Posts Tagged As: DSM

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.

Our Godmothers Exchange Vows

Jim Burroway

June 16th, 2008

The first same-sex marriages took place in California, beginning at just one minute after 5:00 p.m. local time.

Phyllis and Del

This is Phyllis Lyon (right, 83) and Del Martin (left, 87) of San Francisco. They have been together for fifty-five years. They, along with six other women, founded the Daughters of Bilitis in 1955. The Daughters were the first major lesbian organization in the United States. Phyllis edited the DOB’s newsletter The Ladder beginning in 1956. Del edited The Ladder from 1960 to 1962. The Daughters eventually disbanded in 1970 after having established chapters all across the United States

In 1964, they helped found the Council on Religion and the Homosexual, bringing together national religious leaders and gay and lesbian activists for a national discussion of gay rights. Phyllis was also the first open lesbian to serve on the board of the National Organization for Women in 1973. Meanwhile, Del was heavily involved in getting the American Psychiatric Association to remove homosexuality from its list of mental disorders.

When Del and Phyllis met in 1950, the very idea that their relationship would someday be recognized by the state must have seemed utterly outlandish. But these pioneers have made a real difference for millions of gays and lesbians the world over, not just here in the United States. You might say that they are godmothers to all of us and our movement. After all these years of their hard work and dedication to the cause of lesbian rights, it’s hard to imagine a more appropriate couple to be the first to marry in San Francisco.

We not only offer our congratulations, but also our deepest thanks for all that Phyllis and Del have done, and all that they represent.

APA Statements on DSM Workgroups

Jim Burroway

June 3rd, 2008

Last week, we posted a statement from four transgender advocacy organizations on the American Psychiatric Association’s ongoing efforts to update the Diagnostics and Statistical Manual for its fifth edition (DSM-V). This week, we have two statements from the APA. The first one is about the DSM revision process, and the second one is about Kenneth Zucker’s participation on the DSM workgroup.

May 23, 2008

The American Psychiatric Association has received inquiries about the DSM-V process, particularly concerns about the Sexual and Gender Identity Disorders Work Group. The APA recognizes that this work group and others will address difficult and sometimes controversial issues. The APA’s goal is to develop a diagnostic manual that is based on sound scientific data, but also sensitive to the needs of clinicians and their patients. To this end, the APA has created a process that involves opportunities for review and input from persons with varied backgrounds and opinions.

Thirteen DSM-V work groups have been established to review all existing diagnostic categories in the current DSM. Individual work groups may propose revisions to existing disorder criteria, inclusion of new disorders, removal of existing disorders, or no changes to a disorder or its criteria. They may also propose revisions to the text that accompanies the criteria for each disorder. The Sexual and Gender Identity Disorders Work Group, chaired by Kenneth J. Zucker, Ph.D., has three subworkgroups:

  • Gender Identity Disorders, chaired by Peggy T. Cohen-Kettenis, Ph.D.
  • Paraphilias, chaired by Ray Blanchard, Ph.D.
  • Sexual Dysfunctions, chaired by R. Taylor Segraves, M.D., Ph.D.

Each subworkgroup meets regularly, in person or on conference calls. They begin by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses are developed and then investigated through literature reviews and analyses of existing data. They also may further test research questions in field trials involving direct data collection. Because the work groups are limited in size, they may request outside advisors to assist them in these tasks, and to provide reviews and comments from other perspectives. Finally, in order to invite comments from even wider communities of researchers, clinicians, and consumers, the APA launched a web site in 2004, on which these groups can submit questions, comments and research findings, which are then distributed to the relevant work groups.

Based on this comprehensive review of scientific advancements, targeted research analyses and clinical expertise, the subworkgroups will develop draft DSM-V diagnostic criteria. After a period of comment, the subworkgroups will review submitted questions, comments and concerns. The final draft of DSM-V will be submitted to APA’s Council on Research, Assembly, and Board of Trustees for their review and approval. The final, approved DSM-V is expected to be released in May, 2012.

In summary, the DSM-V development process was constructed to achieve a thorough, balanced review of scientific data, with multiple levels of approval required, and opportunities for input from stakeholders. It is important to recognize that the DSM is a diagnostic manual and does not provide treatment recommendations or guidelines. The APA is aware of a need for more scientific and clinical knowledge about the best medical and psychiatric care for individuals with Gender Identity Disorder. To address this need, the APA Board of Trustees voted to create a Task Force to review the scientific and clinical literature on GID treatment. The members of this Task Force will be appointed shortly.

