VOICEOVER 
This is Up Close, the research talk show from the University of Melbourne, Australia. 

LYNNE HAULTAIN
Hello, I'm Lynne Haultain and welcome to Up Close. Homophobia is bad for health. People in the sexual minorities, gay, lesbian, bisexual and transsexual people are according to the research at much greater risk of grave mental and physical health outcomes. They suffer significantly higher rates of depression and anxiety, substance misuse and self-harm. There's evidence that this is closely associated with discrimination, with bullying and social and family exclusion. And this is the case in developed countries where there's allegedly more tolerance as well as in the developing world. So what's going on? Homophobia and transphobia it would seem are still having profound effects even if many of us believe our society is to be more accepting of diversity.
Our guest today on Up Close is Professor Michael King, a psychiatric epidemiologist at University College London and he's been working on these issues for many years.
Michael, welcome.

MICHAEL KING
Thank you for having me.

LYNNE HAULTAIN
Well let's start with some basics. Some definitions. How do you define homophobia and transphobia, which has also recently entered the lexicon?

MICHAEL KING
It's a very odd word and it comes from the 1970s and originally it was thought to be a phobic thing, that people had an irrational fear of either their own sexuality or other people who might be gay or lesbian. It even began before that with what was called homoerotophobia. I thought that was quite a good definition because sometimes it comes from the mixed up feelings of the person themselves. They might be unsure about their own sexuality or fearful of it even if they were heterosexual.
I think it's much better thought of as anti-homosexual prejudice. It's just discrimination like any other. The trouble is it's more pervasive than some of the other isms if you like. The one feature that it really differs on is that it enters the family. The other isms don't seem to do that, racism, ageism, not to the same extent and it's not a choice. Someone in a highly religious family might marry out and therefore have some family discrimination but this is not like that. This is the fundamental being of the person and when parents or siblings learn that someone's gay or lesbian they can reject them and there's no real parallel quite like that. It's not their behaviour. It's not their choice. It's who they are.

LYNNE HAULTAIN
I'd love to tease out the impact, if you like, or the drivers around the people who identify as members of sexual minorities in a few minutes. But the whole notion of being in that bubble, if you like, being the homosexual or transsexual person in the middle of this, it strikes me that the homophobic term because given that it is so widely used, is useful in a way that it does assign the blame, if you like, or the problem to the community rather than to the person at the centre. Is it useful for that?

MICHAEL KING
Yes, I think it is and it puts it squarely in the social domain as a problem of culture and society. Then you understand it a little bit more because you can see how societies vary in how much they discriminate or reject gay and lesbian people or any same sex behaviour really. Many people in other countries wouldn't identify with those sort of political groupings of gay and lesbian at all. You can see what is it about some societies that are more rejecting than others and then begin to tease out what might be behind this.

LYNNE HAULTAIN
How widespread is it? Is it completely universal to most cultures?

MICHAEL KING
To our knowledge it's universal and has been always. That might sound very damning but it really does seem to be the case. The situation of Ancient Greece is often mentioned, was this society that tolerated at least male homosexuality but it didn't. Well I would say it tolerated it but it wasn't seen as an equal status. Same sex relationships weren't understood in the way they are today. Certain privileged wealthy men might have relationships with other younger men but it didn't interfere with them marrying or continuing in their family in what's ostensibly a heterosexual way.

LYNNE HAULTAIN
So they accepted the sexual activity beyond the home?

MICHAEL KING
It was probably more than sexual activity. They did have relationships but it was always a shadow of what they were meant to be. It was tolerated probably at best. That's the only real examples. We do have in some cultural groups around the world intersex people that were almost venerated. That's a slightly different thing but it's not quite what we're talking about in terms of gay and lesbian lifestyles or culture now.

LYNNE HAULTAIN
So it's been around as long as sexual diversity has been around, that people have been reacting negatively?

MICHAEL KING
It has and same sex attraction seems to have been around universally but the word homosexuality is very new. It just appeared at the end of the nineteenth century so people didn't think of it in those terms. It became medicalised really in the twentieth century. That was the problem.

LYNNE HAULTAIN
Why is it a problem that it's become medicalised do you think?

