Response

I was surprised and disappointed to read Azeem Kaleem's letter in the BJPsych, in which he presents a series of unsubstantiated assertions as facts.^{Reference Kaleem1}

From his opening paragraph, Kaleem conflates the experiences of men who have sex with men in India, Pakistan and China and imagines that their female spouses have poor mental health. He does not mention any of the important differences between these countries. For example, in India and China, homosexuality is legal, although there are no provisions for same-sex marriage in either country. In Pakistan, same-sex intimacy is illegal and criminalised, attracting a life sentence.

The papers he then relies on to scaffold his series of hyperbolic statements^{Reference Jaspal2,Reference Wang, Wilson, Chen, Hu, Peng and Xu3} concern heterogeneous groups of men who have sex with men. He inexplicably conflates the gay-identity formation of British Asian men with the experiences of women in China who are married to men who have sex with men and then equates the experiences of these groups with the self-reported experiences of a small group of women who separated from their husbands when the latter ‘came out’ as gay.^{Reference Daly, MacNeela and Sarma4}

Indeed, Kaleem appears not to have understood the phrase ‘men who have sex with men’, which originated around 1988 during the HIV pandemic, to separate same-sex sexual acts from sexual, romantic and cultural gay or bisexual identity.^{Reference Connell and Kippax5} Whereas homosexuality refers to romantic and sexual attraction between members of the same sex, the phrase ‘men who have sex with men’ references sexual acts between men, and includes diverse populations.

As Jean-François Mignot writes in his excellent overview of the decriminalisation of homosexuality since the 18th century:

The men in China, India and Pakistan who have sex with men and who are also married to women are clearly not homogeneous populations. It does the women in such marriages a disservice to suggest all are at great risk of psychological harm or mental ill health. The assumption that all women married to men who have sex with men are naive or in need of ‘psychological counselling’ is problematic, not least because it locates the pathology in the psyche of women, rather than in homophobic cultures. Kaleem has completely overlooked the existence of lesbian and bisexual women in his concerns over ‘wives [ … ] likely to live with the endurance of the oppression of their [homosexual] husbands'.

I would argue that the ‘dire need’ that Kaleem describes is not for ‘care and psychological support to promote the well-being of these women’. The ‘dire need’ is for professionals to pathologise the homophobia, rather than the women in these marriages. Education to dismantle the cultural myths that promote heterosexual marriage as a form of conversion therapy would be an important public mental health intervention.