Lesbian and Gay Health: Power, Paradigms, and Bodies

Tamsin Wilton. Handbook of Lesbian and Gay Studies. Editor: Diane Richardson & Steven Seidman. 2002. Sage Publication.

The Great Divide?

As with so many aspects of lesbian and gay studies and, indeed, women’s studies before it, the academic study of health has a dynamic relationship to political activism around health policy issues. Theory and research feed into activism and vice versa; indeed, academics and activists are sometimes the same individuals. However, unlike other subject areas in lesbian and gay studies, research into health issues and problems tends to be located in a professional arena, that of health and social care practice. This unique combination of factors means that scholarship in the field of lesbian and gay health is split into what can seem like two completely separate halves. This split is partly disciplinary and partly to do with the intentions and motivation of two contrasting groups of scholars. It is very marked, to the extent that work done in one arena may remain very unfamiliar to those working in the other.

The first body of work consists of research located in the policy arena or in practice. This is the aspect of lesbian and gay health studies that is probably the most visible from the point of view of lesbians and gay men outside the academy. It is largely produced by researchers (including practitioners) working from within the broad field of health studies. They aim to focus attention on the health care needs of lesbians and gay men, to encourage greater recognition of homophobia as a malign influence on health and life chances, and to improve health care provision to lesbian and gay service users.

The end product of work of this kind includes articles in practice journals, reports directed at policy-makers, papers or poster presentations at conferences and study days for nurses and other health care professionals. Education and information are also targeted at lesbian and gay community members in the form of educational articles in the pink press, or healthcare handbooks (examples include Shernoff and Scott, 1988; Weatherburn, 1992; McClure and Vespry, 1994; Gill, 1996; Wilton, 1997a).

The second body of work is very much theoretical and concerned with abstract questions. Generally produced in universities, by academics who study health as a contested concept and medicine as a discourse, it incorporates work in disciplines such as sociology or cultural studies, or in multi-disciplinary areas such as queer studies/ sexuality studies, or theories of the body. Here, issues to do with sexual orientation are generally integrated into debates about subjectivity and identity, medical power, the social construction of gender and the medicalisation of gender and sexuality (examples include Hausman, 1995; Waldby, 1996; Rosario, 1997; Shildrick, 1997; Wilton, 1997b; Mort, 1997/2000). Although the focus of such work is more likely to be ‘purely’ intellectual than policy-orientated, many of those carrying out research in this arena are motivated by a more or less implicit concern for social justice and hence for the greater well-being of queer people. Moreover, as I shall argue here, the more pragmatic and policy-driven kinds of research require at least some understanding of theoretical work on sexuality and health in order to underpin future development.

Any overview of health as a topic of concern within lesbian and gay studies needs, therefore, to explore the relationships between activism, policy/practice research and discourse-based scholarship. Here, I have chosen to start by discussing two very different forms of political activism around health; AIDS activism and the involvement of lesbians in the women’s health movement. The discussion then continues with an exploration of more formally academic work on lesbian and gay health from the policy/practice perspective. The second section introduces the more theoretical body of work concerned with analysing medical discourses of gender and sexuality, and the chapter concludes with an assessment of the relationship between these strands of activity and their contribution to the embryonic discipline of lesbian and gay health studies.

Two Kinds of Health Activism

The forms taken by health activism reflect and grow out of the political history of activist movements at different points in time and at various geopolitical locations. Thus, AIDS activism differs in many important ways from activism around lesbian health. The reasons for this are complex, and are to do with such factors as political and professional power, socio-economic inequalities, shifting norms in an increasingly media-filtered mainstream culture and (especially) the influence of sexism on these and other issues.

When, in the early 1980s, the HIV epidemic first made itself felt among the urban gay communities of the United States, it sparked the formation of a new activist community, made up largely of privileged, educated, white gay men for whom such a direct experience of social exclusion was new and bitter (Wilton, 1992; Kayal, 1993). The increasingly coalitional nature of AIDS activism in the USA, as more and more marginalised groups became affected, was a new experience for many of the gay men involved. Although some had experience of lesbian and gay politics, health was never high up the gay rights agenda in the US (see, for example, Jay and Young, 1978, 1994). Even in Britain, where a welfare state and a national health service underpin a very different sense of entitlement, the Campaign for Homosexual Equality (CHE) and the Gay Liberation Front (GLF) paid little attention to health care (see Cant and Hemmings, 1988; Power, 1995).

Lesbian health activism, in contrast, grew out of the women’s health movement and employed many of the strategies developed in the wider context of feminist healthcare politics. As an integral element of the second wave of the Women’s Liberation Movement (WLM), the women’s health movement was, by definition, part of a long-lasting social and political struggle for rights. Moreover, with issues such as reproductive rights, free access to abortion and the struggle against rape and domestic violence at the top of the agenda, sexuality was an integral element of the feminist struggle (Smart and Smart, 1978).

Not only did lesbian health activists cut their teeth on such issues, they also had to fight within feminism, against the heterosexual majority who thought lesbian issues unimportant or who believed that to include lesbians would bring feminism into disrepute (Abbott and Love, 1985; Nestle, 1987; Cruikshank, 1992). Nor was the infant gay movement much better. Since so many gay men were hostile to feminism (Cruikshank, 1992; Power, 1995) and unwilling to acknowledge either lesbian oppression or their own sexism, lesbian issues dropped down the agenda of the gay liberation movement.