MICHAEL KING
I think it's been one of the most stigmatising prejudicial things that's happened. Originally the sexologists had the best possible motives. People often have the best possible motives but it ends in disaster but their motives were look this is something that seems to be fundamental to people, we shouldn't discriminate against, this is something that arises, we don't understand how but it's fundamental in people. The trouble was as soon as you do that then psychoanalysts, psychologists, medical doctors and psychiatrists all decided that you could therefore treat it. If this was the situation why don't we make homosexual people heterosexual?

LYNNE HAULTAIN
It was listed in the DSM, the bible of conditions if you like as a problem that could be treated.

MICHAEL KING
Absolutely, a diagnosis. It still appears in a minor form in the International Classification of Diseases because this still hasn't been revised since 1992. It has been taken out as a pure diagnosis but something remains there called ego-dystonic sexuality and that appears to mean that you're not happy with your sexuality. I haven't met a heterosexual person yet who's unhappy with their sexuality. It's almost universally people are who are homosexual. It's still there in an odd sort of way but the new International Classification of Diseases is about to come out next year and it will be removed completely in any form.

LYNNE HAULTAIN
Does that lead us to the transphobic as well given that if people have a concern about same sex attraction then gender change also tends to throw up?

MICHAEL KING
This is very complex. It's a sort of muddle between sexual orientation and gender identity.

LYNNE HAULTAIN
That's right.

MICHAEL KING
Much of the homophobia is actually aimed at what we call gender discordant behaviour. It's not aimed at same sex contact itself. What seems to be intolerable to many men, because men are more homophobic in their nature than women, is that men are acting in what they would regard as an effeminate way. Boys at school who are not quite typically masculine get bullied much more than other boys. They get called poofters or gay. They might not be at all but it's picking up on that gender discordant behaviour. The same thing as for girls who are not feminine enough.
Now when it comes to transgender then it really is worrying to people because they fear this, when someone rejects their own gender. They can't understand it and anything someone can't understand they tend to reject. I'm afraid transgender people have had an even worse time of it.

LYNNE HAULTAIN
Is there evidence to show that homophobic people are more likely to be transphobic as well?

MICHAEL KING
They do and everywhere that you see homophobia and transphobia you tend to see sexism. It's very interesting. The societies in which this is very strong women often have a lesser role in the society.  They're very patriarchal. Without being too insulting to certain cultures across the Arab world, Latin America, the sort of machismo societies where men are very much in the dominant role it's seen as a betrayal somehow of masculinity to be someone who would have sex with another man. You're making yourself a woman in a kind of a way.
Now not to get too graphic in the detail of sexual behaviour, the man who is what is referred to as passive say in a sexual relationship is in a much worse situation. In those societies the active man is okay. He's just having sex like he might with a woman so that's alright. If he were the object of a sexual encounter in a penetrative way then somehow he's made himself into a woman. It's crazy thinking but it's the sort of thinking that occurs and you can see it's all to do with masculine dominance and power.

LYNNE HAULTAIN
Your research is around how you understand the impact of this on people's mental health. What is the evidence that shows that there are higher rates of mental distress in people who are coming from sexual minorities? How do you gauge that?

MICHAEL KING
The first question is how do you identify people who might have same sex attraction and it's a nightmare because you can't go door-to-door and say give me your homosexuals or something can you? You have to have some way of identifying people who may not regard themselves as gay or lesbian but may have same sex behaviour in their history. We try to do it as best we can.
Normally these are volunteers. A lot of the research up until probably the last 10 or 15 years was based on volunteer surveys but now we have much better ways where we can include sexuality questions in random population surveys. The reason is because it's become more acceptable to do that. We persuaded the Office of National Statistics to include a sexuality question in the mid-noughties, around 2007. That was the first time in a mental health survey we got a random sample of people who would identify in some way with same sex attraction and behaviour. That's what you have to do but you always get an underestimate of what the incidence is. Then you can compare them with their heterosexual peers to see what are the rates of mental disorder and psychiatric history and that sort of thing. You find the rates are much higher.

LYNNE HAULTAIN
By what sort of level?

