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Today In History: APA Removes Homosexuality from List of Mental Disorders

Jim Burroway

December 15th, 2008

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-I) classified homosexuality as a mental illness beginning in 1952. Before then, psychiatrists and psychologists looked at homosexuality as a perversion and as a deviant behavior, but the idea that it was a mental illness was considerably more controversial. Sigmund Freud, the father of psychoanalysis, famously wrote to one American mother in 1935, “Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness.”

But by the early 1950’s American society’s view of homosexuality took a very sharp turn toward the dark side. This turn was partly sparked by the loud controversy stirred by Alfred Kinsey’s Sexual Behavior in the Human Male in 1948. Where before, homosexuality was little talked about; now it seemed suddenly to be everywhere. In the minds of Americans across the country, homosexuality now joined the other emerging threat, communism, as two great menaces to American order. By 1952, there had already been several purges of gays from federal employment. With the APA’s addition of homosexuality to its list of mental disorders, the fates of gays and lesbians would be sealed for the next two decades.

And as is always true in the medical and psychiatric fields, where there is an illness, there’s a quest for a cure. This was true for homosexuality long before 1952, and unfortunately it is still true today in some unenlightened circles. For the most part, the cure consisted of ordinary forms of talk therapy. But other, more abusive forms of therapy — namely electric shock therapy or therapies involving severe nausea-inducing drugs — weren’t exactly rare. And, of course, as long as gays and lesbians were labeled “mentally ill,” all manner of discrimination was made possible against those who officially declared to be operating under a mental impairment.

Thirty-five years ago today, on December 15, 1973, all of that began to change when the American Psychiatric Association’s Board of Trustees “cured” millions of gays and lesbians across America when they voted to pass this resolution (PDF: 464KB/5 pages):

For a mental or psychiatric condition to be considered a psychiatric disorder, it must either regularly cause subjective distress, or regularly be associated with some generalized impairment in social effectiveness or functioning. With the exception of homosexuality (and perhaps some of the other sexual deviations when in mild form, such as voyeurism), all of the other mental disorders in DSM-1 fulfill either of these two criteria. (While one may argue that the personality disorders are an exception, on reflection it is clear that it is inappropriate to make a diagnosis of a personality disorder merely because of the presence of certain typical personality traits which cause no subjective distress or impairment in social functioning. Clearly homosexuality, per se, does not meet the requirements for a psychiatric disorder since, as noted above, many homosexuals are quite satisfied with their sexual orientation and demonstrate no generalized impairment in social effectiveness or functioning.

The only way that homosexuality could therefore be considered a psychiatric disorder would be the criteria of failure to function heterosexually, which is considered optimal in our society and by many members of our profession. However, if failure to function optimally in some important area of life as judged by either society or the profession is sufficient to indicate the presence of a psychiatric disorder, then we will have to add to our nomenclature the following conditions: celibacy (failure to function optimally sexually), revolutionary behavior (irrational defiance of social norms), religious fanaticism (dogmatic and rigid adherence to religious doctrine), racism (irrational hatred of certain groups), vegetarianism (unnatural avoidance of carnivorous behavior), and male chauvinism (irrational belief in the inferiority of women).

The New York Times alerted the world with this Page One announcement:

The American Psychiatric Association, altering a position it has held for nearly a century, decided today that homosexuality is not a mental disorder. The board of trustees of the 20,000 member organization approved a resolution that said in part, “by itself, homosexuality does not meet the criteria for being a psychiatric disorder.” Persons who are troubled by their homosexuality, the trustees said, will be classified as having a “sexual orientation disturbance” should they come to a psychiatrist for help.

The full APA would go on to ratify the policy statement on April 9, 1974. But attempts to cure homosexuality would continue under a new illness inserted into the DSM as a compromise in 1974. Sexual Orientation Disturbance (SOD) defined homosexuality as an illness if an individual with same sex attractions found those attractions distressing and wanted to change. The new diagnosis served the purpose of legitimizing the practice of sexual conversion therapies, even if homosexuality per se was no longer considered an illness. The SOD diagnosis also allowed for the unlikely possibility that a person unhappy about a heterosexual orientation could seek treatment to become gay. Reflecting the realities of clinical practice, 1980’s DSM-III changed SOD to “Ego Dystonic Homosexuality” (EDH). That diagnosis was finally removed in 1987, but resurfaced as a brief mention under “Sexual Disorders Not Otherwise Specified”, which describes persistent and marked distress about one’s sexual orientation.

