Group for the Advancement of Psychiatry
The Group for the Advancement of Psychiatry (GAP) is a U.S. organization of nationally respected psychiatrists dedicated to shaping psychiatric thinking, public programs and clinical practice in mental health. Its 29 committees meet semi-annually and choose their own topics for exploration. They are pioneers in exploring issues and ideas on the frontiers of psychiatry and in applying psychiatric insights into the general medical, social, and interpersonal problems of our times.
The Group for the Advancement of Psychiatry (GAP) was founded shortly after World War II in 1946 by young psychiatrists just returned from the war, impatient with the traditionalism of the American Psychiatric Association at that time. GAP's intended purpose was to produce position statements on relevant and controversial psychiatric issues. GAP reports were concise, published soon after they were written and widely respected and influential. Possibly because of the profound social changes that followed World War II, both the profession and the public were ready to accept revisions of traditional psychiatric attitudes and practices.
GAP's formulated policy to discuss controversial psychosocial issues was announced in 1950, in the Committee on Social Issues' Report, The Social Responsibility of Psychiatry, A Statement of Orientation (GAP 1950b, Report No. 13). In that Report, the Committee noted that two factors had been influential in causing diverse social problems in psychiatry: the role of prejudice in determining attitudes towards social problems and the sparse knowledge about the relationship between society and personality. In this pioneering document, the Committee on Social Issues emphasized the social responsibility of psychiatry. It made a number of suggestions for broadening the conceptual framework of psychiatry to include: "redefinition of the concept of mental illness, emphasizing those dynamic principles which pertain to the person's interaction with society...examination of the social factors which contribute to the causation of mental illness and also influence its course and outcome...consideration of the specific group psychological phenomena which are relevant, in a positive sense, to community mental health...the development of criteria for social action, relevant to the promotion of individual and community mental health....(GAP 1950b)."
The Psychiatric Aspects of School Desegregation (GAP 1957, Report No. 37) also produced by the Committee on Social Issues, addressed the issue of racial prejudice, around which there has been intense and ongoing conflict in American history. The following paragraph from the School Desegregation Report illustrates the way that GAP attempted to integrate psychosocial perceptions in the areas of both racial and sexual prejudice into individual and group psychodynamic theories:
On the deepest personal level, prejudices and their supporting myths can be understood as a means of maintaining feelings of self-esteem and security. In this sense they serve a defensive function. Many people of any race have acute doubts about their own worth, their adequacy in their sexual roles, and their acceptability as members of their groups. Turning attention to others' deficiencies permits one to remove the focus from fear and misgivings about oneself. Relief from intolerable feelings of self-contempt may be sought unconsciously by turning the hatred away from the despised part of oneself onto another person or group who, by the distortion of racial mythology, can represent the bad self. A down-graded minority, then, can become the source of a somewhat illusory security about oneself...the basis that 'I am better than they are...But guilt feelings with associated anxiety are a frequent price for whatever psychological gains may come from such defensive dealing with inner conflicts. The use of the myth as a defense against insecurity, therefore, is self-defeating for it not only fails to reach a realistic solution of the original difficulty but also increases the original burden of guilt. The well-known vicious circle of anxiety, defense, increased anxiety, and increased defensiveness may then ensue. (GAP, 1957)
In 1950, GAP published its first such report, Psychiatrically Deviated Sex Offenders (GAP 1950a, Report No. 9), written by the Committee on Forensic Psychiatry. The Committee's intent was to bring an end to the use of a traditional, stereotyping and unclear legal terms and to bring a fuller measure of psychiatric understanding of sexual behavior to the court system. It stated:
The Committee cautions against the use of this appellation 'psychopath' in the law on several grounds. There is still little agreement on the part of psychiatrists as to the precise meaning of the term. Furthermore, the term has no dynamic significance. The Committee believes that in statutes the use of technical psychiatric terms should be avoided whenever possible. Psychiatric knowledge and terminology are in a state of flux. Once having become a part of public law such a term obtains a fixity unresponsive to newer scientific knowledge and applications" (1950a).
