Olli Stålström & Jussi Nissinen. Journal of Gay & Lesbian Psychotherapy. Volume 7, Issue 1-2. 2003.
The First Wave of Psychoanalysis in Finland
The arrival of new ideas from the outside into Finland has always been slow. Historian Jan Löfström (1994), in a study of the history of homosexuality in Finland, notes that the acceptance of modern attitudes toward homosexuality in this country did not occur until the middle of the 20th century. Although homosexuality was not a taboo topic, discourse about it was either muted or marginal. There was a slow acceptance of psychoanalysis in Finland as well. For example, the first Finnish-language encyclopedia’s 1911 edition (Therman) did not contain any reference to Freud. The entry on homosexuality read, “Homosexual proclivity or sexual attraction to members of the same gender … is mainly caused by same-gender persons residing together for long periods (e.g., in monasteries, boarding schools, etc.) or by debauchery” (p. 563).
Juhani Ihanus (1994), a professor of psychology, has written extensively on the history and diffusion of psychoanalytic ideas in Finland. Ihanus believes cultural resistance slowed the arrival of psychoanalytic ideas to Finland in the 1930s. The path-breaking Finnish psychoanalytic pioneer was a medical doctor, Yrjö Kulovesi (1887-1943), who was personally acquainted with Freud and his work. Kulovesi published several articles and books introducing original psychoanalytic ideas into Finland (1933, 1935). Like many continental psychoanalysts of Freud’s generation, Kulovesi was a cultured, liberal and tolerant person who valued the ideals of democracy and human rights. In an article in the Finnish medical journal Duodecim, Kulovesi (1935) published the first extensive Finnish psychoanalytic article about homosexuality. Kulovesi followed Freud in stating that homosexuality is not an illness, although he nevertheless described homosexuality as a “perversion.” Kulovesi argued that most “homosexuals” may never seek psychiatric treatment because they feel no need to be rid of feelings which do not feel like a disorder to them. Kulovesi noted that in some cases, social pressures, discrimination or legal action against “homosexuals” could cause “painful social anxiety.” Like Freud, Kulovesi emphasized that homosexuality is not a monolithic entity, but a many-faceted phenomenon. He also warned against using simplified labels, such as “psychopathy” or “degenerate” and against making generalization about “homosexuals” based on studies of patient samples (p. 734). Unfortunately, Kulovesi died prematurely and did not have the time to train followers. Mirroring postfreudian developments in other countries (see Drescher, 1998, p. 58; Magee and Miller, 1997, p. 61; Lewes, 1988, pp. 24-47), Kulovesi’s relatively tolerant approach was followed by a more conservative, psychoanalytic re-reading of the meanings of homosexuality.
Conservative, Post-War Developments
In his history of homosexuality in Finland, Löfström (1994) notes that homosexuality as a social identity category began to develop in Finland in the 1950s. In fact, according to Löfström (pp. i-ii), Finnish debates about the social status of homosexuality were almost non-existent until the cold war years. Those were the years when American Senator Joseph McCarthy sought to weed out communists and “homosexuals” from the U.S. Federal Government. In the cold war atmosphere of the early 1950s, these witch-hunts eventually spread to traditionally socially-liberal Scandinavian countries, and resulted in a sharp increase in arrests of gay men in their countries’ capitals (Andreasson, 2000).
The symbol of Finnish psychiatric attitudes of that period was a professor of psychiatry at the University of Helsinki, Asser Stenbäck, who was also a priest of the Finnish State Church. As Stenbäck wrote in Swedish, he had an important influence in the whole of Scandinavia where Swedish is the lingua franca. As a theologian and psychiatrist, Stenbäck deeply influenced the views on homosexuality of the Finnish state church and of Finnish psychiatry as well during the 1950s and 1960s. He would eventually become one of the main influences responsible for importing the Socarides-Nicolosi (Socarides, 1978; Nicolosi, 1991) views of reparative therapy into Finland and Sweden (Stenbäck 1993).
