Gay men’s fears of long-term romance

A psychoanalyst argues that the way gay men’s parents treat them affects their adult relationships.

By Cathy Shufro

The night in June 1969 that gay men fought police raiding the Stonewall Inn in Greenwich Village marked the beginning of wider acceptance of male homosexuals. Homosexuality has not been considered pathological by mainstream psychiatry since the 1970s, and in the years that followed, gay couples have begun to acknowledge their partnerships publicly.

“There’s much more social acceptance than there was 20 or 30 years ago,” said psychiatrist and psychoanalyst Richard A. Isay, M.D., HS ’65.

Many gay men are still suffering, however, said Isay. The main, though not the only, source of their distress, he thinks, lies in the ways their parents treated them as children. He believes that the social acceptance of homosexuality “has not filtered down to the way homosexual boys are raised.” Fathers tend to criticize or shun sons who dislike rough sports, play with dolls or otherwise prefer stereotypically feminine pursuits. Mothers who enjoy the sensitivity and shared interests of gay sons may lean too much on them, using them to fulfill their unmet emotional needs.

Isay believes that these dynamics can prevent adult gay men from forming long-term romantic bonds. “Boys may grow up mistrusting the love of another person and will find many other ways of finding the self-esteem enhancement that they missed in childhood,” said Isay. Many gay men seek affirmation not through an enduring, loving relationship, he said, but in cultivating large networks of friends, pursuing transient sexual liaisons, focusing on professional success and creating flawlessly appointed environments for themselves.

In his new book, Commitment and Healing: Gay Men and the Need for Romantic Love, Isay describes how therapy can help provide gay men with insight into the effects of childhood influences on the capacity to commit to a partner. In a book accessible to nontherapists and illustrated with case studies, Isay shows how gay men can recover from childhood wounds and learn to sustain committed monogamous partnerships. A clinical professor at Weill Medical College of Cornell University and a faculty member at the Columbia University Center for Psychoanalytic Training and Research, Isay draws upon his experience as a Manhattan psychotherapist with mostly gay clients.

Isay published his first book, Being Homosexual: Gay Men and Their Development, in 1989, at a time when he was coming out. He was the first openly gay member of the American Psychoanalytic Association. His 1996 book, Becoming Gay, outlines the ways in which gay teenagers and adults develop self-acceptance.

Isay said that his new book has stirred up some controversy because he argues that gay couples who tolerate sexual adventures outside the partnership may do so out of an unconscious fear of closeness rather than a sense of liberation from traditional heterosexual strictures. “It runs counter to the prevailing doctrines of the gay community that maintain that our relationships are fine, more democratic and better than heterosexual relationships,” said Isay.

He hopes that his new book will help gay men to examine the patterns of their romantic relationships and perhaps seek the guidance of a therapist attuned to gay issues. He’d like parents to pay attention to the way they treat their sons. Ideally, he said, even when a son doesn’t act like a typical boy, “if both father and mother love him as they do their other children, if they value what he has to say about his attractions to others, then they can inculcate the value of love and can greatly influence how he forms loving relationships as an adult.”

Bookshelf focuses on books and authors at the School of Medicine. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.

Book notes

Brain Tumors: Practical Guide to Diagnosis and Treatment
by Joseph M. Piepmeier, M.D., HS ’82, the Nixdorff-German Professor of Neurosurgery, and Joachim M. Baehring, M.D., assistant professor of neurology and neurosurgery (Informa Healthcare) This reference provides information to help clinicians make accurate diagnoses and select the most appropriate treatment regimens for patients with primary and metastatic brain tumors or neurological complications of cancer. The guide reviews the epidemiology, identification and management of brain tumors while explaining the latest advances in the field.

Management of High-Risk Pregnancy: An Evidence-Based Approach, 5th ed.
by Catherine Y. Spong, M.D., John Queenan, M.D., and Charles J. Lockwood, M.D., the Anita O’Keefe Young Professor of Women’s Health and Obstetrics, Gynecology and Reproductive Sciences (Blackwell Publishing) This fifth edition focuses on factors affecting pregnancy, including genetics; diagnostic techniques; maternal diseases; biochemical and biophysical monitoring; anesthesia; complications of labor and delivery; and neonatal considerations. A resource for perinatal care and a reference guide to diagnosis and management of high-risk pregnancies, the book takes an evidence-based approach and expands on several important areas: genetics, Doppler ultrasound, AIDS, Group B streptococcal infections, pre-eclampsia and prematurity.