GAP continued to focus on clinical psychiatric issues in human sexuality in later reports, for example: 1) GAP Report No. 88 (1973), Assessment of Sexual Function: A Guide to Interviewing, formulated by the Committee on Medical Education; 2) GAP Report No. 98 (1977), Psychiatry and Sex Psychopath Legislation: The 30's to the 80's, formulated by the Committee on Psychiatry and the Law; and 3) GAP Report No. 118 (1986), Crises of Adolescence Teenage Pregnancy: Impact on Adolescent Development, formulated by the Committee on Adolescence.
The earliest GAP publication to focus explicitly on sexual orientation was Homosexuality with Particular Emphasis on This Problem in Governmental Agencies (GAP Report No. 30, formulated by the Committee on Cooperation with Governmental [Federal] Agencies, 1955). The Committee hoped that their scientific discussion of what they considered a frequently misunderstood condition, might "result in a more effective appraisal and management of the practical problems that homosexuality creates in society in general and in Governmental agencies...in particular." The stated purpose of Report No. 30 was "to define and describe homosexual behavior and homosexuality from a medical and social point of view in accordance with scientific principles." Consistent with prevailing psychiatric opinion of that time, the Committee responsible for Report Number 30 identified homosexuality as a treatable illness, meaning that an individual's homosexual orientation could be changed to a heterosexual one, and "..a form of sexual perversion...psychological in origin (with) no valid evidence that homosexuality is inherited. Homosexuality is an arrest at, or a regression to, an immature level of psychosexual development. While the treatment of homosexuality is difficult and time-consuming, success has been reported. Psychotherapy offers the best chance of success, particularly in the turbulent transition period from adolescence to maturity wherein sexual goals have not been finally established" (GAP, 1955).
The report questioned the prevailing view that individuals' homosexual orientation posed high security risks due to their "lack of emotional stability...and the weakness of their moral fiber..." and cautioned against the pursuit of "witch hunts." In closing, the Committee observed: "In the governmental setting as well as in civilian life, homosexuals have functioned with distinction, and without disruption of morale and efficiency. Problems of social maladaptive behavior, such as homosexuality, therefore need to be examined on an individual basis, considering the place and circumstances, rather than from inflexible rules."
In the middle of the last century, scientists, scholars and researchers in biology, biochemistry, endocrinology, ethology, evolutionary studies, experimental psychology, genetics, history, literary theory, neuroanatomy, religion, the social sciences, and philosophy began the process of advancing alternative models of homosexuality opened up new knowledge about homosexuality and raised new questions that were not considered by psychiatrists in 1955. However, taken in its historical context, GAP Monograph No. 30 strongly argued against commonly accepted negative stereotypes that depicted a homosexual orientation prejudicially. It is uncertain what influence this Report had on the implementation of antihomosexual policies of U.S. governmental agencies. Of note, brief mention was also made of the topic of homosexuality in the 1960 GAP Report No. 60, Sex and the College Student.
In contrast to directly addressing the issue of homosexuality, the 1975 GAP Report No. 92, The Educated Woman: Prospects and Problems, formulated by the Committee on the College Student, mentioned the topic as a footnote: "In the ensuing discussion we have primarily focused on heterosexual relationships because, besides being statistically most likely, they inevitably highlight issues relating to gender differences." They went on to state:
Most individuals will opt for a heterosexual orientation, but for some a homosexual orientation may represent the orientation of choice. In either case the opportunity exists to learn how one's self concept, gender identity, and sexual responsiveness work in actual practice. In arriving at an adult sexual orientation, patterns of sexual relationships, both heterosexual and homosexual, may become exceedingly complex and will inevitably be affected by earlier developmental events, identification, and conflicts...No single life style can be presumed a priori to be 'healthier' or 'more adaptive' for all persons. What is adaptive may not only differ from one person to another, but may also change for any given person as development proceeds throughout the life cycle. (GAP 1975)
In 1990, fifteen years later, GAP Monograph No. 130, formulated by the same Committee on the College Student, Psychotherapy with College Students, did discuss gay and lesbian students in the section, "Some Special Student Populations." In this later report, the Committee more openly specified student problems to include 1) recognition and acceptance of sexual identity and orientation, 2) difficulties in establishing stable love relationships, and 3) managing relations with fellow students. Special attention was given to concerns of gay and lesbian students seeking psychotherapy in the college mental health services:
Some gay students feel that they would prefer to work with a therapist who is openly gay, because no matter what the therapist claims, such students are suspicious that a therapist, presumably heterosexual, will be critical of their homosexuality. Most, however, are willing to work with any therapist who is non-judgmental and accepting of the student's homosexual orientation. In confirming this acceptance, therefore, it is important for the therapist to be careful about asking questions that can be 'heard' by the student as suggesting or urging heterosexual behavior. As gay students become more open about their orientation, they may become less conflicted about seeking therapy for whatever reasons, but they may also be more influenced by political positions of the campus gay organization. (GAP 1990)
Fear of AIDS, problems with family, and discomfort with their own homosexuality were identified as common concerns in these students. The report was generally supportive of lesbian and gay students' efforts to find a healthy expression of their sexual orientation. Although it had been previously recognized that psychiatrists have to come to terms with their own biases before they can successfully treat members of the other sex or of different races or other minority groups, GAP monograph #130: Homosexuality and the Mental Health Professions: The Impact of Bias, formulated by the Committee on Human Sexuality, was the first to call attention to the issue of AHB, often referred to as "homophobia" in therapy.