Stenbäck presented his ethical and scientific arguments in various Christian publications during the 1940s and 1950s. Reflecting a dimension of the political situation in Finland at that time, Stenbäck promoted an ideology of absolute submission to higher authority. For example, because of the invasion by Stalin’s Soviet Union in 1939, the Finnish Government had formed a military alliance with Hitler to stop the Soviets. In a letter to a Christian journal, which he entitled, “Ourselves and Greater Finland,” Stenbäck exhorted all Finnish citizens to fight for a Greater Finland which would expand it borders to the East “… as a tribute to the efforts by Hitler to wipe out the arch-enemy” (Stenbäck, 1941). However, his principle work on sexual ethics was a handbook for teachers, educators, community physicians, theologians and youth counselors which was published by the Committee of Family Education of the Finnish State Church (Stenbäck and Pautola, 1952).
In his role as professor of psychiatry, Stenbäck disassociated himself from Freud’s theories of sexuality. Instead, the theoretical framework of Stenbäck’s basic text on sexuality paralleled the pathologizing psychoanalytic theories of the Hungarian émigré to the United States, Sandor Rado (1940). Like Rado, Stenbäck believed the biological structure of the genitals is what determines the proper sexual behavior of men and women. According to this perspective, women’s genitalia are designed to receive sperm from the man and to give birth to a new human being. According to Stenbäck, this biological fact gives rise to the differences in sexual instincts of men and women: “The male is active in seeking his sexual object. The woman is also active but she gives it an expression of the will to be submissive to the man” (Stenbäck and Pautola, 1952, p. 43, italicized in original).
In Stenbäck’s theory, sexuality can deviate from the heterosexual norm in two ways: masturbation or homosexuality. Onanism, according to Stenbäck, is a widespread disturbance. It is “against Nature” because it does not serve what he believes to be the two basic purposes of sexuality, procreation and childbirth. It is Stenbäck’s contention that “modern research” regards masturbation as a symptom of a deep-seated defect or disorder of the total personality (Stenbäck and Pautola, 1952, p. 259).
According to Stenbäck, homosexuality is a “fixation” and a “misdirected sex drive.” He also warns that homosexual role modeling and seduction are great dangers: “… in many cases, homosexuality has been caused by seduction or other accidental experiences so early that it must be considered a disease from the point of view of the individual” (Stenbäck and Pautola, 1952, p. 286, italicized in original). If homosexual seduction feels pleasant, it may become a decisive factor leading toward homosexuality (p. 280). He considers homosexuality to be a “perversion” because the genitals are not used according to the purposes defined by Nature: “Because [homosexuality] does not even fulfill the human need for love, it must be considered to be against Nature” (p. 285).
Stenbäck formulated warnings against the dangers of homosexuality which were later adopted in a 1966 sexual doctrine of the Finnish State Church. For example, Stenbäck claimed that the “homosexual” is morally responsible for the results of expressing his proclivities and therefore has a duty to abstain. The demand for abstention is based on Stenbäck’s opinion that homosexuals pose a grave threat to young boys and that their seduction by homosexual men has grave consequences (Stenbäck and Pautola, 1952, p. 288):
Homosexual proclivities can be contained with the help of the Christian faith and suitable medical help even when they cannot be cured. Although the homosexual is not always responsible for his proclivities, everyone has a duty to refrain from acting it out, in the same way an unmarried person must be celibate. The Bible does not warn about this sin in vain. The increase in homosexuality has always been the expression of the moral decay of the era. (Evangelical Lutheran Church of Finland, 1966)
Stenbäck further claimed that most “homosexuals” suffer because of their deviation and consequently, most of them would like to overcome their affliction. Stenbäck proposed a plan for the prevention of homosexuality by, for example, deporting homosexuals from their community of residence, as well as the police surveillance of youth clubs, swimming facilities and public toilets (Stenbäck and Pautola, 1952, p. 290). He also recommended castration:
Many homosexuals, who have been castrated, have even complained that they did not come to be castrated earlier… [With the help of early castration] many valuable mental properties that were blocked by homosexuality can bloom … The most difficult problem is that some homosexuals, who have lost their hope, do not want to get rid of their habit. (p. 291)
Stenbäck’s ideas about homosexuality remained the prevailing psychiatric doctrine on homosexuality in Finland until the 1970s. His religious arguments were later replaced by the Bieberian (Bieber et al., 1962) views imported by another Helsinki professor of psychiatry, the psychoanalyst Kalle Achté. Achté published the first academic textbook of psychiatry in 1971 (Achté, Alanen and Tienari, 1971) in which Irving Bieber was cited as the authority on homosexuality. In his memoirs, Achté (1993) records how important the emerging American psychoanalytic doctrines were for Finnish psychiatry, particularly during the 1950s and early 1960s when the popularity of psychoanalysis was at its highest in the United States. Leading Finnish psychoanalysts and professors of psychiatry of that era, including Achté and others (Tähkä, 1982; Schalin, 1969, 1991; Hägglund, 1981), introduced psychoanalytic theories of homosexuality into this country. Thus, the Rado-Bieber psychoanalytic school and later the Socarides-Nicolosi reparative therapy model became institutionalized for many years in university courses, textbooks, and state church teaching (Stålström, 2001).
