2003). It has

also been suggested that role play and reviewing case material for insensitive approaches

may help students to develop a more thorough understanding of LGB issues (Greene, 1994,

p. 20). Godfrey et al (2006) highlight three areas for adequate training in LGB issues:

1) opportunities for students to acknowledge and discuss any homophobic or

heterosexist biases they might have;

2) opportunities for students to become familiar with the strengths and specific

challenges faced by LGB individuals and their families; and

3) exploration of the similarities and differences between LGB culture and the

dominant culture.

Engaging in self-evaluation should also be an important aspect of any training in LGB

issues. Failure to do this may result in an LGB client receiving ineffective or potentially

harmful therapy (Davies, 1996). Reflecting on ones own feelings about construction of

sexual identity and gender as well as examining internal homophobia, heterocentrism and

heterosexism3 is perhaps one of the most important tasks trainees and therapists can

undertake. It may often involve clarifying, evaluating and potentially changingbiases,

prejudices and values (Godfrey et al. 2006, p. 500). Creating space within training

programs should allow students to undergo this process (Milton & Coyle, 1999). In Bersteins

(2000) Cultural Literacy Model it is suggested that heterosexual therapists should employ

an attitude inventory in order to access their conscious and subconscious anti-gay prejudice

and one of the three steps in Purnell and Paulankas (1998) Cultural Competence Model is

engaging in rigorous self-reflection (Chase, 2004, p. 37). Chase has also developed a

3 Homophobia has usually referred to describe individual bias towards heterosexuals and anti-gay attitudes

or behaviours whereas heterosexism has been employed to describe cultural bias towards heterosexuals andrefer to societal level ideologies and patterns of institutionalised oppression of non heterosexual people (Herek,

1999, p. 2).Heterocentrism is also the assumption that everyone is heterosexual and the attitudes that derive therefrom.Heterocentrism is often subconscious and shows up in less intentional ways (Bowers et al. 2006).


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cultural self-assessment model for music therapists, which may be useful for personal

evaluation.

In university psychology courses in the United Kingdom LGB issues if mentioned at all are

often only addressed by LGB educators and these issues are said to be barely covered in

important areas such as social, developmental and health psychology. And although people

may ascribe to broadly pro gay principles LGB concerns are often ignored, excluded and

marginalised (Clarke & Peel, 2006, p. 2). There is a need for inclusive curricula, teaching

materials and practices and for the hidden curriculum of heteronegativism to be updated

since is a vital and necessary component of the discipline rather than at best marginal,

speciality concernsa mere add on (Clarke & Peel, 2006, p. 2). Training programs need

to address LGB issues, ensuring that their trainees possess empathy, open-mindedness andability and willingness to reflect on ones strengths and weaknesses as well as the essential

qualities for therapists working with LGB clients (Table 1.3.), such as:

Comfort with LGB individuals;Awareness of ones own comfort level, values, biases and prejudices about sex,

gender, and sexual orientation and how these can affect interactions with clients;Interest in the life of the client and willingness to educate ones self about issues and

social conditions for LGB individuals;Willing to hold ones self accountable for values, biases and prejudices;Awareness of ones own construction of gender and sexual identity, and the origins of

related beliefs (e.g., family, peer norms, religion);Understanding that sexual orientation is about affection attachments;LGB affirmative (acceptance and non judgemental attitudes are not sufficient); andAbility to nurture queerness versus manage or cope with it

Godfrey et al. 2006, p. 498

Table 1.3: Essential qualities of therapist working with LGB clients

The literature on LGB issues in psychotherapy and psychology training suggests that LGB

issues in these training environments are often severely neglected. It remains to be seen

whether the same occurs in music therapy training programs and continuing professional

education. Chapter two of this thesis will fulfil the second aim of this study and identify the

central LGB topics and lifespan issues, which are central to providing effective therapy with

LGB clients, relevant for music therapists, and should be included in the provision of LGB

issues in music therapy educational settings.