Finding themselves marginalised within feminism and gay liberation, large numbers of lesbians abandoned both mainstream gay politics and the women’s movement. This historical moment—from the early 1970s to the mid-1980s—was, at least in Britain and the USA, the heyday of lesbian separatism. As a political strategy, separatism required lesbians to devote their energy and time to other lesbians, an approach that included establishing separate clinics for lesbians. The first, begun in New York City in 1973 (Waitkevics and Stein, 1978), established a model that is still relevant, as demonstrated by the slowly growing number of lesbian clinics and well-woman drop-in centres around Britain today (Wilton, 1998).

Scholarship Out of Activism

The contrasting forms of activism over lesbian health and HIV/AIDS1 have given rise to very different bodies of academic work. Work on HIV/AIDS, which may be assumed under the loose umbrella of lesbian and gay studies, takes many forms. Indeed, there has been a dazzling profusion of AIDS-related scholarship by and about gay men and (to a lesser extent) lesbians. This body of work encompasses social science (Altman, 1986; Waldby, 1996), cultural studies (Boffin and Gupta, 1990; Wilton, 1997b), media studies (Crimp, 1988; Crimp with Rolston, 1990), fine art studies (Gott, 1994), literature (Mars-Jones and White, 1988; White, 1997), film studies (Patton, 1991; Gever, 1993), policy studies (Patton, 1985; Wilton, 1992; King, 1993), social history (Fee and Fox, 1988; Kayal, 1993), philosophy (Sontag, 1988) and many other elements.

As lesbian and gay studies/queer studies consolidates its academic position, a queer scholarship of AIDS seems fully integrated into the discipline (see, for example, Abelove et al., 1993; Creekmur and Doty, 1995; Seidman, 1996; Nardi and Schneider, 1998). So variegated and cross-disciplinary has the study of AIDS become, however, that it exceeds the boundaries of anything which could plausibly be called ‘health studies.’ Social scientific research methods of the most familiar and mainstream kind—surveys, questionnaires, interviews—stand side by side with elite theoretical musings on popular cultural artefacts seldom admitted into the study of health.

This proliferation across disciplinary boundaries is typically postmodern and very much in tune with the Zeitgeist of the academy. However, it remains unfamiliar territory to those who actually work in the field of AIDS care, whose training is still largely innocent of input from the humanities and cultural studies. This element of the scholarship of AIDS might more properly be said to belong in our second category of lesbian and gay health studies, discourse-based theory. Yet those scholars, such as Susan Sontag (1988), Catherine Waldby (1996) or Paula Treichler (1988 a, b), who employ sophisticated discourse analysis to understand the social and cultural impact of the pandemic, clearly intend their work to contribute to the struggle against AIDS. This is the first point at which it starts to become clear that high theory and pragmatic policy-driven research are inseparable elements in lesbian and gay health studies.

Dykes without a Theory: Lesbian Health Research

The sheer range of AIDS-related work, from cutting-edge discourse analysis to routine epidemiological data collection, is in sharp contrast to scholarship in the field of lesbian health. Here, relatively few of those working in the field are established academics and almost no theoretical work has been carried out on the complex foundational questions on lesbian health. AIDS acted as a catalyst for plenty of high-theory work on the gay male body, its surfaces, vulnerabilities, representations, health/sickness and its capture by competing discourses (e.g. Bersani, 1988; Hewett, 1990; Meyer, 1998). Of course the contribution made to AIDS theory by lesbian academics and activists has ensured that the lesbian body is a presence—albeit a shadowy one—in AIDS theory (Wilton, 1997b; Richardson, 2000b). However, the paradigmatic body-at-risk, as represented in high theory texts on HIV/AIDS, continues to be a white, gay male body.

The socio-cultural phenomenon that is AIDS (as distinct from the bio-medical emergency that is the HIV pandemic) has engendered a polyvocal and cross-disciplinary body of theoretical work that deconstructs notions of health, pathology, (male) homosexuality, masculinity, medicine and the body. Apart from its footnote status within this body of work, the whole notion of ‘lesbian health’ is, by comparison, profoundly under-theorised and remains a taken-for-granted concept in most published work on the subject (Wilton, 1997c).

Voices from Practice

With the exception of the deconstructive strand of AIDS scholarship, most published work on lesbian and/or gay health is situated within the professional context of health and social care practice. Typically, practitioners who are themselves lesbian or gay carry out pieces of research with the aim of improving one or more aspect of service provision to lesbian or gay service users in their own area of expertise. Since health and social care services are, by their nature, not generally located in academic institutions, opportunities to engage in research may be limited and, in any case, will have very different parameters from those which apply to university researchers.

Research of this kind has, therefore, often been carried out by student practitioners in post-basic training, who may make use of their time in a higher education environment to carry out studies for undergraduate dissertations or postgraduate theses. Examples include Stewart’s (1997) study of the experiences of lesbian mothers, or Das’s (1996) account of homophobia in medical training. There is still a real shortage of reliable data on many lesbian and gay health issues, so there is greater than usual potential for even an undergraduate dissertation to make a meaningful impact in the literature, especially if it is reworked as an article in the practice literature or presented at a practice conference. However, this also gives rise to the risk that work of variable quality may be published and, sadly, this is already the case in some areas of the health and social care practitioner literature on lesbian and gay issues.