MICHAEL KING
For depression and anxiety it's two or three times up to five times the rate. Suicidal behaviour is up to five times the rate. We're talking about high rates but we're talking statistically. That means the majority of gay and lesbian people are perfectly happy like everybody else but there is an increased vulnerability. There is a segment of population - a proportion of their population that has higher rates.
The one thing that worries us the most and is the hardest to study is suicide, actually what we call completed suicide, someone who's taken their own life because you can't know because the young man or woman might take their own life and never have expressed or admitted their sexuality to anyone. How can you possibly know? There is now some studies in Scandinavia where they've had same sex marriage or same sex civil partnerships for 20 years and these studies show that suicide is about two to three times more common in women or men in same sex married partnerships.

LYNNE HAULTAIN
If you're in a registered partnership would that not indicate that you are self-accepting?

MICHAEL KING
Exactly.

LYNNE HAULTAIN
Which would seem to indicate a general well-being around the relationship.

MICHAEL KING
Openness, well-being, presumably support from the family if they've had a civil wedding. It's extraordinary. This is the group that you would expect to have no elevation in rate whatsoever. It does suggest that homophobia from childhood onwards has very severe and long lasting effects, making people vulnerable, even people who seem to be in stable relationships. It's almost like the trauma that you see for other situations in childhood or adolescence. They have long tentacles into adult age and can have effects that go beyond the current stable situation they're in.

LYNNE HAULTAIN
We've seen ample evidence in recent times around sexual assault and abuse of children which as you say have incredibly long tails into people's adulthood. In terms of the evidence base around bullying and discrimination and the impact of homophobic activity at a young age or throughout life, how do you identify that? Do people volunteer that they have been bullied and what the magnitude of that is and the impact of that? How do you assemble that side of the research?

MICHAEL KING
We can do that and there's plenty of studies now looking at that, episodes of discrimination, verbal abuse, physical abuse in the last year or in a lifetime or in school. It's been done with youth where the bullying is quite recent in their history. There's quite good evidence for that but they're not the major episodes of homophobia. A lot more subtle is what we call micro aggressions and this is the sort of situation where a young gay man or lesbian is constantly watchful for what's going to happen.  Whom should he express himself to or not? Which parent knows? Which buddy knows? Which person at work? It's a daily hassle of trying to live several identities. It may be that level, that micro level that's far more damaging than just I was bullied once in Year 12 at school. It's that sort of thing that could be the trouble.
That's a little bit like racism. Many people who experience racism are constantly on the alert for insult or denigration even at a minor level. It's a bit like a black colleague of mine said that every time he gets into a lift the ladies in the lift just tighten their grasp on their handbag. It's just tiny things that he notices that are just prejudicial and silly.

LYNNE HAULTAIN
You mentioned earlier, which was a very striking comment around the fact that homophobia and transphobia comes into the home and can really be enormously detrimental as a result of family exclusion that's not necessarily the case with other kinds of discrimination. Is that a particularly powerful impact in terms of people's longer term mental health?

MICHAEL KING
It is.

LYNNE HAULTAIN
Has that been revealed?

MICHAEL KING
It has. Parental attitudes and support is one of the strongest predictors of trouble in youth or in your 20's as a gay person. An accepting parent can reduce your risk of suicide attempts by 50, 70 per cent. It's enormously important and many parents do worry when their son or daughter tells them that they're gay or lesbian because they say well what have we said? The most accepting parents might say what kind of conversations have you heard? They worry themselves whether they've been negative about it. Of course the parents that are negative are directly negative and that's much more damaging. I had a patient recently, a medical student who went home and told his mother he was gay and she ran upstairs and vomited and then disappeared for the weekend. You can imagine the symbolic nature of that kind of rejection is devastating for people.

LYNNE HAULTAIN
You're listening to Up Close and today we're discussing the impact of homophobia and transphobia around the world with psychiatric epidemiologist Professor Michael King.
Michael, we've been talking about the experience of people in sexual minorities but what do we understand about the drivers of homophobia?

MICHAEL KING
It's not always understandable. I think there's all sorts of levels. There's certainly their own sexual uncertainty and that's often in men and that's not often in the family so much but it's religion.  Strong conservative moral view of life and religion is very important. Most religions are anti any idea of homosexuality or same sex behaviour save one or two but the mainstreams religion are really against it. A strongly religious family would fear that their child had chosen a sinful path. I use the word chosen advisably because many religious groups will promote the idea that this is a life choice.  Now why on earth a young man or woman would choose a path in direct opposition to society's acceptance or their family is quite incredible but that is the idea. Many people think immediately my son is going wrong.