Achté reprinted conclusions of the 1962 Bieber study, essentially with only minor revisions, in all the editions of the textbook published between 1971 and 1991. His basic approach follows that of Bieber (Bieber et al., 1962; Bieber, 1967) and defines homosexuality as a “disturbance” and a “fear and inhibition of heterosexual expression” caused by faulty parenting, i.e., a dominating mother and/or a detached father. Achté also claimed that “homosexuals” suffered from the mental disorder of querulous paranoia, which he defined as “protesting against real or imagined injustice.”
Other prominent, Finnish psychoanalysts who regard homosexuality as psychopathology, in either their texts or teachings, are Veikko Tähkä (1982), Lars-Olof Schalin (1969, 1991) and Tor-Björn Hägglund (1981). Tähkä, in a widely read handbook on patient-physician relationships, replaced the terms “love,” “loved one” and “sexual pleasure” with “disturbance,” “patient” and “symptom.” Schalin called homosexuality a “disorder” and warned against the seduction of young boys (1991, p. 110). Hägglund also accused “homosexuals” of attempting to molest young boys and compared homosexuality to blinding oneself.
Critique of the Illness Model
In Finland, there were four sources of criticism of the illness model of homosexuality. The first came from the growing American empirical research which criticized that model (Kinsey, Pomeroy and Martin, 1948; Kinsey et al., 1953; Ford and Beach, 1951; Hooker, 1957). This research, which was also responsible for the American decision to remove homosexuality from its diagnostic manual, spread to Europe via universities and scientific textbooks. The second source of criticism came from the so-called anti-psychiatric movement of Cooper (1967), Basaglia (1968/1972), R. D. Laing (1971/1973), and Thomas Szasz (1965, 1974). The Norwegian Haugsgjerd (1975/1970) was one of those who introduced anti-psychiatric ideas to Scandinavia. The third source of critique grew out of the remaining influence of the traditional European homosexual emancipation movement, initially inspired by Karl-Heinrich Ulrichs and later embodied in Magnus Hirschfeld’s Scientific-Humanitarian Committee (WHK) in the late nineteenth century. The fourth source of critique came from a range of left-wing women’s liberation movements from other Scandinavian countries, as well as French existentialism. It should be noted that there was overlap between the four sources insofar as they complemented each other’s opposition to traditional ways of thinking about homosexuality.
The Anti-Psychiatry Movement in Finland
A critique of psychiatric violence in general, and of the illness model of homosexuality as well, was introduced to Finland in the early 1960s by an anti-psychiatry movement which was largely inspired by the American psychiatrist and psychoanalyst, Thomas Szasz (1965, 1974). The Finnish pioneers of this movement were two radical medical students, Ilkka Taipale (1966) and Claes Andersson (1968). They organized several debates and panel discussions during the so-called “sex spring” of 1965 and became torchbearers of sexual emancipation. In that year, the Helsinki Student Union newspaper published an issue devoted to the theme of sexuality.
A number of single-issue movements sprang up in the emerging student radicalism: a peace movement, women’s liberation, a pedestrian movement and a general anti-authoritarian movement called The November Movement. The sexual radicalism arising largely from anti-authoritarian, critical New Left ideologies was not, however, unconditionally accepting of homosexuality. Two more traditional schools of thought still had a strong hold on people’s minds: Marxism and American Psychoanalysis. Some Finnish sexual radicals of the 1960s were only conditionally tolerant of homosexuality. Some adhered to the prevailing Soviet contention that homosexuality, as defined in the Great Soviet Encyclopedia of the 1950s (Vvredenskiy, 1952), was a social pathology of capitalist society. Many left-wing reformers believed that homosexuality would somehow disappear when other social problems of capitalism were overcome. Consequently, although some left-wing radicals of the 1960s halfheartedly supported sexual equality, Moscow-oriented leftists of the 1970s actually opposed sexual equality for gays and lesbians.
