What Freud Really Said About Homosexuality - And Why
by Joseph Nicolosi, Ph.D.
There is increasing public and professional debate over the normality and treatability of male homosexuality. This warrants a return to the earliest professional understandings of the condition, i.e., the origins of Sigmund Freud’s psychoanalytic theory. While gay-affirmative theorists dismiss early psychoanalytic theory regarding the nature and causes of homosexuality, this perspective continues to offer a foundation for understanding same-sex attractions and for the application of effective therapeutic interventions. While often unclear about his views on homosexuality, in three primary and other peripheral writings, Freud depicts his diverse, perhaps ambivalent, views on the phenomenon. These views are summarized in seven categories: 1. The Reality of Reproduction. 2. The Theory of Universal Bisexuality. 3. Psychosexual Immaturity. 4. Homosexuality and Narcissism. 5. Reparative Concept. 6. Therapeutic Pessimism. 7. Homosexuality as “Perversion.” Working within the limited theoretical framework of the Oedipus Complex, Freud offered basic observations and fundamental principles which modern psychodynamic-oriented theories and therapies continue to develop.
There is increasing public and professional debate over the normality and associated treatability of male homosexuality. Freud’s own words on homosexuality have been exploited by both sides of the “normal versus pathological” debate. The “easy lifting” of Freudian quotes to support each side of the debate is partially due to his own uncertainty and ambiguity on the subject. Throughout his life Freud approached the subject with caution and made only tentative assumptions.
For example, gay-affirmative apologists, in order to support their view of homosexuality as “normal,” refer to Freud’s “Letter to an American Mother,” in which he says that “Homosexuality . . . is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness: we consider it to be a variation of the sexual function.” However, gay-affirmative apologists omit the telling, final passage of the letter, which states, “[Homosexuality] is produced by a certain arrest of sexual development” (Freud, 2014d, p. 786).
A sincere attempt to gain a psychological understanding of homosexuality necessitates an inquiry into classical psychoanalysis, the school of thought offering the first professional, psychotherapeutic analysis of homosexuality’s origins and consequences. This inquiry begins with Freud. As the founder of psychoanalysis, Freud laid the foundation for more than a century of scientific investigation. From this historical context, we ask the reader to consider that critical, judgmental, and even deprecatory concepts and vocabulary to be understood from that perspective.
Over the course of his life, Freud expressed various ideas about homosexuality, which beginning in 1905 he sometimes referred to as “inversion” (Freud, 2014c, p. 136). Some of Freud’s statements were fragmented, incomplete, and even self-contradictory (Lewes, 1988). At times he implied that homosexuality was an illness, while at other times merely a “variation of the sexual function” caused by “an arrest in sexual development” (Freud, 1951, p. 786).
Freud considered homosexuality to be a perversion in the classical psychoanalytic sense of that term, i.e., a condition that includes self-object limitations, narcissism, and an underdeveloped superego (Freud, 2014). While he thought homosexuality to be one of the “perversions,” which he defined as deviations from “the normal sexual aim . . . regarded as being the union of the genitals in the act known as copulation” (Freud, 2014c, p. 46), Freud also made impassioned arguments for the higher human achievements accomplished by homosexuals, pointing to da Vinci and Michelangelo in particular (Freud, 1932).
Freud strongly opposed social intolerance of homosexuals. He wrote:
It is one of the obvious social injustices that the standard of civilization should demand from everyone the same sexual life-conduct which can be followed without any difficulty by some people, thanks to their organization, but which imposes the heaviest psychical sacrifices on others. (Freud, 1959a, p. 192)
At the same time, he took what some would call a moralistic view, stating:
What are known as the perverse forms of intercourse . . . in which other parts of the body take over the role of the genitals, have undoubtedly increased in social importance. These activities cannot, however, be regarded as being as harmless as analogous extensions [of the sexual drive] in love relationships. They are ethically objectionable, for they degrade the relationships of love between two human beings from a serious matter to a convenient game, attended by no risk and no spiritual participation. (Freud, 1959a, p. 200)
In addition, Freud’s intended professional, scientific views were sometimes accompanied by his personal sentiments. For example, Freud wrote three essays on the theory of sexuality in 1905, where he stated that “We never regard the genitals themselves . . . as really ‘beautiful’” (Freud, 2014c, p. 155). In 1910, Freud wrote “Leonardo da Vinci and a Memory of His Childhood,” where he describes fellatio as “a loathsome sexual perversion” (Freud, 1932, p. 86).