A parallel strand of more formal practitioner-initiated research in this field is carried out by more experienced professionals who have succeeded in getting funding for specific projects. Often this work is supported by professional bodies, such as (in the USA) the Gay and Lesbian Medical Association or (in Britain) the Royal Colleges, who recognise the need for practice improvements in order better to meet the needs of their lesbian and gay clients. The British model for research of this kind is the Royal College of Nursing (RCN)’s working party on lesbian and gay nursing issues.

Set up in response to pressure from lesbian and gay nurses, the working party has carried out a substantial body of work on many aspects of the nursing care of sexual minorities, and has produced several key Statements on important issues such as the nursing needs of lesbian and gay patients (RCN, 1994) or the vexed question of next-of-kin status in families with lesbian or gay members (RCN, 1998). These Statements are the chief means by which the RCN establishes and maintains good professional practice in nursing, so the existence of these examples represents a significant step forward. The RCN working party has also published widely in the nursing literature, ensuring that research findings and implications for practice are disseminated widely through the profession. More recently, this model has been taken up by the Royal College of Midwives (RCM), who funded a survey of lesbian mothers to identify strengths and weaknesses in service provision (Wilton and Kaufmann, 2001). The RCM also established a working party to devise a formal Policy Statement on the maternity care of lesbian mothers, drawing on the expertise of academics in the field as well as experienced midwives and midwife tutors.

Important interventions in practice, such as the work done in the USA by the Institute of Medicine (Solarz, 1999) or in Britain by the Royal Colleges, are almost invariably instigated by practitioners who are themselves lesbian or gay. For example, the RCM’s ground-breaking programme was initiated in response to a lesbian student midwife who contacted the College to express deep concern at the homophobia she experienced during her own professional training. It is therefore important to recognise that work of this kind remains impossible in those areas where homophobia retains a powerful professional, cultural or political sanction (Rosenblum, 1996). It is still the case that, for those working in the health care professions, openly asserting a lesbian or gay identity demands real courage.

The final element in this practice-orientated field is research carried out by trained professional researchers, usually employed by universities, using funding obtained from the larger institutional funding bodies, such as England’s Health Development Agency (formerly the Health Education Authority), New Zealand’s Health Funding Authority or the US Department of Health and Human Services. It is notoriously difficult to persuade funding bodies that work of this kind is relevant or important, and homophobic stigma remains an obstacle both in terms of obtaining funding and in carrying out work in practice areas. Farquhar (1999: 81) is fairly typical in meeting stubborn resistance from staff working in genito-urinary medicine (GUM):

a ‘flagship’ GUM service, … which had initially agreed to participate in my research, declined at the last moment to do so (after full ethics committee approval had been granted), on the grounds that it was not possible to find a member of clinic staff willing to take named responsibility for liaising with a study on lesbian sexual health.

Nevertheless, it is certainly easier now to obtain funding than has ever been the case in the past, and the body of knowledge generated by this means is growing rapidly. Such studies vary greatly in scale and scope, from small-scale survey work carried out in a local area (examples include Dockery, 1996; Mugglestone, 1999) to major studies with a national focus, of which the most significant recent example is the Institute of Medicine report on lesbian health in the United States (Solarz, 1999).

Characteristics

This important and growing body of work is almost always funded out of the public purse. There seems to be little funding available from commercial sources in the private sector, with the important exception of work on HIV/AIDS which, at least in the USA, is often funded by drugs companies hoping to improve their standing with the gay community. In Britain, local authorities or local healthcare trusts have funded some key studies in their area.

In relation to this body of work it is often difficult to detach ‘lesbian and gay health’ from sexual health or, indeed, from a specific focus on HIV prevention. On one level, this is problematic, since it powerfully reinforces the social construction of lesbian and gay identities as primarily sexual and of lesbians and gay men as sexual deviants interested in little else. In terms of a public health agenda, locating lesbian and gay health under the umbrella of sexual health makes it very difficult to explore either the wider consequences of homophobia for health or the impact of heterosexism within the medical profession.

However, concern to prevent the continuing spread of the HIV/AIDS pandemic may often lead to a recognition of the wider needs of gay men and/or lesbians for health education more generally. AIDS charities may fund research into a broad spectrum of gay health issues, often in collaboration with community groups. In Britain, for example, research into such gay-related issues as homophobic bullying in schools, or into safe sex practices, has been supported by charities such as the AIDS Education Research Trust (AVERT), the lesbian and gay campaigning group Stonewall or the Terrence Higgins Trust. By their very nature, such projects may adopt a more or less critical perspective on existing services, so are more likely to be based in established academic centres of excellence than carried out by practitioners.

Non-governmental organisations (NGOs), such as human rights groups, may also fund research into lesbian and/or gay health, as may service-user groups or single-issue health charities such as, for example, the British mental health charity, MIND. Such groups may be particularly interested in exploring questions of equitable treatment or access to services, and they may or may not collaborate with government agencies, depending on the local political situation.