A parallel ideological problem among the new left was that to many of its members, orthodox psychoanalysis seemed to offer a set of absolute truths which were above all criticism. Even the radical Claes Andersson, who later became a psychiatrist, author and cabinet minister, was careful not to challenge psychoanalysis in the 1960s. In his preface to Ullerstam’s Finnish edition of Sexual Minorities, Andersson (1968) demanded the decriminalization of homosexuality and criticized psychiatric stereotypes and dehumanizing psychiatric language. He further describes how Ullerstam had to face a “vicious attack” from the state church and psychoanalysts in Sweden when his book was first published. Nevertheless, Andersson criticized Ullerstam for challenging psychoanalysts, reminding the latter that “psychoanalysts have largely contributed to what we know about the causes of sexual deviations” (p. 7). Andersson argued that “[gays and lesbians] cannot be expected to organize to demand their civil rights.” He believed that the best way to help gay people was to enlighten one’s own thinking. However, after the gay and lesbian movement had organized in the 1970s, Andersson gave the movement his full support.
Ilkka Taipale is a pioneer of anti-psychiatry and social psychiatry in Finland–a local Thomas Szasz. Taipale also criticized psychiatric terms like “degeneration,” “perversion,” “psychopathy,” “psychosexual infantilism,” “neuropathy,” etc., which he believes makes it almost impossible to deal “rationally” with the issues surrounding homosexuality. Taipale’s arguments draw upon the Kinsey studies, as well as the historical, biological, anthropological and psychiatric studies, which challenged the beliefs that homosexuality would always indicate underlying pathology or that people belonging to sexual minorities would somehow be inferior to others. Taipale further demanded that repressive laws and psychiatric labels be replaced by understanding and acceptance. He criticized a culture that grants sexual satisfaction only to heterosexual individuals, and even then only within marriage. Taipale calls for value-free empirical research and the need for a sexological research institute, which would employ physicians, psychiatrists, biologists, sociologists, anthropologists and historians.
Radical Movements in Finland
International ideas of gay and lesbian liberation began to enter Finland in 1968 from two sources. The first was the traditional European emancipation movement which originated with Magnus Hirschfeld’s WHK and continued with the Dutch COC after World War II. A second and later influence was the gay liberation movement in the United States. Nineteen sixty eight was also the peak year of Finnish student radicalism, a time when the Old Student House in Helsinki was occupied and the anti-authoritarian November Movement was founded. The movement’s leader, Claes Andersson, criticized the way in which traditional moralism was being transformed into a kind of “humane” neo-intolerance in which the “sexual deviant” now needed “treatment.” Small, radical homophile groups emerged alongside the November Movement which published, in 1968 and 1969, two issues of Homo et societas, the first homophile magazine in Finland. This magazine introduced radical new visions, from Dutch, Scandinavian and American radical movements, of social equality and integration through confrontation. Homo et societas was also the first publication to introduce the comparative studies of Evelyn Hooker in 1968. In the same year, Hooker’s (1968) introduction to social scientists in her chapter in the International Encyclopedia of Social Sciences further widened the gap between psychoanalysis and the social sciences.
The November Movement provided fertile ground for the development of a general sexual-political movement, SEXPO, and a homophile movement as well (Psyke). The latter was radicalized in 1974 and became the Finnish Organization for Gays and Lesbians (SETA). The emergence of SETA was caused by a general impatience with the cautious politics of the earlier homophile movements; a growing indignation with the antihomosexual attitude of the politically powerful state church of Finland; and the censorship law of 1971 which prevented publication of information about homosexuality.
SETA was also influenced by the American Psychiatric Association’s 1973 decision to remove homosexuality from the DSM-II (Bayer, 1981). From its inception, SETA strongly criticized psychoanalysis’ illness label of homosexuality. SETA took the position that while homosexuality is not a disorder, discrimination and societal pressure against gay people could lead to their developing mental problems and suicidal thoughts–unless proper help was made available. It urged a total revision of what was written about homosexuality in psychiatric and medical textbooks, in the field of mental health education, and suicide prevention. SETA further demanded that homosexuality be deleted from the national classification of disease.