LYNNE HAULTAIN
And that they are destined to life in purgatory or hell forevermore.

MICHAEL KING
Absolutely and therefore they would take them to a psychiatrist or take them to a psychologist, is this an illness? This is where I think we come back to the medicalisation of this because we haven't discussed it but psychiatrists and psychoanalysts for years did these treatments to try and convert as they called it homosexuals to heterosexuals. It's still active to some degree around the world.  So-called reparative therapies in the United States come from a spiritual and religious basis. Now these are very damaging. These promote the stigma against homosexuality in the world because people say you're sick, you need treatment. That's the worst kind of homophobia if you like, in quotes, of all and of course there's no evidence that it has any impact on people at all except negatively. There's been a lot of research on this now, historically what happened to people who went through these treatments.
Now it's not to say that these doctors and psychologists were sadists. They weren't trying to be cruel to their patients. They felt back in the '60s and '70s and even '80s actually that if you could make someone heterosexual then they would be happier and more fulfilled. It was only gradually it dawned on them when they saw the evidence and when politically it was opposed that they saw this was damaging.

LYNNE HAULTAIN
On the upside there is extensive evidence to show that minds can be changed. The acceptance of same sex relationships is now much higher and certainly in Australia and I'm sure it's the same in the UK and large parts of Europe where it's much, much more accepted and in fact celebrated.

MICHAEL KING
Absolutely. I think we're being very bleak in this interview because there are many positive things here. I would emphasise again as I said before that the vast majority of gay and lesbian people are perfectly happy ordinary people who are completely bored by all the fuss about this. I really want to emphasise that.
I would say that attitudes have changed a lot and societies are a lot more liberal about this but they also go backwards. There's several societies in the world that are going backwards rapidly. There are several African countries now who have become very repressive and homophobic if you like. Russia's an example of that and some eastern European countries where it's now very difficult to live as a gay or lesbian person. It's not all good. The Arab world, something like nine or 10 countries that still have the death penalty for any same sex behaviour. I think although we congratulate ourselves in northern Europe, Australasia and United States it's not good all around the world.

LYNNE HAULTAIN
It's fragile.

MICHAEL KING
Exactly.

LYNNE HAULTAIN
But it does demonstrate that minds can be changed and that previously homophobic people can shift.  People can be moved. How do they repair their homophobia?

MICHAEL KING
Well first of all you've touched on the most important thing - I think it's political and cultural - that leaders can make a huge difference here and just as we've seen in Russia and some eastern European countries that go backwards because the leaders are homophobic, in the West we've seen it move forward very fast because people have shown leadership. Legislation is tremendously important. Equality acts, same sex marriage or equal marriage, whatever you want to call it, those things lead and often people's opinions follow behind. That can be very helpful. Education in schools is tremendously important even at the primary school level is where is needs to start.
All those things are tremendously positive and I think we will get to a stage where all of this will be very boring and no one will notice anymore but I still have a feeling that we're quite a long way from that because there's still this sense of shame in some people. There's still this sense of difference that's leading to these higher rates of mental disorder because you would have thought with young generations now in these countries we've mentioned should be fine. Why are we still seeing quite high rates of depression and anxiety? Something's not right there still.

LYNNE HAULTAIN
Exactly so despite the increase in tolerance, in Australia it's now 80 per cent of people are quite supportive of same sex marriage for example and yet we see these higher rates of mental distress in people from sexual minorities continuing.

MICHAEL KING
It may be like turning an oil tanker around. It takes a long time for that to feed through and it might be another generation yet before we see an improvement. I would emphasise again and keep on emphasising that we're looking at the negative side of this a lot and that most gay and lesbian people are fine. I think in the transgender world though it's even further behind and many transgender people experience enormously overt discrimination. If they don't quite pass in the other sex in the street and things like that it can be devastating, in schools and that's where they have a whole change in their lifestyle from one gender to another. It's a big leap for other people. I think the transgender community are still facing many, many difficulties.

LYNNE HAULTAIN
We're seeing a huge increase in the capacity if you like for people to transition. Is that part of the issue that it is now a much higher profile matter than it used to be?