Increasing global concern for human rights has been an important means of getting fundamental questions of lesbian and gay health and well-being onto political agendas. At the European and Atlantic Governmental Preparatory Conference in Vienna in 1994, the International Lesbian and Gay Association and the International Gay and Lesbian Human Rights Commission both presented formal Statements on the human rights of lesbians and gay men (Rosenblum, 1996). Human rights organisations have been slow to recognise the significance of sexual orientation as a valid human rights issue, but this situation shifted rapidly in the last decade of the twentieth century.

This shift has had a significant impact on lesbian and gay health politics and research. In Canada, for example, the Michigan Organization for Human Rights (1991) funded a major survey of lesbian health. South Africa, although in dire need of investment to underpin its collapsing economy, has enshrined lesbian and gay civil rights in the new, post-apartheid constitution. This offers (at least in theory) powerful political support for groups concerned with the health and well-being of lesbian and gay South Africans. A recent study of the health education and care needs of lesbian, gay and bisexual residents of Cape Town, carried out by local community group the Triangle Project, was funded by the Health Systems Trust and the Department of Health (Griffin, et al., 1998).

Lesbians and gay men who are citizens of countries of the European Union may soon make good use of the Human Rights Act, which came into force across the Union in October 2000, to underpin legal challenges against homophobic and/or heterosexist health care provision. The Act specifically prohibits discrimination against individuals on the grounds of sexual orientation (MacEarlean, 2000) and, since its remit covers all public services, it is likely to have a positive impact on health care. It is not possible at the time of writing to predict the response of health care providers, but it will arguably be much more difficult to justify spending public money on research or services that fail to take account of the needs of lesbian and gay service users.

Future Research Questions for Policy and Practice

Clearly it is not possible, in the space available here, to detail all the research that remains to be done in the field of lesbian and gay health from a policy/practice perspective. Nor is it possible to predict the directions such research might take in response to shifts in local, national or international policy agendas. In Britain, for example, the policy agenda of Tony Blair’s New Labour government is dramatically different from that of the Tories under John Major or Margaret Thatcher. In particular, a determined focus on health inequalities and social exclusion has resulted in a redirection of funds towards primary care and a recognition of the social factors that contribute to ill health. This suggests that the time is ripe for researchers to argue that sexual orientation functions as a mode of social exclusion in homophobic societies, and that homophobic bias is a public health problem. Certainly, new thinking on sexuality and citizenship (e.g. Richardson, 1998; 2000a) would support such a move.

However, research into sexualities and health is far from straightforward. Both sexual orientation and health are contested concepts and are, in any case, contingent on many other social and cultural factors. A cursory glance at two issues, breast cancer and homophobia, will serve to illustrate the breadth and complexity of this research area.

Lesbians and Breast Cancer: A Moot Point

The vexed question of lesbians and breast cancer offers a cautionary tale about the difficulties of establishing links between sexual orientation and vulnerability to disease, and about the importance of accurately representing research findings.

There is an assumption current in many lesbian communities that lesbians are at increased risk of developing breast cancer relative to non-lesbian women. This assumption, importantly, is not based on comparative research. Rather, it is a conclusion reached by extrapolating from research findings which indicate that childlessness, failure to breastfeed, obesity and excess consumption of alcohol may result in increased risk of developing malignant breast disease (Kerner, 1995). By assuming that these factors are likely to be characteristic of lesbian populations, you reach a position where you can hypothesise a greater relative risk for lesbians.

However, these extrapolations need to be treated with some scepticism. First, we do not know what proportion of lesbians have children, and methodological problems mean that this situation is unlikely to change in the forseeable future. Even if we did have this information, it is still childlessness, rather than being a lesbian, which is significant. The protective factor, breastfeeding, remains the same whatever your sexual orientation.

Even those research findings which seem to indicate that lesbians are disproportionately likely to be obese or to abuse alcohol need to be treated with caution. They are almost all from the United States, where excess consumption of both food and alcohol is high on the list of health-damaging behaviours for the population in general, and all have real problems with sampling and sample size. There is, for example, a strong possibility that lesbians recruited by researchers are particularly likely to have problems with food and alcohol ab/use, simply because the very nature of recruiting ‘hard to reach’ groups means that samples are often drawn from a community culture based in bars and clubs (Whisman, 1996). Even if it were the case that lesbians are more likely to experience problems with food and/or alcohol than non-lesbian women, any increase in breast cancer risk is due to obesity and alcohol abuse, not lesbianism.

This single example demonstrates just how complex is the relationship between sexual orientation and health. It also suggests that researchers need to take care not to present data in such a way that it risks contributing to homophobia. Those who manipulate existing data on obesity, alcohol ab/use and breastfeeding to suggest that lesbians are a high risk group for breast cancer, may be inadvertantly colluding with homophobic claims that lesbians are sick or unnatural.

Homophobia and Health: Uncharted Territory

It is important to bear in mind that the extent to which lesbian and gay citizens are discriminated against by political adminstrations, legislatures and social infrastructures varies widely between countries. Such institutional homophobia clearly has consequences for health and access to services, and little comparative research has yet been carried out into the experiences of lesbians and gay men in different health care and policy systems. Someone accustomed to the very high levels of institutional homophobia found in Britain or the USA may be surprised by countries such as Sweden or Denmark where the situation is very different (Tatchell, 1990; Griffin and Mulholland, 1997).