1981: The Finnish Declassification of Homosexuality
The momentum to formally delete homosexuality from the World Health Organization (WHO) classification used in Finland began in the late 1970s. The Finnish gay rights movement was assisted by Michael W. Ross, a New Zealand psychiatrist who did post-graduate studies and research at both the Universities of Helsinki and Stockholm at that time (see Ross, Paulsen and Stålström, 1988). With his assistance, Finnish medical authorities were made aware of earlier decisions to declassify homosexuality as a mental disorder in Australia (1973), the United States (1973), Norway (1978) and Sweden (1978). In 1978, Ross even gave a guest lecture at Achté’s (see above) psychiatric hospital, informing his Finnish colleagues about new research in psychiatry. He also gave interviews on the subject in the Finnish daily press.
SETA repeatedly requested of the Finnish Board of Health to bring its classification system into line with other Western countries and to remove the diagnostic category of Anomaliae sexuales (302.00). SETA argued that the diagnosis had a wider significance beyond its usage as a code for medical documents, noting it was used to stigmatize gays and lesbians–even in high school textbooks (SETA, 1979). The Finnish Board of Health’s initial response paralleled the 1973 APA decision to replace homosexuality per se with egodystonic homosexuality (Bayer, 1987). The Board recommended that the diagnostic labels in group 302 should not be used unless the patient her/himself has come to treatment for problems in this diagnostic category (National Board of Health, 1980, emphasis added).
This compromise was unacceptable to SETA and to many Finnish psychiatrists as well; they demanded the unconditional deletion of the diagnostic category. After a heated public debate, and citing precedents in other Nordic countries, the Finnish National Board of Health ruled that the diagnostic codes referring to “sexual anomalies” would no longer be used in Finland (National Board of Health, 1981).
Psychiatric Textbooks
From 1971 to 1991, each edition of Achté’s textbook, Psykiatria, continued to pathologize homosexuality from a Bieberian perspective. Even after the diagnostic classification of homosexuality was deleted from the Finnish diagnostic classification in 1981, Achté refused to change the pathological labelling of homosexuality. Even the 1992 formal demand by the Student Union of the University of Helsinki that the books be updated or be withdrawn had no effect. The textbook was never updated.
Traditionally, American textbooks are highly esteemed in Scandinavia. In a 1996 televised retirement interview, Achté said the books he valued most were the Bible and Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. It seems the pathological labeling of homosexuality in Finland could not end before the American source itself changed. Consequently, it was an event of international significance when Terry Stein (2000) wrote a chapter in the 7th edition of Kaplan and Sadock which discarded the pathologizing labels and psychoanalytic stereotypes of previous editions (Gadpaille, 1995). In fact, a completely new Finnish psychiatric textbook, Psykiatria, was published by a new generation of psychiatrists (see Heikkinen, 1999). This textbook closely follows the American DSM-IV classification in which homosexuality is not mentioned. It also makes it clear that homosexuality is no longer considered a clinical entity and rebuts some of the most widespread psychoanalytic theories that claim it is.
There is a startling episode in the Finnish textbook debate which involved one of this paper’s authors (Stålström). In 1997, Stålström published his doctoral dissertation on the history and removal of the diagnostic label of homosexuality in the Unites States and Finland: The End of the Sickness Label of Homosexuality. In his dissertation, Stålström criticized the work of a Finnish psychiatrist, Kaija Eerola (1996). One of his criticisms was that Eerola had defined homosexuality in terms of deviance and disturbance and referred to this as the “prevailing view” in Finland on the subject. She subsequently sued Stålström for libel. After police interrogations, the public prosecutor brought libel charges against Stålström and his publisher, Helsinki University Press. The prosecutor’s office also demanded the wholesale confiscation of all published copies of the dissertation as well as a financial compensation of 50,000 Euros21 to Eerola.