MICHAEL KING
Yes, I think so and I think people are more prepared to come forward and seek help if they feel very strongly that way.

LYNNE HAULTAIN
Michael, we've talked about the experience of this from both sides if you like but I'm fascinated to know if there are other analogues we can draw here because gay rights and trans rights have become high profile civil rights issues if you like. Are there parallels we can draw with the experience of African Americans, of women in terms of the health effects that they suffered at various points in their civil rights campaigns? Is there a parallel that can be drawn at all there?

MICHAEL KING
I think we can. I mean it’s been known, now I don't want to make a leap here particularly about women's equality but we know that women suffer higher rates of anxiety and depression than men and have done for a long time and that these may change too as women achieve equality. I think in terms of ethnic minorities it's certainly true. There's lots of research to show that if ethnic minority families or individuals live in a district or a suburb where they are very much in the minority, say for example white majority were very much in the majority they're much more likely to suffer mental disorder than where they're living where they've got wider support. There are quite a lot of parallels where that's the case. Of course you can imagine with this family problem in gays and lesbians it's even more devastating because they're not even getting the support within the family but I think there are definitely parallels.

LYNNE HAULTAIN
Is that useful medically?

MICHAEL KING
I don't know if it's useful medically. It gives guidance on how social support can be given and how cultures and communities can be much more open and equal. I like the term equal marriage for example instead of same sex marriage. Also I think in England the equality laws have been the real leader. Sexual orientation has been put together with race, sex and age as a situation in which discrimination is just unacceptable. When they're put together like that then it makes sense. One is not just held out as slightly different.

LYNNE HAULTAIN
Just to come right back to your specialty in medicine, it's very difficult to treat the society as opposed to the individual.

MICHAEL KING
Yes and I wouldn't attempt to. I don't think it's a role of medicine. Possibly public health. I think public health is where all this lies to the best extent. Education, that's where these real preventative efforts could be. We know - there's evidence from schools and colleges - that you can change things and governments are leading as we have discussed. I think there are real ways forward. I don't think it involves doctors a lot of the time. Doctors are there picking up people at the bottom of the cliff but public health doctors might have a role.

LYNNE HAULTAIN
Michael, you've said in the past that you would never recommend psychiatric treatment for homosexual people but would you for homophobic people?

MICHAEL KING
I think that homophobic people are very unhappy and need to discuss what's going on as well but no, I don't think there's a role for psychiatrists. I think you can support gay and lesbian people going through these situations. It's funny, we've entered a topsy-turvy world because psychiatry really doesn't have a good name with gays and lesbians because - for good reasons. Treatments were really instigated not always with people's consent. I know in Australia it happened a lot and in New Zealand and in England. The courts would divert men usually caught for what was called gross indecency and I suppose they thought it was humanitarian, send them to a doctor rather than to prison. Thus psychiatry doesn't have a good reputation and of course patients now will come and fear that psychiatry's too liberal because they want to become a heterosexual. It's a minefield, the whole thing.
There are still young men and women who can't bear the thought of being gay or lesbian and seek treatment to change it. It's a dilemma how to help people like that, who just won't accept counselling to come to terms with their sexual orientation. You've got to look at well where is that fear coming from? Where is the pressure for them not to accept themselves? That's the key thing.

LYNNE HAULTAIN
There's another whole debate as well. Michael, thank you very much for joining us.

MICHAEL KING
Thank you.

LYNNE HAULTAIN
I've been speaking with Professor Michael King about the adverse impacts of homophobia and transphobia on victims. He's a psychiatric epidemiologist from University College London who specialises in the design and conduct of studies and randomised trials of complex mental health interventions in primary and secondary care. His particular interests include as we've discussed, the stress and stigma faced by gay and lesbian people and the role of religious and spiritual beliefs in mental wellbeing. You'll find links on the Up Close website as well as a transcript of this program and all our other programs.
Up Close is a production of the University of Melbourne, Australia and this episode was recorded on 9 March 2017. It was produced by Kelvin Param with audio engineering by Gavin Nebauer. I'm Lynne Haultain. Thanks for listening and I hope you can join us again soon.

VOICEOVER
You've been listening to Up Close. For more information visit upclose.unimelb.edu.au. You can also find us on Twitter and Facebook. Copyright 2017, the University of Melbourne.