This book is a valuable addition to the literature available to help therapists understand and work with gay, lesbian, and bisexual patients. I attended the authors’ lectures on human sexuality during my psychiatric residency at Columbia University, and they have deftly provided a framework for much of their classroom material. The book is divided into two sections: the first reviews current scientific understanding of the origins of sexual orientation and adds some new ideas, and the second uses extensive vignettes to help inform current clinical practice.

In the first section, Friedman and Downey stress the importance of "extrapsychoanalytic" research in the fields of genetics, psychoendocrinology, psychological development, and sexology. The authors believe that psychoanalysis has much to offer in its ability to explore one individual deeply, but theories of normative development require more statistically based sciences that rely not only on an exploration of meaning but also on specific physical observations. As examples, they rightly point out that psychoanalytic theories failed to uncover clitoral orgasm or the sex arousal cycle in women. Also, psychoanalysis started from a theoretical assumption of personality pathology in homosexual people that was not contradicted empirically until the 1960s by the work of Evelyn Hooker. Until recently, the authors point out, psychoanalysis approached homosexuality as only "a special instance of a general problem." Friedman and Downey accurately discuss the dangers of psychoanalytic theorizing divorced from basic science and insist on a systems approach to human sexuality that integrates clinical and theoretical understanding.

For the authors, the most crucial "extrapsychoanalytic" contribution to understanding sexual orientation is the study of prenatal hormonal influences. They continue to focus on the prenatal hormonal environment throughout the "science" section of the book. Using animal studies and human populations affected by disorders of sex steroid hormones, they develop an approach based on theorized prenatal differences in sex steroids to explain later formation of gender identity and sexual orientation.

They do not dismiss the idea that caretaker influences on children can affect gender role behavior, but they assign it less importance than prenatal hormonal influences on the developing brain. For example, they are supportive of an idea developed by Daryl Bem that children are aroused by peers who are different from them (in play, for instance) and that this arousal eventually leads to formation of erotic attraction and sexual orientation. Their argument that the play interests of children are directed by the prenatal hormonal environment serves as an explanation of how earlier events can influence later development.

Jack Drescher +(1) described this approach as emphasizing a possibly pathological early event (such as alteration in prenatal steroid exposure) with a subsequent inevitable developmental pathway that is not itself pathological. Friedman and Downey, however, do not label the possible differences in prenatal hormonal environment in gay people as pathological, despite their willingness to use the term elsewhere in their book.

They cite a wide array of findings to support the importance of sex steroid exposure in utero, beginning with a discussion of sexual fantasy and differences in erotic development between males and females. Examples include the earlier appearance of male sexual fantasy and the focus of men on erotic motivations for sexual experiences (while women are directed toward relational and procreational interests). They use examples of androgen exposure gone awry to buttress their arguments, such as excess androgen exposure in some intersex disorders in females leading to decreased maternal interest in play. Also, in girls with congenital adrenal hyperplasia, sexual fantasies may be somewhat more frequently homosexual.

The authors argue that "a late childhood critical period" exists in which a template for later erotic interests is formed. Although for a minority there may be some later plasticity, the sexual fantasies and erotic objects of most people are determined in that period. Noting the relative dearth of literature about female homosexuality, the authors still see a possibly greater plasticity in the development of sexual orientation of women, partly because life narratives of women are less likely than those of gay men to tell a story of difference early in life inexorably leading to an early realization of being gay.

The authors have been at the forefront of the movement within psychoanalysis challenging previously orthodox ideas based on the concept that development of homosexual orientation is intrinsically disordered. Although these ideas are much less widely held now, their book includes valuable sections that debunk them.

In their commentary on the Oedipus complex, they place themselves among the revisionists of Freud’s theories (and, in fact, point out that Freud likely would have disagreed with some of his followers). For instance, they doubt that the dynamics of the Oedipal phase are critical to establishing gender identity because gender identity is formed much earlier. For them, early sexual desire (as opposed to the need for love or identification) is likely to be a result of abuse or neglect rather than a normal developmental pathway. Against Richard Isay’s idea of fathers shying away from the sexual desire of their gay male children +(2), they assert that fathers actually are uncomfortable with these children’s gender atypical play.

Again emphasizing hormonal influences, Friedman and Downey use the predominance of "rough and tumble" play in boys as evidence for differences in androgen exposure between boys and girls (and presumably, between boys later destined to become straight or gay). They do not believe that the rough play of boys is primarily due to social influences leading to an unhealthy release of destructive instincts. Rather, they see this type of play as important in the development of most boys (for instance, in the instillation of the concept of teamwork); they see homophobia partly as an outgrowth of this form of bonding and perhaps somewhat inevitable.

The second section of Friedman and Downey’s book moves into the clinical realm, with a particular focus on homophobia and internalized homophobia. In general, they are sympathetic to the idea that many difficulties of gay people are a result of societal homophobia and its concomitant, internalized homophobia. They see internalized homophobia as a nearly universal experience among gay people that can be used psychologically in many different ways. For instance, it can be a way in which guilt about other things is expressed, and they describe the possibility of an unsuccessful treatment (a negative therapeutic reaction) in a patient in which internalized homophobia is just part of an all-encompassing self-hate.

In a beautiful clinical vignette near the end of the book that illustrates the discussion of internalized homophobia, the psychotherapeutic treatment by Downey of a women in her 80s is depicted. Downey’s flexibility of approach is clear—she reads seminal works in lesbian literature with her patient, and when her patient is hospitalized, she gives her a telephone so that her patient will be less isolated. The application of these supportive (and revealing) techniques has general relevance in the treatment of gay and lesbian patients, who may need a more open and active therapist to counterbalance the effects of homophobia and internalized homophobia. This book will serve therapists well in guiding them toward better clinical care of their gay and lesbian patients, beginning with an understanding grounded in science.

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