The tragic emergence in 1981 of the AIDS epidemic made it obvious that AHB not only impeded adequate care of AIDS patients, but also prevented educational measures and interfered with rapid governmental funding for medical research. The compelling, practical need to better understand the nature of AHB and to reduce its impact both in the larger social picture and in the specific area of clinical psychiatry was the principal topic of that monograph. It was also the first to address the question of AHB specifically within psychiatric practice, training and professional relationships. It also raised questions about the adequacy of knowledge and training of psychotherapists in the areas of sexual orientation and the impact of AHB in the treatment setting.
In 1989, GAP created its first Committee on Human Sexuality. Founding members of this Committee were interested in how to effectively combat prejudice through fostering attitude reassessment and modification. They favored an approach that emphasized overcoming prejudice in small group settings where conflicts about sex roles, gender identity, moral values and other areas could be openly discussed.
Two GAP members, Drs. John Spiegel and Bertram Schaffner, were eager to find a way to extend these principles to the area of bias about homosexuality. They felt that AHB was as pervasive in the medical profession as it was in the general population, and usually ignored in medical and psychiatric education. They requested that the officers of GAP consider forming a new Committee whose initial task would be to take up this issue. GAP's positive response was consistent with its commitment to open discussion of subjects that have been traditionally avoided in the psychiatric community.
At one GAP meeting, speakers discussed problems faced by lesbian and gay psychiatrists. They reported that considerable numbers of gay and lesbian psychiatrists felt the need to be secretive or "closeted" about their sexual orientation. They described obstacles gay physicians faced in obtaining a psychiatric residency. They reviewed the well-known discriminatory policies of psychoanalytic institutes who considered lesbian and gay candidates unfit for training.
Following the presentation, the discussion period began with a memorable ten to twelve minutes of tense silence, an awkward reaction which seemed to mirror the anxiety, confusion, and conflict about homosexuality present in the psychiatric profession as a whole. The dialogue that followed was also more anxiety laden than usual, despite GAP's long history of focusing on controversial topics. It was productive, however, and in 1989 the Committee on Human Sexuality was established with Dr. Schaffner as Chair. The Committee published in 2000 its first report, Homosexuality and the Mental Health Professions: The Impact of Bias.
In 2003, GAP offered some of the members of the Committee on Human Sexuality the option of starting a new Committee specifically focused on LGBT issues. The new committee was initially chaired by the late Richard O. Hire, MD and called the Committee on Sexual Minorities. After Dr. Hire's passing in 2005, the Committee, then co-chaired by Vernon Rosario, MD and Serena Volpp, MD, changed its name to become the GAP Committee on LGBT Issues. The completion of this on-line curriculum would not have been possible without the trailblazing efforts of those earlier contributors as well as the leadership of the Committee's chairs, Drs. Rosario and Mary Barber, and other members.
- Richard O. Hire, MD, Founding chair
- Vernon A. Rosario, MD, Co-Chair
- Mary Barber, MD, Co-Chair
- Kenneth Ashley, MD
- Lisa Capell , MD
- Jack Drescher, MD
- Marshall Forstein, MD
- Jeffrey Guss, MD
- Edward Hanin, MD
- Sarah E. Herbert, MD
- Amy Hoffman, MD
- Benjamin McCommon, MD
- Scott Masters , MD
- Serena Y. Volpp, MD