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Chapter II

Literature Review


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2.1. LGB Sexualities and Therapy

2.1.1. Historical Perspectives

The history of the psychological treatment of LGB individuals by the mental health experts is

marked by a repeated pattern of good intentions and negative consequences, and is often

linked to the Freudian psychoanalytic tradition (Eubanks-Carter et al. 2005,p. 3). It is said

that Freud had a complex view of homosexuality. On one hand he described homosexuality

as an arrest in psychosocial development and on the other observing that same sex

attraction is found in people whose efficiency is unimpaired and who are indeed

distinguished by especially high intellectual development and ethical culture (Eubanks-

Carter et al. 2005, p. 4). Freud also believed that people were born with both heterosexual

and same-sex feelings. Nevertheless later psychoanalysts did not follow Freuds view thatpeople were born with psychological bisexuality, and proposed that LGB individuals could

be converted through long-term psychoanalysis. It has been observed that post-Freudian

American psychoanalysts in the 1940s and 1950s such as Bieber, Bergler and Socarides

mobilised an almost McCarthyite zeal in labelling homosexuals as sick, inadequate

personalities and grievance collectors (Milton, Coyle & Legg, 2005, p. 182). LGB

individuals up to the mid 1990s were also barred from training as psychoanalysts in the

United States and Britain due to their unresolved and unanalysable neuroses and the fact

that they were seen as too political and therefore inappropriate for training. (Neal &

Davies 1996, p. 22)

Psychology and more specifically psychoanalytical theory have often contributed towards

the turbulent relationship between mental health and LGB sexualities (Neal & Davies, 1996,

p. 22). Psychoanalytical theories on LGB sexualities have been criticised for not being

empirically tested on the grounds that the personal beliefs and attitudes of the analyst

biased observations and furthermore subjects who were already in psychiatric care were

used (Herek, 2007). Although there is still much discussion of LGB sexualities in

psychoanalysis and many issues are unresolved, psychoanalysis has at least engaged with

its ambivalence towards same-sex sexualities (Milton, Coyle & Legg, 2005, p. 184).

Behavioural therapists throughout the twentieth century also tried to cure same-sex desire,

developing a range of techniques to convert LGB from sexual activity with the opposite sex.

These included: the use covert conditioning, where clients were asked to imagine same sex

activities, while being exposed to anxiety-inducing images, chemical aversion therapy and

electroshock treatments (Eubanks-Carter et al. 2005). The idea of cure and treatmentthroughout much of the twentieth century was derived from quasi-medical models, which


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seemed more appealing than the models of good and evil which, they largely replaced

and measures such as: neurosurgery, hormone injections, heterosexual assertiveness training,

religious exorcism and prayer were sometimes used in an attempt to cure homosexuality

even into the 1970s and 1980s (Neal & Davies, 1996, p. 17).

From the 1950s some researchers endeavoured to not only show that LGB sexuality was a

degree on the sexual orientation continuum, but also that there was no difference in

psychological functioning between LGB persons and heterosexuals. Kinsey, Pomeroy &

Martins landmark study (1948) posited a sexual orientation continuum, revealing that many

more American adults than previously thought had engaged in same sex behaviour or

experienced homoerotic fantasies (Herek, 2007). Evelyn Hooker was one of the most

influential researchers of homosexuality of the twentieth century and her 1957 study wasground breaking in several ways. Hooker recruited a group of gay men who were not

under psychiatric care and used a control group of heterosexual men who were matched

for IQ and education. Hooker in her famous case-controlled study known as the fairy

project found no difference in adjustment or psychopathology between gay men who were

not under psychiatric care and heterosexual men (Kimmel & Garnets, 2003). Hookers

studies were replicated later with lesbian and heterosexual women and had a direct hand

in the de-classification of homosexuality as pathology. This directly affected psychological

practice, paving the way for new affirmative models in psychotherapy (Rothblum, 2003).