Freud was unclear about whether homosexual object-choice should be considered a singular and unitary entity, or several, separate varieties (Freud, 1932, p. 101). In other words, Freud was not sure if homosexuality was a singular phenomenon or had various manifestations. He continually returned to the question of causation, offering several theories but never diverging very far from his foundational theory of the Oedipus Complex.
The Oedipus Complex
According to Freud, the Oedipus Complex occurs within the phallic stage of a boy’s psychosexual development (ages 3–6 years), during which time the mother becomes the object of her son’s infantile libidinal energy (sexual desire). Because the father is the one who is privileged to sleep with his mother, the boy is propelled into an emotional rivalry with his father. To facilitate union with the mother, the boy’s id-driven impulse prompts the wish to kill the father (as did Oedipus), but the boy’s more pragmatic ego, in light of the reality principle, knows that the father is stronger. The boy thus remains strongly ambivalent about his father’s place in the family. Fear of “castration” (the father’s ability to render him powerless), eventually prompts abandonment of this death wish and the boy instead identifies with him. The resolution of the conflict between the drives of the id and the ego is the defense mechanism of identification through which the boy internalizes the personality characteristics and the masculinity of the father. In identifying with the aggressor, the boy diminishes his castration anxiety and defends himself from the father’s wrath as the two contend for the mother.
The boy’s identification with the father is the successful resolution of the id-ego conflict, which in turn leads to the formation of a mature sexual identity—in other words, heterosexuality. Failure to successfully resolve the Oedipus Complex fixates the boy’s identification with the mother, directing his libidinal cathexis onto the father. This negative Oedipal outcome may result in adult homosexuality.
The Limitations of the Oedipus Theory
One of the limitations of the Oedipus Complex theory as an explanation for homosexuality is Freud’s presupposition that the Oedipus Complex is the central phenomenon in the developmental period of early childhood. Freud used the Oedipus Complex alone to explain child development and attempted to explain homosexuality with that model solely. In this model, it is the boy’s resolution of the Oedipus Complex (i.e., an inevitable competition with his father for the love of his mother) that transitions the child from auto-eroticism and narcissism into true object-relatedness and heterosexuality. Homosexuality is seen by Freud as the result of a failed resolution of the Oedipus Complex. This could occur either when this complex was not worked-through completely, or because a previous trauma had caused a psychosocial fixation within the pre-Oedipal state, preventing the child from beginning the Oedipal dynamics (Freud, 2014c, p. 242).
An additional limitation of the Oedipus Complex model is that it views the parent-child bond as a sexually based attachment, i.e., libidinal cathexis, rather than an emotional-identification bond (Freud, 2014b, p. 174). An example of the Oedipal model’s narrowness is found in Freud’s attempt to explain same-sex attraction in erotic, rather than identification terms. He was clear about the boy’s over-identification with the mother, but believed that this identification was due to libidinal attachment, and so he could not account for how the father then becomes a sexual object. His best explanation was that the child who becomes homosexual identifies with the mother and therefore loves men as she would (Freud, 2014c, p. 145 n.). These limitations restricted Freud’s consideration of self-identity and especially gender identity, which would be described more fully by later clinicians in self-psychology and object-relations theory.
Freud’s Diverse Views on Homosexuality
While Freud wrote no major work exclusively dedicated to the subject, his views on the topic of homosexuality appear in diverse papers, notably “Three Essays on the Theory of Sexuality” (2014c); “Some Neurotic Mechanisms in Jealousy, Paranoia and Homosexuality” (2014g); and “Leonardo da Vinci and a Memory of His Childhood” (1932). From these three essential and other peripheral writings, Freud’s diverse views on homosexuality can be summarized in six categories:
1. Freud’s Philosophical Foundation: “The Reality of Reproduction”
Freud began his investigation of homosexuality with the assumption that biological complementarity is the basis of normal sexuality—what Rado would later term Freud’s “standard pattern” (Rado, 1940, p. 464) of male-female sexual relationship. Central to this pattern is the potential for reproduction. Based on nineteenth-century biological theories and Darwinism, Freud’s theory saw the role of sexual activity as the union of the genitals of members of the opposite sex for the purpose of continuing the race (Rado, 1940, p. 464). Summarizing this view, Arlow (1986) states that “for Freud the question of what should be considered normal as opposed to perverse sexuality posed no particular problem. He used a biological criterion” (p. 249).