This suggests, among other things, that a researcher trying to understand the consequences of homophobia for health needs to take an international perspective. It does not take a vivid imagination to recognise that the health and well-being of a gay man living in the redneck depths of Alabama is likely to be very different from that of his counterpart in Copenhagen or Gothenburg. The fundamental question, in whatever socio-political context, is why is the health care profession failing to meet the needs of its lesbian and gay service users? In order to begin exploring this question, we must turn to the second, theory-based, strand of research in lesbian and gay health studies.

Queerying Medical Power

This deconstructive approach to lesbian and gay ‘health’ has to do with more abstract questions than those addressed in a policy/practice context. The two central issues here seem to be, first of all, the ‘grand question’ of sexual identity (or orientation or preference, depending on your model of sexuality) and, secondly, that central theme of the sociology of health and illness, the power of the medical profession and its role in the cultural construction of difference. The two are, of course, closely entwined. In fact, taking sexual orientation as a ‘case study’ exposes with particular clarity the role of medical discourse in social control, and the appropriation of the body by the medical profession. This makes it particularly frustrating that sexual orientation is so widely ignored within mainstream health studies, precisely the discipline that concerns itself with such issues (see, for example, Jones, 1994; Moon and Gillespie, 1995; Turner, 1987/1995; Annandale, 1998; Petersen and Waddell, 1998).

The medicalisation of homosexuality is a product of the history of the medical profession in European culture. Since the time of the Enlightenment, Western scientific medicine has been extraordinarily successful in establishing its professional dominance and credibility. In particular, the profession has asserted a privileged claim to scientific objectivity, claiming that its descriptions of, and explanations for, human behaviours are disinterested and transparent accounts of the ‘real’ world. The hegemony of medicine as a paradigm, world view and social institution enables its practitioners to speak with great authority about what is normal and what is deviant. In particular, medicine has co-opted the authority to distinguish categorically between health and dis/ease, both of bodies and of behaviours, and to act on bodies in order to destroy disease.

Historically, a medical model for homosexuality replaced older notions of sin, as the power of organised religion was superceded by that of organised medicine. This shift in paradigm was enormously significant, since it marked a shift in attention away from behaviours to identities. As Foucault so famously explained:

As defined by the ancient civil or canonical codes, sodomy was a category of forbidden acts; their perpetrator was nothing more than a juridical subject of them. The nineteenth-century homosexual became a personage, a past, a case history … a type of life … with an indiscreet anatomy and possibly a mysterious physiology …

The sodomite had been a temporary aberration; the homosexual was now a species. (Foucault, 1976: 42-3)

Social historians disagree about the consquences of this for the formation of a homosexual social identity and for the development of homosexual communities (see Weeks, 1985; essays in Duberman et al., 1989; Boswell, 1994). However, there were important consequences for the relationship between people whom we now think of as lesbian or gay, and the medical profession. In particular, biomedical research into the ‘cause’ of homosexuality could not happen unless same-sex erotic desires and activitives were at some point conceptualised as symptoms of an individual disorder (whether physiological or psychological).

Looking for the Outward Signs of Queer Desire

Biomedicine has successfully commandeered the body as its professional territory, and has accrued enormous social, cultural and political power by establishing monopoly rights over the business of identifying and ‘curing’ organic disease processes. Biomedical professionals therefore have an investment in claiming that forms of human difference have their origin in the body. This is particularly so for those differences that are socially significant, such as gender, or socially troublesome, such as criminality or homosexuality. It is therefore hardly surprising that biomedical researchers have constructed a disease model for homosexuality, since this enables them to get funding to explore its symptomatology, identify its aetiology (causes) and, by implication, suggest strategies for prevention and cure.

There is not the space here for a detailed summary of the history of biomedical theories of homosexuality (for summary accounts see Ruse, 1988; Byne, 1994; Rosario, 1997; Wilton, 2000b). It is, however, worth pointing out that such theories have been driven at least as much by developments in medical technology as by socio-cultural factors. As new technical developments enabled the medical gaze to extend its surveillance from the surface of bodies (with the unaided eye) to its cells, endocrine system, brain structure and chromosomes, theories of the origin of homosexuality have followed. Where early medical researchers spent their time measuring the depth of ‘sex variant’ women’s vaginas with a crude depth indicator bodged out of a piece of wire wound round a finger, their twenty-first-century counterparts rely on magnetic resonance imagery of brain tissue, or strive to isolate individual chromosomes (for a summary see Wilton, 2000b).

With the exception of social Darwinism and its socio-biological explanations for homosexuality as an aid to species survival, the essentialist theories of homosexuality are all located within a primarily clinical paradigm (see Birke, this volume). Moreover, they all rely on what Foucault (1976: 43) called ‘a kind of interior androgyny, a hermaphrodism of the soul.’ In other words, whether the cause of homosexuality is sought in the brain, the DNA, the endocrine system or early childhood experiences, the underlying assumption is that desiring men is an inherently female characteristic, and desiring women is inherently male.