Psychologists and psychiatrists could not ignore the weight of empirical data with which they

were being confronted as more and more studies were undertaken over the next two

decades confirming that homosexuality was not pathology and LGB individuals had similar

mental health to heterosexuals (Neal & Davies, 1996). Furthermore the growth in humanistic

models of therapy fostered a shift in ways of thinking about human sexuality (Mair, 2003).

As a result in 1973 homosexuality was removed from the list of mental illnesses in the

American Psychiatric Associations (APA) Diagnostic Statistical Manual (DSM) III.4

Nevertheless in a survey conducted of 2500 psychologists soon after declassification it was

evidenced that a majority still though homosexual to be pathological and also perceived

4Although homosexuality was declassified a new classification was introduced in 1980 called ego-dystonic

homosexuality where a person has failed to accept their homosexuality and consequently experiences persistentdistress and wishes to be heterosexual (Milton, Coyle & Legg, 2005: 183). This has been seen as a loophole forconversion therapies, which continued to cause oppression on LGB individuals and it was removed entirely in1987 (Davies & Neal, 1996).


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homosexuals to be less happy and less capable of mature, loving relationships than

heterosexuals (Rothblum, 2003: 675). Old habits die hard!

In an attempt to influence this majority The American Psychological Association in 1975

adopted a resolution, Homosexuality per se implies no impairment in judgement, stability,

reliability, or general social or vocational capabilities (Garnets et al. 1991, p. 964). This

resolution not only supported the removal of homosexuality as pathology, but also

advocated equal civil and legal rights for all LGB persons, urging psychologists to remove

the stigma that had become linked to LGB sexualities and to foster affirmative approaches

with LGB clients (Eubanks-Carter et al. 2005). The shift in thinking about homosexuality

moved at a more rapid pace in the United States than elsewhere, perhaps due to the

founding ofthe Journal of Homosexuality in 1974 and other journals that followed, and the

establishment of such organisations as The Society for the Psychological Study of Lesbian,Gay & Bisexual Issues, who promoted of LGB affirmative research & practice (Kilgore et al.

2005).

In Europe and in other parts of the World, the shift in thinking was much slower.

Homosexuality was still classified as a pathology by the World Health Organisation until

1992 (Neal & Davies, 1996) and was only decriminalised in Ireland, a member of the

European Union in 1993. During the last two and a half decades there has been a

significant growth in gay affirmative therapy and LGB psychology as well as changingattitudes in relation to LGB individuals and their health care needs. Nevertheless, recent

theorists such as Limentani (1994), Rayer (1986), Socarides (1978) and others still view

homosexuality from a pathological perspective (Milton & Coyle, 1999). Socarides is quoted

to have said as recently as 1997 that Homosexuality is a psychological and psychiatric

disorder, there is no question about itIt is a purple menace that is threatening the proper

design of gender distinction in society (Tozer & McClanahan, 1999, p. 725).

2.1.2. Homophobia & Heterosexism

Homophobia and Heterosexism are central issues for LGB individuals, which can not only

greatly affect their daily lives, but can have immense impacts on the level of treatment and

care they receive in the healthcare domain. Homophobia as a term was coined by clinical

psychologist Weinburg in 1972 to describe the phenomenon in heterosexuals of the dread

of being in close quarters to gay persons. Its equivalent in gay persons manifesting as

self-loathing (Shidlo 1994, p. 177). This was later expanded by Hudson and Ricketts

(1980) to include feelings of anxiety, disgust, aversion, anger, discomfort and fear, whichheterosexuals may feel in the presence of gay people (Davies, 1996, p. 41). The term