Basing his definition of “perversion” on the biological reality of reproduction, Freud stated in 1920:
The common characteristic of all perversions, on the other hand, is that they have abandoned reproduction as their aim. We term sexual activity perverse when it has renounced the aim of reproduction and follows the pursuit of pleasure as an independent goal. (Freud, 1955, p. 273)
Gay-affirmative apologists claim that Freud’s fundamental criterion of procreation is archaic and unnecessary. They regard Freud’s criterion of procreation as overly simplistic and narrow, and propose instead that sexuality is valid merely for pleasure and relational intimacy. In so doing, the gay-affirmative apologists join the contemporary trend among therapists and theoreticians in the mental health professions to substitute the individual’s subjective experience for an objective model of health. By equating Freud’s teleological (biological design-based) principle to a moralistic principle, gay-affirmative apologists have shifted the object of study from biological design to the person’s own subjective experience of meaning. This effectively moved psychoanalytic theory away from the objectivity of the natural sciences upon which Freud had attempted to build psychoanalysis. These theoretical departures from the reproductive function of sexual activity to the subjective and qualitative experience of human sexual relations served to further divide psychoanalysis from the natural sciences.
2. The Theory of Universal Bisexuality
Freud’s theory of universal bisexuality remained a fundamental, if problematic principle of psychoanalysis until 1940, when Sandor Rado (1940) decisively challenged that assumption. Freud thought that homosexuality was rooted not only in the unsuccessful resolution of the Oedipal Complex, but also in some undiscovered biological component that predisposes some children to homosexuality. Freud assumed that there exists either inborn (as in prenatal-hormonal) or genetic potential for homosexuality prior to the environmental events of the child’s psychosexual development. Freud considered that narcissism also might have a biological component.
Describing the evolutionary basis of sexuality, Freud wrote:
Psychoanalysis considers that a choice of an object independently of its sex—freedom to range equally over male and female objects—as it is found in childhood, in primitive states of society and early periods of history, is the original basis from which, as a result of restriction in one direction or the other, both the normal and the inverted types develop. Thus from the point of view of psychoanalysis the exclusive sexual interest felt by men for women is also a problem that needs elucidating and is not a self-evident fact based upon an attraction that is ultimately of a chemical nature. (Freud, 2014c, p. 144)
Gay-affirmative apologists have turned to Freud’s theory of universal bisexuality to attempt to deconstruct his belief that the fundamental requirement of healthy sexual development must be genital functioning in the service of reproduction. These theorists argue that whether the individual uses his sexuality for reproduction or pleasure, this should not be the gauge of his psychosexual maturity.
Rado (1940) rejected Freud’s notion of universal bisexuality and traced that idea to the pre-scientific mythologies of hermaphrodites and animism. He concluded that homosexuality finds its origins in childhood anxieties and not in biological constitution. Returning, like Freud, to the reproductive system as the criterion for normal sexuality, Rado claimed that Freud’s theory of universal bisexuality overlooked the obvious reparative function of same-sex behavior.
3. Psychosexual Immaturity
In spite of his theory of universal bisexuality, Freud viewed normal psychosexual development as inevitably ending in heterosexuality. Homosexuality represented an inhibition in development and did not represent mature sexuality (2014c, p. 145–47 n.). The cause for this inhibition, he maintained, could be found in constitutional and early family factors.
Anticipating the release of the Bieber, et al. (1962) study by over fifty years, Freud summarized his understanding of the familial causes of homosexuality:
In all our male homosexual cases the subjects had had a very intense erotic attachment to a female person, as a rule their mother. . . . This attachment was evoked or encouraged by too much tenderness on the part of the mother herself, and further reinforced by the small part played by the father during their childhood. Indeed, it almost seems as though the presence of a strong father would ensure that the son made the correct decision in his choice of object, namely someone of the opposite sex. (Freud, 1932, p. 99)
Despite his lifelong equivocation on some aspects of homosexuality, Freud maintained the consistent view that homosexuality results only when normal and natural heterosexual development is thwarted. His premise was that if the child’s psychosexual development is not derailed, or if there is not some constitutional predetermination, the child will naturally attain a heterosexual object-choice.
