Bridging psychoanalytic thought and sexual science, a new book by two leading New York psychiatrists brings sexuality back to the center of psychoanalysis, showing how important it is for students of human sexuality to understand motives that are irrational and unconscious. The authors present a new perspective on male and female development, emphasizing the ways in which both sexual orientation itself and the homophobia encountered by many gay and lesbian individuals begin early in life.

Sexual Orientation and Psychoanalysis: Sexual Science and Clinical Practice (Columbia University Press; $35) sums up several decades of research and practice by Dr. Richard C. Friedman, Clinical Professor of Psychiatry at Weill Cornell Medical College, and Dr. Jennifer I. Downey, Clinical Professor of Psychiatry at Columbia University College of Physicians & Surgeons.

Both authors were once Chief Residents at the New York Psychiatric Institute (at Columbia Presbyterian Medical Center) and are now Attending Psychiatrists at NewYork-Presbyterian Hospital. They have been involved in psychoanalysis and psychiatry for the past three decades, studying such topics as the endocrinology of sexual orientation. Their articles on sexuality and sexual orientation have appeared in leading journals such as the New England Journal of Medicine. In the 1970s, Dr. Friedman was involved in the work that removed homosexuality from the standard psychiatric classification as a pathology. He is the author of the acclaimed Male Homosexuality: A Contemporary Psychoanalytic Perspective (1988).

The new book presents a model of child development different from that of Freud in works like Three Essays on Sexuality. Scientific research carried out after Freud’s death shows that genetic and prenatal hormonal influences shape the psychological functioning of men and women throughout life. Childhood is marked by the intertwined effects of play and peer relationships. During late and middle childhood, boys and girls develop peer cultures that are quite different from each other. In late childhood, especially among boys, homophobia begins to develop. This book is the first to emphasize the importance of psychobiological determinants of homophobia.

The second part of the book is clinical. It extensively discusses homophobia from a psychodynamic and psychotherapeutic perspective. It looks at the recent concept of “internalized homophobia,” by which some patients develop negative self-images because they are gay, having internalized the homophobic images of other people during development. One reason why patients with severe internalized homophobia suffer is the prolonged and malevolent effects of early life trauma. Such trauma, caused by either adults or peers, has later consequences that may require psychotherapy.

The authors focus on some patients who do not improve despite supportive gay affirmative interventions without appropriate psychotherapy. They discuss a particularly enlightening and humanistic clinical presentation of a woman who came out of the closet when she was 84 years old.

In their concluding chapter, the authors critically assess the reasons that psychoanalysis remained for so long committed to a model of homosexuality as pathology. They demonstrate why a modern, psychoanalytically informed model of the mind is crucial for understanding sexual orientation. From a clinical perspective, their insights into the developmental underpinnings of homophobia are especially valuable.

The rich scientific and clinical perspectives in this book will help therapists better understand and treat self-destructive and high-risk sexual behavior. It will help scientists understand the sexual behavior of their subjects. By building bridges between science, developmental psychology, and psychoanalytically oriented psychotherapy, the book provides a framework for psychoanalytic psychology in the 21st century.