Update: The last paragraph describing subsequent diagnoses was revised and clarified, with thanks to Dr. Jack Drescher.

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SuzyQ
December 15th, 2008 | LINK

Ironically a few years later the APA took the extremely reactionary step of making Transsexuality a mental illness thereby stigmatizing people born transsexual with the same burdens that had been removed from L/G folks.

Rick
December 15th, 2008 | LINK

Happy Not-Mentally-Ill-Because-You’re-Gay-Day!

Ephilei
December 15th, 2008 | LINK

Thanks so much for that APA quote! It’s insightful to their motivation.

I think the DSM’s influence is overrated. As Jim said, cures were attempted long before the DSM labeled it a disorder and have continued after removing the label. Discrimination was and is based on homophobia which pays no heed to science. All that is true for transexuals too.

Swampfox
December 15th, 2008 | LINK

Thanks for the reminder.

Bill Ware
December 15th, 2008 | LINK

Whoa, SuzyQ, let’s look at practice practicalities. Everything in the health care system is run be those pesky DSM generated numbers. Every physical and mental condition has a number. Insurance will not pay for services without a number. Hospitals will not allow doctors to admit patients without a number and so on.

For a doctor to start medical treatment, the person needs counseling and evaluation. Gotta have a DSM number for the referral. Before that first estrogen prescription, gotta have a number. To admit someone to the hospital for what otherwise would seem like unnecessary surgery, gotta have a number for that, too.

So while these designations may evoke negative reactions, in order to receive medical treatment, these designations are required for any services to be provided at all.

Kith
December 15th, 2008 | LINK

Suzy, not to get too far from the base here, but lets look at this line.

“For a mental or psychiatric condition to be considered a psychiatric disorder, it must either regularly cause subjective distress, or regularly be associated with some generalized impairment in social effectiveness or functioning.”

Are you willing to say that transsexualism does not “regularly cause subjective distress”?

I know every day until treatment, hard coded medical treatment, my transsexual friends cannot get over the hump of their disorder. Casual cross dressing didn’t solve their problems, having their friends and loved ones treat them as their desired gender didn’t solve their problems. They needed medical intervention. Even my non-op friends usually need hormones and/or cosmetic procedures, electrology, mastectomy, orcindectomies, thercial shaves, breast augmentation. . . and before you compair this to a teenager who will die without a nose job, like so many of the surgery on demand people do, the needs of these surgeries go to the core of their identity.

Now then how about the second part are you going to tell me that untreated transsexuals don’t regularly suffer “generalized impairment in social effectiveness or functioning.”

When not under treatment, transexuals are often left outside of socity, facing a form of dissasoiated disorder. They can’t connect properly with people, when they do they are often plauged with doubts. They suffer for their problem and it effects their social function. While I’ll admit that while many “pre-discovery” transsexuals have great lives, it is generated by a need to prove they are not broken, then when the “discovery” process starts how many end up systematically destroying their old life? That alone mimics a good many disorders. Sure some of the problems are generated by ignorance and negative impressions, but many come from the transsexual themselves who suddenly find themselves in a new adolescence as they must re-learn their lives, while facing the emotional distress caused by a pharmacological soup and physical distress of multiple medical procedures and the social stress of huge financial burden.

To compare if a person suffered a head injury or stroke, that forced them back into adolescence, forced them to re-learn every aspect of their lives, could only be treated through heavily pharmaceuticals and painful/expensive surgical procedure, we would not blink at recognizing that they suffered an illness. Yet because of the political burden of the trans issue, people want to cast such suffering people, many of whom are teenagers or pre-teens, to the four winds.

Swampfox
December 15th, 2008 | LINK

Suzy, I understand the stigmatization. I grew up at a time when homosexuality was considered a mental disorder that was treated and supposedly cured. I bought into that ideology for far, far too long. Last year I nearly took my own life.

I tend to understand the caution of the medical community, including psychiatrists, when it comes to the trans-sexual issue ….. surgery and reconstructive surgery is radical and should not be entered into without considerable thought and reflection.

SuzyQ
December 15th, 2008 | LINK

Gee… I came out before Stonewall. Ran the National Transsexual Counseling Unit in SF between 1971-73.