Throughout his life, Freud’s writing on homosexuality shows that he consistently understood homosexuality as an unresolved fixation, and not simply a “preference” based upon free choice. He explained that homosexuality is a derailment from the natural sexual object. Freud explained that “any established aberration from normal sexuality” was “an instance of developmental inhibition and infantilism” (Freud, 2014c, p. 231). Regarding causation of homosexuality, he later wrote that “sexual aberration in adults—perversion, fetishism, inversion (homosexuality) . . . will reveal an event such as I have suggested, leading to a fixation in childhood” (Freud, 2014a, p. 182).
Freud also wrote that “perverse sexuality, in brief, is nothing more than infantile sexuality divided into its separate tendencies” (Freud, 1920, p. 268). Finally, Freud cites homosexuality as an example of “an inhibition in development” (Freud, 2014c, p. 208).
4. Homosexuality and Narcissism
From his earliest formulations on the nature of homosexuality, Freud recognized the narcissistic structure of the condition: “Homosexual object-choice originally lies closer to narcissism than does the heterosexual kind” (Freud, 2014e, p. 426). He conceptualized homosexuality as a developmental mid-point between immature narcissism and mature heterosexuality (Freud, 1958). According to Freud, this mid-phase of narcissism “seeks for the subject’s own ego and finds it again in other people” (Freud, 2014c, p. 222 n.).
The narcissistic nature of a boy’s same-sex, sexual-object choices is first established within his identification with the mother (Freud, 1932). This narcissistic identification with her remains an impediment to authentic relationships in adulthood.
While Freud wrote his ideas on homosexuality in scattered form, his paper on Leonardo da Vinci (1932) may be considered the most insightful and detailed analysis of the homosexual condition. In this paper, for the first time, Freud linked this inhibition in development to narcissism:
. . . [the homosexual] finds the objects of his love along the path of narcissism, as we say: for Narcissus, according to the Greek legend, was a youth who preferred his own reflection to everything else and who was changed into the lovely flower of that name. (Freud, 1932, p.100)
Detailing the narcissistic component in homosexuality, Freud stated:
We have discovered, especially clearly in people whose libidinal development has suffered some disturbance, such as perverts and homosexuals, that in their later choice of love-objects they have taken as a model not their mother but their own selves. They are plainly seeking themselves as a love-object, and are exhibiting a type of object-choice which must be termed ‘narcissistic’. In this observation we have the strongest of the reasons which have led us to adopt the hypothesis of narcissism. (Freud, 2014f, p. 88)
Detailing the forms of narcissistic attachment, Freud stated: “A man can love himself as he is, he can love himself as he was, he can love someone who was once a part of himself, and he can love what he himself would like to be” (2014f, p. 90). Elaborating on this last type of love, Freud described the “impoverished” person who loves someone who possesses excellences he himself never had” (2014f, p. 101).
5. Reparative Concept
The narcissistic component of homosexuality is further explained as the “satisfaction” (2014c, p.222) that was sought for ego-wounding. The ego seeks some kind of repayment for an offense suffered, or for a perceived loss or defect. This compensatory function of the ego came to be understood in terms of narcissism.
Freud viewed homosexual behavior as a mechanism used as a defense against anxiety and fear. Earlier, Freud noted the reparative function of homosexuality in describing it as a defense against fear of women: “Their compulsive longing for men has turned out to be determined by their ceaseless flight from women” (Freud, 1932, p. 43).
Offering a clinical example of the reparative function of same-sex behavior, Freud stated:
In the history of homosexuals one often hears that the change in them took place after the mother had praised another boy and set him up as a model. The tendency to a narcissistic object-choice was thus stimulated, and after a short phase of keen jealousy, the rival became a love-object. (Freud, 2014g, p. 232)
6. Therapeutic Pessimism
Freud often expressed pessimism about the treatment of homosexuality, not because he was opposed to it in principle, but because he judged that the techniques of the time were ineffective. He explained:
In general, to undertake to convert a fully developed homosexual into a heterosexual does not offer much more prospect of success than the reverse, except that for good practical reasons the latter is never attempted. The number of successes achieved by psycho-analytic treatment of the various forms of homosexuality, which incidentally are manifold, is indeed not very striking. (Freud, 1955, pp.150–151)
Another reason Freud was pessimistic about treatment was that he saw the homosexual as a pervert (in the psychoanalytic sense) rather than a neurotic. Typically the neurotic was sufficiently enough distressed by his symptoms to motivate him to seek professional help. Because he experienced anxiety regarding his symptoms, he developed a transference onto the therapist, which is necessary for psychoanalytic treatment success. On the other hand, the “pervert” was thought to feel no internal conflict and gained too much ego-pleasure from his behavior. As Freud wrote, “Perverts who can obtain satisfaction do not often have occasion to come for analysis” (Freud, 2014a, p. 197).