Researchers are therefore, in essence, trying to track down evidence of a fault in the biological mechanisms which they see as responsible for producing sexual difference in human beings. Studies to date seem also to have assumed that the best way to identify such evidence is to do comparative measurements of the size of specific physiological elements within a binary sex framework. In other words, if some part of the human anatomy is generally larger in women than in men, it will be larger in gay men than in heterosexual men, and smaller in lesbians than in heterosexual women.

To this end researchers have expended much time, energy and money in measuring penises, anuses, vaginas, pelvic basins, clitorises, nipples, fingers and even ears (Ruse, 1988; Wilton, 2000a). On a microscopic level, different structures in the brain have been measured (LeVay, 1993), as have chromosomes and the level of so-called ‘sex-hormones.’ As many critics have pointed out (see essays in Gonsiorek and Weinrich, 1991; Terry and Urla, 1995; Rosario, 1997), such research is unlikely to produce anything of scientific worth. Any social scientist will tell you that establishing a working definition of ‘gay’ and ‘straight’ is dauntingly complex, yet biomedical researchers are often extraordinarily cavalier about assigning their research subjects to one category or another. For example, Simon LeVay, the US researcher who claims to have identified physiological differences between gay and straight men’s brains, labelled all his female cadavers as heterosexual by default, purely on the basis that there are not many lesbians around (LeVay, 1993).

Nor are the purported physiological distinctions between women and men as clear-cut as they are generally claimed to be. Supposedly generalisable findings about sex differences in brain structure seem to be particularly weak. Neuroanatomist and psychiatrist William Byne (1994: 295) warns that, ‘Of the supposed sex differences in the human brain reported over the past century, only one has proved consistently replicable: brain size varies with body size. Thus, men tend to have slightly larger brains than women.’

The history of biomedical research aimed at identifying the cause of homosexuality seems naïve and anachronistic from a social scientific perspective. The complex social and cultural factors which police and produce ‘gender,’ ‘sex’ and ‘sexuality’ have been rigorously theorised, and bio-essentialist hypotheses compare badly with social constructionist models of sexuality. As Mary McIntosh pointed out as long ago as 1968:

The failure of research to answer the question [whether homosexuality is an innate or acquired condition] has not been due to lack of scientific rigour or to any inadequacy of the available evidence; it results rather from the fact that the wrong question has been asked. One might as well try to trace the aetiology of ‘committee chairmanship’ or ‘Seventh Day Adventism’ as of ‘homosexuality.’ (McIntosh, 1968: 31)

In short, homosexuality is a social role and, as such, is simply not a proper object for biomedical scrutiny. Social constructionist theories, drawing on research in anthropology, social history, cultural studies and sociology, constitute a substantial and impressive body of evidence that undermines the epistemological and ontological foundations of biomedical models of sexual orientation (see Foucault, 1976 and essays in Stein, 1990; Seidman, 1996). The question now becomes, not ‘what are the biomedical causes of the homosexual condition?’ but ‘why and how does biomedical science claim the authority to explain homosexuality?’

Medicine and the Social Control of Gender and Sexuality

To answer this question we must examine the social control function of biomedical science and, in particular, its role in policing and reproducing a binary regime of gender. As we have seen, ‘scientific’ hypotheses about the cause of the homosexual condition inevitably depend upon some variation of a gender-inversion model for same-sex desire and eroticism. This unthinking acceptance of what I have called a heteropolar model of gender and sexuality (Wilton, 1996 a, b) tends to produce quite catastrophic collapses in biomedical logic. Take, for example, Dean Hamer and Peter Copeland’s discussion of the likely impact of the chromosome block, Xq28, on sexual attraction:

There is no way to be sure yet, but it’s unlikely the same version of Xq28 associated with male homosexuality also is associated with lesbianism … If Xq28 influenced sexual orientation by directing a person’s sexual attraction, it would be unlikely to influence both gay men and lesbians, because the objects of their affection are just the opposite. (Hamer and Copeland, 1994: 289, my italics)

So this, apparently highly sophisticated, hypothesis concerning a genetic origin of same-sex desire is predicated upon an unproblematised socio-cultural metaphor of ‘opposite sexes.’ Yet in what sense may male and female humans be said to be ‘opposite’? Are we here talking about bodily configuration? If so, the notion of opposites can only refer to a naïve kind of genital functionalism, whereby penis is the ‘opposite’ of vagina in the way that plug is the ‘opposite’ of socket or foot is the opposite of sock. The everyday language of sexual oppositeness makes it fairly obvious that the model has been appropriated from physics, where ‘opposites attract’ and a sexual ‘charge,’ rather like electricity, moves of necessity from one pole (the male) to the other (the female). Here, male sexual potency is constructed as an electromagnetic charge that builds up (from friction, or simply from unstoppable production within the body) and must be discharged onto a body bearing the opposite polarity. It is this socio-cultural story of heteropolarity that provides the unquestioned structuring logic of almost all biomedical models of gender.

Moreover, because heteropolarity produces gender as a function of uni-directional sexual desire and activity (you are a man because you want to put your penis in a vagina and a woman because you want a penis in your vagina), it is not possible to disengage gender from the erotic or vice versa. So scientists carry on trudging endlessly (and somewhat randomly) through the spaces of the body, seeking physical signs of female matter out of place in the gay male body. As Byne comments (1994/2000: 295), ‘the notion that gay men are feminized and lesbians masculinized may tell us more about our culture than about the biology of erotic responsiveness.’