Physicians’ Cancer Chemotherapy Drug Manual, 2007
by Edward Chu, M.D., professor of medicine (medical oncology) and pharmacology, and Vincent T. DeVita Jr., M.D., HS ’66, the Amy and Joseph Perella Professor of Medicine (medical oncology) and professor of epidemiology (Jones and Bartlett Publishers) Completely revised for 2007, this handbook provides an overview of the field of cancer chemotherapy. It includes a comprehensive catalog of more than 100 drugs commonly used in cancer treatment, including several new agents. The authors discuss antiemetic drugs; clinical pharmacology; indications and dosages; and toxicity and drug interactions. The book also provides diagrams of drug structures and metabolic pathways.

Soft-Tissue Surgery of the Craniofacial Region
by John A. Persing, M.D., professor of surgery (plastic) and neurosurgery; and Gregory R.D. Evans, M.D. (Informa Healthcare) This reference work covers the latest technologies in soft-tissue surgery to improve function and enhance cosmetic appearance for patients with disfiguring and debilitating facial defects from trauma, congenital deformity or disease. The book includes chapters on laser imaging, burn treatment, cleft palate reconstruction and facial paralysis.

Lewis’ Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed.
by Andrés S. Martin, M.D., M.P.H., associate professor in the Child Study Center and of psychiatry, Fred R. Volkmar, M.D., the Irving B. Harris Professor in the Child Study Center and professor of psychiatry, pediatrics and psychology, and the late Melvin Lewis, M.B.B.S., HS ’59, former professor emeritus and senior research scientist in the Child Study Center (Lippincott, Williams & Wilkins) The fourth edition of this classic text emphasizes the relationship between basic science and clinical research and integrates scientific principles with the realities of drug interactions. The book has been thoroughly updated, with two-thirds of the contributions coming from new authors. It also combines discussions of economic factors and diversity in the patient population with a strong focus on evidence-based practice. New chapters consider genetics; research methodologies and statistics; and the continuum of care. A companion website provides searchable access to the text.

Manual of Dermatologic Therapeutics: With Essentials of Diagnosis, 7th ed.
by Kenneth A. Arndt, M.D. ’61, HS ’62, and Jeffery H.S. Hsu, M.D. (Lippincott, Williams & Wilkins) This manual outlines the pathophysiology, symptoms, clinical findings and assessment of skin diseases as well as offering detailed guidelines for choosing among therapeutic options. An up-to-date formulary provides information on medications and other products used in dermatology.

Cell Biology: With STUDENT CONSULT Online Access, 2nd ed.
by Thomas D. Pollard, M.D., Sterling Professor of Molecular, Cellular and Developmental Biology and professor of molecular biophysics and biochemistry and of cell biology, William C. Earnshaw, Ph.D., and Jennifer Lippincott-Schwartz, Ph.D. (Saunders) This text offers a modern approach to the study of cell biology. It explores the ways in which cellular structure, function and dysfunction result from specific macromolecular interactions. Boxes on most pages contain key principles, helpful summary tables, diagrams and research figures. The second edition contains a new chapter on the origin and evolution of life.

Preventive Cardiology: Insights Into the Prevention and Treatment of Cardiovascular Disease
edited by JoAnne Micale Foody, M.D., associate professor of medicine (cardiology) (Humana Press) This new three-part edition provides an overview of opportunities to prevent the progression or, in some instances, reverse the process of coronary atherosclerosis and incorporate these strategies into the daily practice of clinical medicine. It represents a move away from the emphasis in the 1990s on technological interventions toward a molecular perspective. This book provides clinical cardiologists, internists, primary care providers and allied health care professionals with the tools and understanding necessary for practicing preventive cardiology.

Pocket Guide to Chemotherapy Protocols, 4th ed.
by Edward Chu, M.D., professor of medicine (medical oncology) and pharmacology (Jones & Bartlett Publishers) Spiral-bound and arranged alphabetically by cancer type for easy access, this pocket guide serves as a quick reference for physicians, nurses and other health care providers treating cancer patients. The guide contains combination and selected single-agent regimens for solid tumors and hematologic malignancies. The regimens selected are based on published literature and are used in clinical practice in the medical oncology community.