Freud later explained:
The homosexual is not able to give up the object that provides him with pleasure, and one cannot convince him that if he made the change he would rediscover in the other the pleasure that he has renounced. If he comes to be treated at all, it is mostly through the pressure of external motives, such as the social disadvantages and dangers attaching to his choice of object, and such components of the instinct of self-preservation prove themselves too weak in the struggle against the sexual impulsions. One then soon discovers his secret plan, namely, to obtain from the striking failure of his attempt a feeling of satisfaction that he has done everything possible against his abnormality, to which he can now resign himself with an easy conscience. (Freud, 1955, p. 150)
Freud found that most homosexuals entered treatment due to “external motives, such as social disadvantages and danger attaching to his choice of object” (Freud, 1955, p. 151), but that his true motivation was not to be cured, per se, but rather to avoid social criticism, and to assure himself that he tried his best to change and “can now resign himself with an easy conscience” to his sexual pleasure (Freud, 1955, p. 150). This, and the belief that homosexuality was in part due to biological predetermination, apparently were the causes for Freud’s pessimism.
While Freud was pessimistic about treatment success, he did not exclude the possibility of change, but rather thought that psychoanalysis could offer the patient a more conflict-free adjustment to his homosexuality. Thus, Freud wrote:
It is not for psychoanalysis to solve the problem of homosexuality. It must rest content with disclosing the psychical mechanisms that resulted in determining the object-choice, and with tracing back the paths from them to the instinctual dispositions. There its work ends, and it leaves the rest to biological research. (Freud, 1955, p. 171)
This limited perspective is illustrated by his response to a mother who hoped Freud could cure her son of his homosexuality:
What analysis can do for your son runs in a different line. If he is unhappy, neurotic, torn by conflicts, inhibited in his social life, analysis may bring him harmony, peace of mind, full efficiency, whether he remains a homosexual or gets changed. (Freud, 2014d, p. 786)
Since Freud’s time, psychoanalysis has developed a more refined distinction between the neurotic and the pervert, as well as techniques to counter resistance in therapy. For example, Socarides and Freedman (2002) thought that confronting the patient’s denial of reality would create sufficient intrapsychic conflict to lay the foundation for the therapeutic alliance. Similarly, Chasseguet-Smirgel (1974) was hopeful in believing that “. . . there exists in the sexual pervert’s mind a more reality-oriented ego-ideal which is revealed in analysis” (p. 351). Cultivating these reality-oriented aspects of the patient’s mind, along with other efforts, have brought more positive reports of treatment since Freud’s time.
7. Homosexuality as “Perversion”
While the term “perversion” today has taken on a pejorative connotation, we need to consider the historical context in which Freud intended the use of the term. Socarides tells us that “While Freud himself deplored the word removed perversion because it carried a moralistic connotation, he continued to use it free from its pejorative meaning and in a scientific sense. He used it to denote sexual arousal patterns that are unconsciously motivated, stereotyped, and derived from early psychic conflict” (Socarides, 2002, p. 5).
In addition, Freud cautioned that it is difficult, if not impossible, to draw a clear distinction between “mere variations” and “pathological symptoms.”
No healthy person, it appears, can fail to make some addition that might be called perverse to the normal sexual aim; and the universality of this finding is in itself enough to show how inappropriate it is to use the word perversion as a term of reproach. In the sphere of sexual life we are brought up against peculiar and, indeed, insoluble difficulties as soon as we try to draw a sharp line to distinguish mere variations within the range of what is physiological from pathological symptoms. (1905/1949, p. 39)
For Freud, the term perversion should be understood: “. . . in the content of the new sexual aim . . . in its relation to the normal” (Freud, 1949, p. 39). “The normal” for Freud remains the biological reality of reproduction” (Freud, 1955).