Indeed I was a patient of Dr. Benjamin who coined the term Transsexual. I picketed the APA conference at the Jack Tar to protest the labeling of L/G as mental illness.

All this was years before the APA turned the thingie in Deuteronomy that makes trannies an abomination into our version of what they did to gays with the Leviticus abomination. They manufactured a psychiatric illness called GID. This is faith based pathology. GID is also what Foucault would call a pure social construct.

I had an innate condition called transsexualism, more intersex than psychological.

The psychiatric profession has created more scams to bilk insurance companies than virtually any other branch of the health industry.

Before they disempowered us we used to run our own peer to peer groups.

As for sex reassignment surgery being “radical” humm?? I never saw it that way. But then I saw those parts as a useless deformity.

SuzyQ
December 15th, 2008 | LINK

BTW I realize that there isn’t that much inter tribal communication in the LGBT/T world.

The reality is that we might as I said at the LA Christopher Street West Celebration in 1974 get together for a parade but most of the rest of the year we are off in our own communities.

I’m a radical old woman on my blog, http://womanrebel.blogspot.com I describe myself as anarcha-feminist and my range of issues are far broader than trans-specific ones. Same sex marriage is one, unionization and worker’s rights are others.

However there is one trans-issue I am involved in and that is the same issue I marched with L/G folks on 35 years ago. Transsexualism is not a psychiatric disorder but is a fiction made up by some pretty anti-LGBT/T people.

Also many of those who are pushing the hardest to keep GID in the DSM are associated with reparative therapy on queer kids and such organizations as NARTH.

Kith
December 16th, 2008 | LINK

When has SRS not been radical? Radical means to remove an organ. SRS is radical just as Open heart surgery is Radical Surgery. This is not an outpatient procedure. Here is the medical definition. http://medical.merriam-webster.com/medical/radical

I will accept that it may not be a “mental disorder”, but you have a long way to go to establish that brain/body divide. Even if you could, you can’t honestly claim that there isn’t a medical condition that needs medical treatment.

What ever you want to call this condition, physical, mental, biological it is only “socially” constructed in the sense that gender is socially constructed and it still cannot be proven that “Transsexualism” would not exist in a society with full gender fluidity, since we have no real way to be sure if it is the physical sex or the gender identity that has to match the brain “sex”.

This whole problem is fundamentally different then the medical tagging of homosexuality because there is no “non-medical” solution for most transsexuals. You can’t talk it away, you can’t pray it away, you can’t just accept it and move on. You need to medically intervene. You need to mess around with body chemistry, you need to physically alter key functions of physical anatomy, you need to alter both internal and external perceptions. This isn’t fixed by “accepting” that you are just a guy/gal, unless you want to force them into a lifetime of hell. So without a medical name, diagnosis, and treatment path, where is a transsexual left to turn?

I can’t argue that there are those who would use the diagnosis against others, but there are those who use depression, bi-polar, and schizophrenia against others. Yet all these, like Transsexualism, can be treated and when they are the person is no different then anyone else. Also like transsexualism the root problem never fully goes away, it’s always a lifetime a of treatment and care. The solution isn’t to remove medical diagnosis and leave people flopping around without help. The solution is to remove the negative stigma attached to having such a diagnosis.

It’s funny because right now the same “remove the metal illness” game is being played with Asperger’s. A growing contingent of people want to remove the stigma of having a “mental disorder” and be treated just like everyone else. Yet the funny thing is having worked closely with a person who suffered Asperger’s if it wasn’t for the fact that he had a mental disorder he would have been fired on his third day at work. Of course talking with him I heard this similar argument, “they don’t have a problem it’s just an inflexible social system that doesn’t understand them.”

Duncan
December 16th, 2008 | LINK

If a person with Apergers’ cannot function in his job, he does not need the protection of a mental illness, he needs a job more appropriate to his peculiar skills. (And that’s not just data processing) I have high-functioning Aspergers’, but if you suggest I suffer from it be glad this blog is anonymous. Aspergers’ is best thought of as a different set of innate abilities.
And any cure for autism or Aspergers’ (as opposed to therapies to help them function socially) is like a vaccine against atheism.

SuzyQ
December 16th, 2008 | LINK

Kith..

Transsexuality isn’t a mental disorder. And psychiatry bears only a vague connection to science.

“So without a medical name, diagnosis, and treatment path, where is a transsexual left to turn?”