Choices in Breast Cancer Treatment: Medical Specialists and Cancer Survivors Tell You What You Need to Know
edited by Kenneth D. Miller, M.D., assistant professor of medicine (medical oncology) (Johns Hopkins University Press) This book combines contributions from specialists with personal narratives by breast cancer survivors. Topics covered include risk factors, screening, genetic testing, prevention, diagnostic methods, the doctor-patient relationship, surgical treatments, adjuvant treatments, breast reconstruction and clinical trials.

Out of Order: Poems
by Laura M. Manuelidis, M.D. ’67, HS ’70, professor of surgery (neuropathology) (iUniverse) Although she is best known for her work on spongiform encephalopathies, Manuelidis is also a poet whose work has appeared in the Nation and the Connecticut Review. In this collection, she writes of love and loss, of places remembered and of life’s wonder and pain.

What’s Toxic, What’s Not
by Gary L. Ginsberg, Ph.D., lecturer in epidemiology, and Brian Toal (Berkley Trade) Every day, people work, live and play amid potentially harmful toxic substances, sometimes unwittingly. People are exposed to these substances in their homes, neighborhoods, schools, workplaces, foods and other consumer products. This comprehensive guide distinguishes between risks and myths, explaining how to identify problems and what to do about them. Charts to help assess risk, a special homebuyer’s guide and Q&A segments discuss mold, lead, radon, asbestos, food additives, power lines, arsenic, mercury, pesticides, dioxin and toxic gases, as well as ways to guard against them.

The descriptions are based on information from the publishers.

Send notices of new books by alumni and faculty to Cheryl Violante, Yale Medicine, 300 George Street, Suite 773, New Haven, CT 06511, or via e-mail to cheryl.violante@yale.edu.

In circulation

For the busy researcher, help from medical librarians with publishing papers

Picture the typical researcher’s desk, with journals piled high. Now imagine a librarian who can make those journals disappear—and reappear in a customized electronic library.

Perhaps you’re an investigator ready to submit an article. After countless revisions you need a fresh pair of eyes. Enter an editor, referred to you by the medical library. The editor checks for spelling, punctuation and grammar and suggests ways to streamline the piece. And here comes a librarian who will walk you through the software that will format your citations and bibliography to conform to the journal’s style.

Your article has been accepted—and published! You know you should submit it to PubMed Central, the free online archive of biomedical and life science journals operated by the NIH’s National Center for Biotechnology Information in the National Library of Medicine. But you’re busy. And you’ve spent enough time on that article. No problem: a librarian from the medical library will submit it for you.

These are a few of the services provided by librarians at the Cushing/Whitney Medical Library—the new Publishing Support page on the library website describes all that they do.

Services include classes on using the library, links to online style manuals and help choosing bibliographic software. The Publishing Support page lists liaison librarians, who are specialists assigned to each department and research center to provide guidance to researchers in their area.

Other support services include information on a given journal’s impact factor, which is based on how often articles are cited in journals. Other information on the support site includes instructions for formatting papers; information on copyright issues; lists of library classes; and online tutorials on topics including scholarly publishing and using Ovid MEDLINE.

The new page, said Reference Librarian Lynn H. Sette, M.L.S., “is a natural extension of the kinds of things we have always done for people. Publishing and the library go hand in hand.”

The page can be accessed from the Cushing/Whitney home page or at http://www.med.yale.edu/library/publishing.html.

—Cathy Shufro

In Circulation focuses on activities at the Cushing/Whitney Medical Library. Send suggestions to Cathy Shufro at cathy.shufro@yale.edu.



Fine		Friedland



Mongan		von Eschenbach

On campus

A third party to speak for the terminally ill

Doctors and nurses in cases involving medically futile treatment often clash with a patient’s loved ones over whether to continue that treatment. An extrajudicial process, however, allows both sides to appeal to a committee of physicians, nurses, community representatives and other caregivers, a medical ethicist told an audience at pediatric grand rounds in September.