The point at which a child became fixated in his psychosexual development determined whether or not he suffered from a perversion. The etiology of homosexuality placed the fixation before the period of the Oedipus Conflict, making the condition a perversion. One characteristic of the perversions is the attempt to master anxieties by excessive erotic investment in the “loved” object, i.e. libidinization. This, in turn, leads to a disturbance in the patient’s relationship to reality.
Success in mastering the Oedipal conflict allows the boy to move beyond the narcissistic phase of development, with its more primitive need-gratifying object relations, to a maturity that allows true object-relatedness. When the boy successfully navigates the Oedipal period, his identification with the father allows him to develop an authentic connectedness with social reality, a healthy superego, and the ability to internalize social/moral and aesthetic norms.
The homosexual’s continuing focus upon narcissistic object choices restricts his ability to establish a mature sexuality based upon healthy object relations. This focus on narcissistic gratification limits his sexual-object choices to those which offer reassurance against depletion of his masculinity (threats of castration). His tendency to seek an idealized object to fulfill his unmet narcissistic needs means that his relationships will be built upon psychic projections and repetitive enactments of reassurance.
Freud was the first to report the commonly found association between homosexuality and some degree of paranoia, which was frequently confirmed by other psychoanalysts (Lewes, 1988). He believed that such paranoia resulted from the homosexual’s inability to accept his own homosexuality. The transformative process from intolerable homosexuality to paranoia begins as follows: “I (a man) love him (another man).” This results in a reaction-formation defense mechanism, which protects him from the intolerable idea of homosexual attraction: “No, I don’t love him—I hate him.” The resulting paranoid delusion, therefore, is “And the reason I hate him, is that he persecutes me” (paraphrased from Freud, 1958, p. 63).
8. Homosexuality and Healthy Personality
The fundamental question for Freud was whether homosexual love could be truly other-related; or, was it simply an extension of infantile pleasure-seeking, or an attempt at narcissistic gratification with a partial object?
Freud was impressed by the great artists whom he thought to be homosexual, such as da Vinci and Michelangelo, and he viewed them as some of the highest-level contributors to culture and mankind (Freud, 1932). While Freud believed that homosexuality was an inhibition of normal psycho-sexual development, he recognized that it need not be an obstacle to development of the personality in other respects:
[Homosexuality] is similarly found in people whose efficiency is unimpaired, and who are indeed distinguished by specially high intellectual development and ethical culture [and] . . . found in people who exhibit no other serious deviations from the normal. (Freud, 2014c, p. 35)
In addition, Freud did not see homosexuality as invariably a problem with masculinity. He thought it possible for a homosexual man to be completely masculine-identified. He wrote, “In men, the most complete mental masculinity can be combined with inversion” (Freud, 2014c, p. 142). Years later, Freud noted: “A man with predominantly male characteristics and also masculine in his erotic life may still be inverted in respect to his object, loving only men instead of women” (Freud, 1955, p. 170). In this respect, his views precede what Socarides later described as post-Oedipal type of homosexuality (Socarides, 1989; Nicolosi, 2009).
Classical psychoanalysis contains substantial contributions to the understanding of homosexuality. Recent political changes have resulted in the questioning of its foundational conclusions. Psychoanalysis’ founder, Freud, proposed ideas that have since been interpreted differently by both sides of the debate, with one side claiming that Freud supported the view that homosexuality is a “normal sexual variant,” while the other side asserts that Freud expounds the view that homosexuality is a “pathological condition.” Self-serving selections of Freud’s own words are easily obtainable due to, as this paper has shown, Freud’s own uncertainty, ambiguity, and sometimes self-contradiction on the subject.
Nevertheless, considering the limitations of Freud’s historical and cultural perspective, along with his limited theoretical framework of the Oedipus Complex, he was able to establish fundamental principles that have proven fruitful to psychodynamic thinking during the one hundred years since he first wrote. These principles include the likelihood that a male homosexual experienced over-identification with his mother, and a poor relationship with his father; that narcissism is a common feature of male homosexual development; and that homosexual attractions serve a reparative function to compensate for the preceding factors. These principles have repeatedly been confirmed by mental-health professionals over a century of clinical practice.
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