The name of what I was born with is transsexualism or HBS Harry Benjamin Syndrome and they are discovering that it has several genetic markers.

Further you speak like all outsiders to having the condition.

Life time of treatment and care is total BS. Most of us in the late 1960s and early 70s prior to the APA socially constructing us in to the mental illness model only saw psychiatrists as part of the screening process to insure we didn’t have a mental disorder.

This is quite a reversal to go from having to demonstrate I wasn’t mentally ill to people now having to demonstrate they have a mental illness.

At any rate there are the same sort of organizations lead by women born transsexual and men born transsexual WBT/MBT to remove GID from the DSM as there were L/G people who fought to remove homosexuality back when.

BTW I recall those in the homophile movement who argued it was better to be considered sick than perverted.

CiCi
December 16th, 2008 | LINK

Happy anniversary!

Bill Ware said,
“Whoa, SuzyQ, let’s look at practice practicalities. Everything in the health care system is run be those pesky DSM generated numbers. Every physical and mental condition has a number. Insurance will not pay for services without a number.”

The fact is, the psychiatric DSM for transsexualism excludes far more people from care that it enables. Most good gender counselors don’t use it, as it sends up too many flags. With the exception of some psychiatrist visits (frequently NOT coded under transsexuality) most U.S. transsexuals foot the bill at all stages. Many, if not most, complete medical transition following WPATH standards without anyone in the medical system ever making or recording a DSM transsexual diagnosis. (Hormones and surgeries typically require letters from the caregivers) The lifetime outlook for these individuals is no different that someone that has come to terms with their homosexuality, (or for that matter, their heterosexuality) no better, no worse,

Your own words and those in other comments make the case for the stigmatization of transsexuals as having a higher incidence of functional impediments related to transsexuality vs gays having impediments as a result of coming to terms with homosexualty. There is no basis in scientific fact for that belief. You fell into the stigma trap, set by the original, faith based, DSM authors and those current groups like NARTH that would perpetuate the belief.

We all know individual that have struggled in life, straight, gay, transsexual, etc. We should all know better that to generalize that to a population.

A few large corporations are just beginning to cover the medical costs to treat transsexualism, but removal of the psychiatric DSM has won’t reverse this positive trend.

I am not the expert in this area,(Dr. Winters is: http://gidreform.org/) but, make no mistake, for U.S. transsexuals, the psychiatric DSM for transsexualism will not be missed one bit. Except it may help to dispel the stigma that exists, even within the LGBT community!

I wish your comments were true, then the nature of the debate might be different, but it is simply not the state of transsexual treatment in America at this time.

CiCi

Holly B
December 16th, 2008 | LINK

Kith writes: “… Are you willing to say that transsexualism does not “regularly cause subjective distress”? … When not under treatment, transexuals are often left outside of socity, facing a form of dissasoiated (sic) disorder. They can’t connect properly with people, when they do they are often plauged (sic) with doubts. … ”

I’m willing to say what I think you mean. I will say distress is caused not by transsexualism, but by ostracism from society and by transphobia. No-one likes being hatred for no good reason. But to tar a person with a mental diagnosis because they are hated is, quite simply, wicked and amoral. Zucker and his ilk are wicked and amoral.

In fact the DSM-IV-TR directly addresses this issue , see page xxxi, first paragraph in pertinent part “… Neither deviant behavior (e.g., political, religious, or SEXUAL) nor conflicts primarily between the individual and society are psychiatric disorders, unless the deviance or conflict is a symptom of dysfunction in the individual, as described above. …” (EMPHASIS added)

Thus, by the DSM’s own words. GID is NOT a psychiatric disorder (and should be removed from the DSM manual).

De-psychopathologization of GID and transsexualism will help greatly, as it did to homosexuality 35 years ago as of yesterday. It is mere scaremongering to suggest that treatments ALREADY PROVEN SUCCESSFUL will be abandoned merely because voodoo psychiatry is at last debunked.

justme
December 16th, 2008 | LINK

Hi Kith,

I’m perfectly willing to admit that my transsexualism regularly causes subjective distress not related to conflict with society. That does account for about half of it, but the other half is due to direct conflict with my own body, not because of how others perceive me because of it.

On the other hand, the numb spot on my finger where I have nerve damage from a power tool accident causes subjective distress due to a conflict with my own body. So did the cyst I had on my backside, until I finally had it removed a couple of years ago, and the ganglion cysts in my hand and wrist, and the twinges I get from time to time from an old ankle sprain. So, for the sake of logical consistency, are you going to also insist these qualify as mental disorders, for which I should require a DSM code before I can get any kind of treatment?