These unprecedented court proceedings drew international attention. Concerned about Finland’s international reputation, an umbrella organization representing all Finnish publishers retained an internationally known human rights lawyer and Member of European Parliament, Matti Wuori, for the defense. Many expert witness, from both Finland and abroad, either testified or submitted written statements refuting the scientific claims of Eerola’s chapter. The Municipal Court of Tampere issued its verdict on December 18, 1999 and found Stålström not guilty of libel and all demands for compensation were denied.
Mental Health Professional Attitudes Toward GLB Patients
In the last decade, there appears to be a paradigm shift taking place in relation to homo/bisexuality in Finnish health care. Nevertheless, there is little open dialogue about the needs of GLB patients. There are several studies about the attitudes of Finnish mental health professionals toward gay, lesbian and bisexual patients/clients. Valtanen (1990) studied attitudes of physicians, psychotherapists, and nurses working in mental health care outpatient units toward homosexual patients. In all three professional categories, more than one half of those surveyed felt that their professional training had not given them adequate sources of information about homo/bisexuality. Instead, the respondents stated they found newspaper articles, radio and television programs and their own clients to be the best sources of information.
There is some new empirical data regarding workers in the health care field and homo- and bisexuality in Finland. Nissinen (1995) measured the attitudes of and knowledge about homo/bisexuality among physicians, therapists, social workers, nurses and other staff (N = 200) working in substance abuse outpatient and inpatient service units. According to these studies, 7-10% of respondents had homophobic reactions to homosexuality on the Hudson and Rickerts scale (Hudson & Rickerts, 1980). Nissinen also found that treatment teams did not openly discuss the sexuality of their homo/bisexual clients. This lack of discussion could explain how one therapist estimated that about 10% of his clients had been homo/bisexual, whereas another therapist, practicing the same number of years on the same treatment team, believed he had never encountered a single lesbian, gay or bisexual client. One therapist in a unit might refer a lesbian/gay/bisexual client to reparative therapy, whereas another one might work using a gay-affirmative approach. The great majority of therapists, however, totally ignore the issue of a patient’s sexual orientation.
Therapists reported uncertainty about how to discuss homosexuality in an open way. Some feared heterosexist/homophobic attitudes of colleagues based upon comments they made. Respondents also had little understanding of gay identity formation. Some thought of homo/bisexuality solely as a personal identity but did not know much about the value of social identification and peer groups. In addition, homo/bisexual professionals could be accepted on an individual basis as colleagues, but the respondents did not consider it appropriate for gay, lesbian and bisexual professionals to form networks.
Training of Psychotherapists
At the present time in Finland, scarce attention is paid to homo/bisexuality in the training of health care professionals. An exception can be found in the paraprofessional and intermediate level institutes (Polytechnics) which train ancillary health care personnel, including nurses. These programs have actively included courses on sexuality and diversity in their training program which they developed with the assistance of gay and lesbian organizations (SETA). In contrast, university-level teaching (physicians, psychologists, social workers) and professional education (psychotherapy training, family therapy training) either totally ignore health care issues regarding sexual minorities or address them superficially.
In 1996, the Organization for Lesbian, Gay and Bisexual Professionals within Health Care and Social Work (STEAM) was founded. Its aim is to serve as a network providing support and information and develop training and job supervision for professionals. As part of its mission, in early 2001 STEAM sent a questionnaire to about 20 organizations which organize psychotherapy training. One of the original goals of the questionnaire was to gather information for this article. It asked the training organizations how they dealt with a client’s homo/bisexuality in their training programs. The questionnaire also asked them whether they would be interested in cooperating with STEAM in the development of GLB-sensitive training. Only one organization bothered to reply to the questionnaire and its answers were so superficial that no useful data was provided.
In the absence of more systematically gathered information, there is only anecdotal data to report. In the psychotherapy training and job supervision experience of one author (Jussi Nissinen), homo/bisexuality is seldom openly discussed. When it is, homosexuality is often defined as a problem to be explained or a form of disturbance/arrested development. There is little attention paid to the kinds of problems that homo/bisexual clients face in interactions with their heterosexist social environments. In Nissinen’s training in family therapy, senior teachers express the belief that same-gendered partnerships do not form a good basis for the emotional growth of children. Clearly, more work is needed in this area. In fact, as open gay and lesbian mental health professionals have increasingly entered the field in the 1990s (Lehtonen, Nissinen and Socada, 1997), they have begun to have an impact on the training and practice of psychotherapy.