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homophobia has not been widely accepted in the literature, as it is not considered to be a

phobia in the classic sense. It is also seen to reflect a prejudice reinforced by society as

opposed to an individual phobia (Herek, 1990). Unlike a clinical phobia, homophobia often

includes hatred and anger, it is sometimes judged to be understandable or justifiable, it

often manifests as aggression or hostility, it can be politically based and is not seen as a

disability with a motivation to change (Bowers et al. 2006, p. 31). Other suggestions for

the term have been homoerotophobia, homosexism, homonegativism, and anti-gay

prejudice to name a few (Davies, 1996). Davies (1996) points out that it has been

demonstrated that some individuals may have a fear response to homosexuality and says

that for this reason the use of the term homophobia seems reasonable. On the other hand

Herek (1999, p. 1) proposes the term sexual prejudice linking it with the research tradition

on prejudice in social psychology. It may be a more suitable because it conveys noassumptions about the motivations underlying the negative attitudes and avoids value

judgements about such attitudes.

Heterosexism has been used over the last two decades sometimes interchangeably with

homophobia and was chosen for its parallel structure to racism and sexism. Heterosexism

or heterosexist bias was defined by Morin (1977) as the belief system that values

heterosexuality as superior to and/or more natural or normal than gay and lesbian

orientations (Greene, 1994, p. 8). Homophobia has usually referred to describe individual

bias towards heterosexuals and anti-gay attitudes or behaviours whereas heterosexism

has been employed to describe cultural bias towards heterosexuals and refer to societal

level ideologies and patterns of institutionalised oppression of non heterosexual people

(Herek, 1999, p. 2).

Heterocentrism or heteronormativity should not be confused with heterosexism and are

terms used to express the perceived reinforcement of beliefs whether by social institutions

or policies, which assert that heterosexuality is the only normal or natural orientation,

against which other sexualities are to be judged. Heterocentrism is also the assumption that

everyone is heterosexual and the attitudes that derive therefrom. Heterocentrism is often

subconscious and shows up in less intentional ways (Bowers et al. 2006).


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2.1.3. Societal & Institutionalised Homophobia/ Heterosexism

Bowers et al. (2006) highlight that for LGBT5 people, the impact of discrimination on

cultural, institutional, inter-personal and internalised levels leads to a reporting invisibility in

relation to harassment, a poorer general health status, diminished utilisation of health carefacilities and a decreased quality of health services (p. 12). Societal homophobia and

heterosexism can be influenced by and reflected back by the media, and have an effect on

LGB individuals in many areas of their daily lives. In educational, employment and health

care sectors, institutionalised homophobia and heterosexism may have negative impacts

resulting in direct mental health problems for LGB individuals. Rather than being inherent in

humans, homophobia is considered to be a cultural phenomenon, something thatis a learnt

behaviour. If homophobia is indeed cultural and it a learnt belief, it is widespread. Eighty-

five member states of the United Nations consider LGB sexuality a criminal offence, and this

type of state sponsored homophobiapromotes a culture of hatred reinforcing sexual

prejudice and continuing the cycle of oppression and discrimination of sexual minorities

(Ohosson, 2007, p 4).

2.1.3.1. Education

In education sectors there has often been a fear of discussing, or portraying positive images

of, LGB sexualities. In the United Kingdom for many years the promotion of LGB sexualitieswas forbidden under Section 28 of the Local Government Act 1990 and as a result many

schools omitted discussion of LGB identities, increasing the conspiracy of silence (Tinney,

1983, in Davies 1996, p. 45). Davies (1996) highlights that the omission of representations

of positive LGB lives in school curricula further stigmatised and devalued the sexualities of

those students who might be LGB and denied them opportunities to learn about themselves.

Davies (1996) also observes how history has been edited to excludepositive references to

homosexuality and the contributions made by LGB people in many disciplines (p. 45). The

situation today has not improved and one recent study revealed that 70% of secondary

pupils have never been taught about LGB people or seen LGB issues addressed in class

(Hunt & Jensen, 2007). Homophobic language is commonplace and current comments like

thats so gay (meaning bad) and general verbal abuse is often overlooked. Homophobic

5 LGBT lesbian, gay, bisexual, transgendered. Transgender is an umbrella term used to describe peoplewhose gender identity (sense of themselves as male or female) or gender expression differs from that usuallyassociated with their birth sex. Many transgender people live part-time or full-time as members of the othergender. Broadly speaking, anyone whose identity, appearance, or behaviour falls outside of conventional

gender norms can be described as transgender. However, not everyone whose appearance or behaviour isgender-atypical will identify as a transgender person (American Psychological Association, 2007a).