The doctrine of heteropolarity lies at the heart of the medical profession’s unhelpful relationship with those of its service users who are not heterosexual men. Moreover, it infests cultural stereotypes of other forms of difference, including ‘race’ and disability. White supremacist discourse produces, and depends upon, constructs of race that are sexually marked in specific ways. The sexual voracity of women of colour, the black super-penis, the lascivious Asian or Oriental schooled in the erotic arts, these and other constructs of racialised sexuality serve to demarcate the boundaries of white European sexuality as controlled and civilised. To be white is to be in firm control of the animal within and hence to be destined master of those ‘races’ whose animal sexuality marks them as child-like, savage, needful of mastery (Fausto-Sterling, 1995; McClintock, 1995; Tolen, 1995). It is not difficult to recognise the heteropolar paradigm of necessary gender hierarchy here. The subordination of racialised ‘others’ to white dominance mirrors the subordination of women (childlike, closer to nature, needful of mastery) to men in European culture.

Thus a critical examination of the construction of ‘homosexuality’ in medical discourse offers intellectual support for a coalitional approach to key questions of social justice and human rights. The social exclusion and political marginalization of queers, women and people of colour stand in a particular relationship with a bioreductionist paradigm of difference. Questions of masculinity, femininity and the erotic are closely interwoven within this paradigm to produce bodies that are marked with signs of disorder. One key element of a critical study of lesbian and gay ‘health’ must be to identify the role of medical science in this complex project of social control.

Medicine Making Gender: Sex Reassignment Surgery

Any such critical deconstruction of medical discourses of gender introduces contradictions into lesbian and gay health studies. Importantly, this has consequences for political coalitions and health advocacy. At the heart of such contradictions lies an apparently marginal issue: transsexuality.

Increasingly, the umbrella of minority sexuality is seen to encompass individuals whose experience or performance of gender is at odds with their assigned biological sex. The inclusiveness of queer politics means that both activism and service provision within queer communities are more and more likely to be addressed to ‘lesbian, gay, bisexual and transgender’ individuals. In terms of lesbian and gay health issues the question of transsexuality introduces two, deeply contradictory, issues for consideration.

The first is that, if transgender and trans-sexing people are indeed part of the ‘queer nation,’ their healthcare issues have a place on the political and research agendas. This is far from insignificant, since there are many key health problems associated with the various forms of gender crossing. The standards of care associated with sex reassignment surgery (SRS) are extremely variable, and remarkably little is known about the long-term implications for physical and emotional well-being of the surgery itself, ancillary cosmetic procedures and the necessary life-long dependence on high doses of artificial hormones (Califia, 1997; Hausman, 1995). We also lack information about the attitudes of health and social care practitioners to service users whose ‘manning’ or ‘womanning’ (Ekins, 1997) is non-conformative. Research questions such as these may fit the existing lesbian and gay healthcare needs agenda in a relatively straightforward manner.

Less straightforward are issues to do with the theory and clinical practice of SRS, and what these suggest about the medicalisation of gender and sexuality and about the heteronormalising role of the medical profession. After all, the diagnosis of transsexuality was invented by a clinician who was at a loss to know how to respond to a male patient who insisted that he was female (Califia, 1997). Indeed, as Bernice Hausman (1995) so meticulously argues, the very idea of gender, as currently understood, arose out of the need for clinicians to justify surgical interventions on the bodies of babies born with ambivalent genitalia. Before this time, ‘gender’ was a term used only in the study of languages.

It is perhaps ironic that what started out as a technical term, coined in response to these developments in genital plastic surgery, subsequently became a keystone of feminist theory and activism. Gatens, who identifies Robert Stoller’s work on transsexuality as the originary moment of ‘gender,’ writes that:

his work was generally hailed as a breakthrough in the area of sexuality and socialization. As such it was quickly taken up by feminist theorists as offering theoretical justification for the right to equality for all independently of sex. His work has been used by Greer, Millett, Oakley … Chodorow, Dinnerstein and Barrett, to name a few. (Gatens, 1991: 142)

It is salutory to remember that this was a major paradigm shift. The ability theoretically to detach something called ‘gender’ (meaning masculinity or femininity) from biological sex (meaning maleness or femaleness), which is now so taken for granted and which remains so fundamental to both feminists and queer theorists, dates only from the late 1960s. Far from being a marginal issue then, clinical discourses of transsexuality and intersexuality turn out to be the very foundations of contemporary Western constructs of gender as a property of bodies. This has major implications for lesbian and gay health studies, particularly for any critique of the medical model of homosexuality which, as we have seen, insists that same-sex desires are somehow caused by a fault in the body’s gender programming.