The Texas Advanced Directives Act of 1999, the first statewide attempt to resolve such disputes, has created “a legal safe harbor,” said Robert L. Fine, M.D., director of the Office of Clinical Ethics at Baylor Health Care System. When a case is deemed futile, it may go before the ethics committee, which does not always agree with the medical team. If the committee agrees with the medical team, treatment may be withdrawn unless an alternative health care provider is found within 10 days.

Most cases are settled within the 10-day process. “In many cases the family is relieved,” said Fine, who helped write the Texas law. “They didn’t let go. It lifted the burden.” Doctors are relieved, too. “Sometimes the highest level of care is to withdraw medically inappropriate treatment.”

—John Dillon

TB, an Atlanta lawyer and 52 South African patients

At first glance a diagnosis of tuberculosis seems to be all that unites Andrew Speaker, an Atlanta lawyer, with 52 impoverished South Africans who died of drug-resistant TB in a remote rural area in 2005. The cases “couldn’t appear more different on the surface,” said Gerald Friedland, M.D., professor of medicine and epidemiology at Yale, at internal medicine grand rounds in August.

Speaker made headlines last spring after being diagnosed with extensively drug-resistant tuberculosis (XDR-TB) and then putting fellow airline passengers at risk by traveling on seven separate commercial flights. He later received treatment at a top-rated TB hospital. Most of the rural South Africans, on the other hand, had all died by the time laboratory testing revealed the diagnosis of XDR-TB, said Friedland, who reported the cases in The Lancet in 2006.

Friedland said both Speaker and the South Africans suffered from the slowness of TB diagnostic tests and limited treatment options for drug-resistant TB. Friedland says the presence of growing numbers of cases with XDR-TB underlines the longstanding neglect of TB and the more recent rise of TB and HIV coinfection. “If there’s a silver lining,” he said, “it’s that the world attention focused on both of these cases has been a wakeup call for the need for resources to promote scientific advances and improved care for TB.”

—Jennifer Kaylin

Seeking a national solution to health care for all

Medicine is witnessing the best and worst of times because of the “staggering difference” between lifesaving advances and the “very broken” economics of health care delivery, said James J. Mongan, M.D., president and CEO of Boston-based Partners Health-Care System, during a talk at the medical school in September.

Mongan, who delivered the 11th annual Samuel O. Thier Lecture in Health Policy, said that the landscape of health care finance has shifted from one dominated by government programs to a regulatory/free-market hybrid that includes Medicare, Medicaid and managed care. Attempts to broaden coverage through employer mandates have failed because of a “tenacious desire for autonomy” in the private sector—businesses have exploited “our national ambivalence about heavy-handed government regulations” and taxation.

Meanwhile, 45 million uninsured Americans get emergency room treatment when they are sick instead of preventive care. Ignoring the cost of this tendency is dangerous, Mongan warned. While Massachusetts has a “promising” if flawed system to insure its residents, providing health care for all citizens “will demand some national action,” Mongan said, though he wasn’t optimistic that such action could be taken in the heat of a presidential campaign. “We currently stand as a nation without a good answer.”

—J.D.

Speeding the pace of biomarker discovery

Biomarkers that identify cancer in its early and more treatable stages have emerged as the newest tools in its prevention, diagnosis and treatment. But according to Andrew C. von Eschenbach, M.D., commissioner of the Food and Drug Administration (FDA), a urologic surgeon and oncologist as well as a cancer survivor himself, more effective collaboration among scientists and between the public and private sectors is needed to hasten the discovery of these molecular or cellular indicators of disease states.

“We have enormous talent but we haven’t brought it together,” von Eschenbach said in October at “Discovery to Delivery: A Public Forum About the Future of Cancer Research,” a colloquium sponsored by Yale Cancer Center, Yale-New Haven Hospital and Friends of Cancer Research. “We have superstars, but not a superstar team.”

To bring researchers together, the FDA has joined the Foundation for the National Institutes of Health, the National Institutes of Health and the Pharmaceutical Research and Manufacturers of America to launch the Biomarkers Consortium. This public-private biomedical research partnership will make its findings on newly discovered biomarkers available to scientists worldwide.

—Jennifer Kaylin


			Originally published in Yale Medicine, Winter 2008. Copyright © 2008 Yale University School of Medicine. All rights reserved.