I’m pretty sure Stephen Hawking’s ALS regularly causes him subjective distress due to conflict with his own body. So is that a mental disorder, too?

As for Asperger’s, without knowing much more about it than has been said here (though probably more than the average person in the street), I would have no problem backing its removal from the DSM. As far as I’m concerned, that book is largely a tool for the systematic pathologization and stigmatization of human variation.

The Lauderdale
December 17th, 2008 | LINK

Long-time lurker at Box Turtle, breaking silence to say:

This thread takes an interesting tangent. I’m glad to be reading it for contrasting perspectives on the DSM and its treatment of/implications for transexualism.

justme
December 17th, 2008 | LINK

Oh, and Kith? You’re right, technically SRS does fit the medical definition of “radical.” But that has nothing to do with Swampfox’s original use of the term, meaning “drastic, alarming, not to be undertaken lightly.” By the medical (i.e. your) definition, the removal of the cyst from my backside was “radical” surgery, because she took the entire thing out, curing the problem permanently–even though it was done in her office, in five minutes, under local anaesthetic and I was able to sit on it immediately afterward with only mild discomfort (not much worse than the cyst itself). I find a lot of confusion and miscommunication arises from using a term two “radically” different ways like this without being aware of it, so I thought I’d better point that out.

As for Swampfox’s original concern, of course; no invasive surgery should be undertaken lightly, without adequate thought and reflection. SuzyQ’s point was simply that to her it didn’t seem like any big dilemma as to whether to get it done or not.

You have to realize that most transsexuals will have been thinking and reflecting about this very thing since childhood, and aren’t doing it on any kind of whim. Why should the medical community, psychiatrists in particular, be any more concerned with how transsexuals decide to have corrective surgery than anyone else with a disfiguring birth defect or an annoying growth? Should a person born with harelip, for example, and who wants reconstructive surgery, be required to submit to a diagnosis of a mental disorder, then forced to spend a couple of years in therapy or seeing a psychiatrist, and a year or two wearing a prosthetic upper lip in public to make sure it’s right for them, before allowing it?

Just because the doctor or psychiatrist isn’t empathic or open-minded enough to understand, doesn’t somehow make the surgery any more “radical” (drastic, alarming, not to be undertaken lightly). It certainly isn’t so to the transsexual, at least for many of us–not all that different from breast reduction surgery for women who need it to relieve their back pain, really. And in any case it’s not anyone else’s decision to make, is it? The whole system as it exists now, thanks to the DSM classification, is patronizing and condescending at best.

Personally, I wouldn’t object to a medical classification on par with, say, harelip, cleft palate, or even medically-indicated breast reduction surgery, if it’s really needed for insurance coverage purposes. The point is, it doesn’t belong in the DSM any more than those other diagnoses do; it’s not a “mental disorder” by any reasonable definition of that term, and the effect of that classification has proven to be far more harmful than beneficial.

Ben in Oakland
December 17th, 2008 | LINK

The reason the APA dropped homosexuality from its list of mental disorders was that there was absolutely no evidence that being gay is a mental disorder. They had a definition of mental disorder, but to make it stick for gay people they had to ignore their own definiton, and say that “Of course. Gay people are mentally disordered BY definiton. Just not THIS definiton.” It could not hold up to any kind of scientific scrutiny. The really homophobic psychiatrists, like Bieber and Soccarides (father of a gay son!!!), the ones who earned their living “curing” gay people, tried to force a referendum on the APA, but it also failed. The whole procedure underlined that prejudice was really the defining issue, not homosexuality, as is often the case on this particular issue. (Not surprisingly, religious reactions to gay people are very similar). First, a whole category of people is defined as mentally ill (or particularly sinful) with no scientific or experiential (or biblical) reason to do so, only a cultural and religious prejudice. They they have a vote, and presto-change-o, a whole category of people are “cured” overnight. Then, the people who whose livelihood depend on the the “mental illness” issue try to make another vote to make all of those people “sick” again. Clearely, not a matter of good science or good medicine, just prejudice. You might call it the politics of diagnosis. There is a great book on the whole fiasco called “Homosexcuaility and American Psychiatry” by Ronald Bayer. It’s a great read.

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