The ramifications of SRS for our critique of the medical model of gender/sexuality are therefore profound. It would be difficult to argue that sex reassignment surgery represents a radical challenge to the heteropolar model that, I have argued, remains dominant in western scientific medicine. Sociologists Dwight Billings and Thomas Urban firmly locate the socio-medical construction of transsexualism at the heart of biomedicine’s professional colonisation of ever increasing areas of social and cultural concern. They write:

There is hardly a more dramatic instance of contemporary professional authority than so-called ‘sex-change’ surgery. Physicians perform cosmetic surgery yet certify that their patients have undergone a change of sex … public acceptance of sex-change surgery attests both to the domination of daily life and consciousness by professional authority as well as the extent to which many forms of deviance are increasingly labelled ‘illness’ rather than ‘sin’ or ‘crime’ … Sex-change surgery privatises and depoliticises individual experiences of gender-role distress. (Billings and Urban, 1996: 99)

The key problem for research and activism in the broad area of sexuality and health seems, then, to be that advocacy and support for the right of transsexual or transgender individuals to high standards of care and treatment in all aspects of health and social care delivery must go hand in hand with an informed and rigorous critique of the politics of SRS. For, although the numbers of individuals seeking SRS are relatively small, the theory and clinical practices of sex-reassignment have clear implications for the medical politics of gender and sexuality more generally (Wilton, 2000b).

Including a Sociology of the Body

Lesbian and gay health studies may initially appear to be a relatively simple issue. Yet, as we have seen, even basic research into healthcare policy and practice is fraught with contradiction and difficulty. This is because both sexual orientation and health are, by definition, located in various ways in bodies. And the dynamic relationship between our selves or subjectivities, our bodies and the social and cultural worlds we inhabit are extraordinarily complex. It is not difficult to see that those social and cultural worlds discipline and constrain our bodies, our behaviours and our identities in ways that impact on our health and the expression of our sexual desires, and this recognition underpins most practice/policy research into lesbian and/of gay health.

However, our bodies, behaviours and identities are also produced by the social and cultural worlds that we inhabit. This dynamic, too, has profound implications for health, and for the activities and power of the medical industry. Therefore the more abstract, discourse-based, theoretical work on sexualities and health, which can seem so far removed from the practical concerns of most healthcare researchers, is in fact an entirely necessary element of lesbian and gay health studies.

Directions for the Future

Given the interwoven strands of practice-based, empirical research and more abstract, theoretical work which constitutes lesbian and gay health studies, any attempt to predict the direction of future developments within such a vast and multi-disciplinary field can be little more than informed guesswork. However, there are important gaps in the existing literature, and it is increasingly likely that funds will be available to carry out the work needed to fill in some of the missing pieces in our knowledge.

In practical terms, research is needed to underpin human rights-driven political demands for egalitarian access to good quality health care. Here, there is an urgent need to develop a more sophisticated, empirically grounded understanding of the impact that homophobia has on the health and well-being of individual lesbians and gay men. The complex cultural and psychological parameters of homophobia require that such research is carried out in different localities, cultures and nations, and that it takes into account the intersections of homophobia with racism and sexism, as well as its observable tendency to undergo historical shift (Neild and Pearson, 1992; Kennedy and Davis, 1993).

Related to this is the need to identify and challenge the heterosexism that permeates medicine at every level. This requires interventions in the education and training of health care professionals, and such interventions must be evidence-based. Existing data on the knowledge, attitudes and practices of staff (Stern, 1993; Wilton, 2000b) needs to be supplemented with text-based analyses of medical discourse and with research into health policy at micro and macro levels.

The social, political and medical struggle against HIV, and its disproportionate impact (at least in the industrialised nations of the West) on the gay community, will continue to demand research activity. So, too, will the need to expand our knowledge of lesbian sexual health and of lesbian health more generally through the life-course.

However, there is precious little point in research activity of any kind unless it informs changes in practice. It is notoriously difficult to ensure that research findings—even the most pragmatic ones to do with the effectiveness of clinical therapies—are widely enough disseminated among practitioners. Here, the extraordinary efforts which were made by the AIDS community to ensure that combination therapies were used appropriately and effectively (Gay Men’s Health Crisis, 1998) offer a sound model of best possible practice. The unique coalition between activists, user groups, physicians and drugs companies, presents a powerful example of what can be done to navigate the power relations of capitalist medicine—albeit in the wealthiest nation in the world. It offers a template for those working on other lesbian and gay health issues, who want to ensure that their findings lead to improvements in practice.

The more theoretical element of lesbian and gay health studies has its roots in so many disciplinary areas that it is more difficult to predict or suggest future developments. However, it is clear that a heteropolar model of same-sex desire remains stubbornly dominant in biomedicine, and continues to underpin all ‘scientific’ research into sexual orientation. Given that this biomedical model of sexuality seems little short of naive to social scientists and cultural theorists, its continued dominance within medical science indicates that medicine suffers from a profound intellectual insularity. This suggests a fairly urgent need to develop ways of speaking across the traditional disciplinary and epistemological divide between the social and the physical sciences. Lesbian and gay health studies may yet prove to be the catalyst for the demolition of this stubborn divide.

All research into lesbian and gay health, whether empirical or theoretical, traces the points of intersection of biopower (Gastaldo, 1997) with medical constructs of health and pathology, sexual normalcy and deviance, professionalism and consumerism. As such, lesbian and gay health studies forms a potent element in the wider project of lesbian and gay studies in its focus on the (embodied) power relations that both discipline and engender all of us. Hopefully, therefore, a scholarship of health will become less marginal within lesbian and gay studies.