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bullying is also said to have reached endemic levels in British schools with two-thirds

(156,000) of LGB pupils experiencing being victimised. From this group 92% had

experienced verbal homophobic bullying, 58% had been ignored or isolated, 41% had

been physically bullied and 17% had received death threats. It was also revealed that

teachers often turn a blind eye to homophobic language and bullying (Hunt & Jensen,

2007). It is paramount that students are educated about LGB issues and this kind of bullying

is not tolerated. Many of these students will be tomorrows health care workers.

2.1.3.2. Media

LGB individuals are not often portrayed in the media, and when they are they are often

stereotyped or negatively portrayed as mal-adjusted or dangerous. Hollywood is noted for

its homophobia, the absence of positive portrayals of LGB people and resorting to LGBstereotypes, unlike the fringe cinema and stage where diverse sexualities have been

celebrated (Davies, 1996). Television can be a powerful influence in challenging prejudice,

but also in perpetrating it. In over 168 hours of broadcasting by the BBC in 2006,

portrayal of lesbians and gay men occupied a mere 6 minutes. Furthermore, 80% of LGB

references were negative, 72% of references were in the entertainment sector relied on

clichd stereotypes while half of all gay references were for comic effect (Cowan, K. &

Valentine, G, 2006). There were no scenes of homophobia being challenged and in 30

instances gay male sexuality was used as an insult in 22 programs. There were also no

references to LGB individuals with disabilities or from ethnic backgrounds, and no

references to bisexuality (Cowan & Valentine, 2006). These negative or stereotypical

portrayals of LGB identities oppress sexual minorities and further add to the collective

homonegativism which exists in the dominant culture, providing intolerant heterosexuals with

limited information of LGB lives that may well sustain or solidify their negative attitudes

(Greene, 1994).

2.1.3.3. Health Care

In health care professions there has been and still exists institutionalised homophobia and

heterocentrism. Bowers et al. (2006, p. 17) argue that despite being charged with a

fundamental caring role and being a safe-haven for those in need, the health care system

has been repeatedly documented in various studies to have endemic levels of

discrimination and disadvantage against LGBT peoples health care.

Although the relationship between LGB sexualities and the mental healthcare systems hasgreatly improved, there still exists widespread homophobia and heterosexism within these


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systems (Davies, 1996, McFarlane, 1998). LGB individuals are more likely to use mental

health services than their heterosexual counterparts, with problems often stemming from

negative reactions to their sexuality and discrimination. Nevertheless research has

suggested that such service users are likely to encounter the same homophobia in the mental

health services as they do in wider society (National Disability Association, 2005).

LGB individuals may face many barriers in accessing services or in the process of coming

out6 to health professionals. They often have fears of availing of services, especially those

who were treated for homosexuality in the past.

Fears may include

Safety concerns

Being judged negatively, stigmatised or pathologisedConfidentiality concerns

Invisibility or lack of acknowledgement of diversity

Multi-oppression7 (McFarlane, 1998: 43).

The decision to disclose ones sexual orientation to mental health workers may still result in

negative outcomes for the LGB individual according to recent studies in Europe, Australia

and the US (Golding, 1997, McFarlane, 1998; King & McKeown, 2003). In one study 73%

of LGB service users in mainstream health services had experienced some form of prejudice

or discrimination in relation to their sexual orientation (Golding, 1997). Furthermore, in the

cases of 51% of participants, their psychological distress had been inappropriately

affiliated with their sexual orientation by mental health professionals. This was supported

by the fact that for LGB service users negative experiences were found to be more common

than positive ones. These include

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