Statement on Dr. Kenneth Zucker and Gender Identity Disorder (5/23/2008)

Kenneth J. Zucker, Ph.D., C.Psych., the Chair of the DSM-V Sexual and Gender Identity Disorders work group, is a widely respected and pre-eminent scholar in the world of academic sexology research. As Chair of the work group for Sexual and Gender Identity Disorders, Dr. Zucker’s role is to coordinate and facilitate the work of the three sub-work groups addressing Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders. Further information on the DSM-V development process can be found at [this web site].

Dr. Zucker has published 97 peer-reviewed journal articles, 48 book chapters, and a landmark textbook. His published work addresses psychosexual differentiation and its disorders, based on a wide range of empirical research studies on children and adolescents with gender identity disorder, with a focus on diagnosis and assessment, and their associated behavioral and psychological distress. As the current Editor of Archives of Sexual Behavior, the premier human sexuality research journal, he also has a wide familiarity with the disparate areas of sexual dysfunctions and paraphilias. Since 2001, he has been the Psychologist-in-Chief at the Centre for Addiction and Mental Health (CAMH), is a Professor in the Departments of Psychiatry and Psychology at the University of Toronto, and is on the Scientific Staff (Division of Child Psychiatry) at the Hospital for Sick Children. He was the President of the International Academy of Sex Research in 2005-2006.

Dr. Zucker and his service team at CAMH in Toronto have the longest standing research-clinical service for children and youth with gender identity problems in North America. Since the mid-1970s, Dr. Zucker and his team have evaluated over 900 children and youth with gender identity issues. Dr. Zucker is one of the few researchers who is doing long-term follow-up of the patients he has treated.

The philosophy of Dr. Zucker’s team is to provide client-centered care that maximizes benefit and minimizes harm to each child or youth. The goal of treatment is a well-adjusted youth, regardless of ultimate gender identity or sexual orientation, who feels she or he has been genuinely helped by her or his healthcare providers. Dr. Zucker has offered a variety of treatment options, understanding that options may vary greatly with the age of the client. For younger clients, therapy options include helping the child to overcome discomfort with his or her body, i.e., helping clients learn to live comfortably in their natal sex. Diagnosis and treatment of other problems that may be present, such as anxiety, depression, or substance abuse are also available, as are services for family members.

For adolescent patients (including those who first came to the clinic as young children), Dr. Zucker follows the Standards of Care Guidelines of the World Professional Association for Transgender Health. The treatment options include helping patients make a satisfactory transition to the opposite sex, including the institution of hormonal treatment to facilitate transition. In some cases, treatment may include helping an interested adolescent obtain sex-reassignment surgery.

For all patients, regardless of age, the focus of therapy is the patient’s gender identity, not the patient’s sexual orientation. Dr. Zucker’s therapeutic approach has no relationship to so-called reparative or sexual conversion therapies that attempt to change homosexual orientations to heterosexual ones. The goal of his therapy is the opposite of conversion therapy in that he considers well-adjusted transsexual, gay, lesbian or bisexual youth to be therapy successes, not failures.

Transgender Advocates’ Statements on APA DSM Workgroups

Jim Burroway

May 30th, 2008

The American Psychiatric Association has convened several panels to discuss revisions to the Diagnostics and Statistical Manual (DSM), which is currently in its fourth edition (DSM-IV). It’s a standard practice for the APA to revise the manual every decade or so in order to incorporate knowledge generated by more current research.

The APA has begun the work of compiling the data for DSM-V, and that process has sparked several strange rumors around the Internet that really didn’t ring true with me. According to a few of these rumors, the American Psychiatric Association (APA) is poised to either reinstate homosexuality in the Diagnostics and Statistical Manual (DSM), or that the APA was going to decide to approve of sexual reorientation therapy. There is nothing however to suggest that anything like that will be happening.

But most of these rumors surround the diagnosis of Gender Identity Disorder (GID), which is of particular interest to the transgender community. These rumors are centered around two researchers who have been appointed to some of the working groups: Kenneth Zucker, who chairs the Sexual and Gender Identity Disorders work group, and Ray Blanchard, who chairs the Paraphilias subworkgroup under Zucker.

To understand transgender people’s concern about these two appointments, some background is in order. Kenneth Zucker and Ray Blanchard are associated with the Centre for Addiction and Mental Health in Toronto, Canada. This center resulted from the merger of four mental health centers, one of which was the Clarke Institute of Psychiatry. The Clarke Institute was the referral agency for transgender clients who wanted to surgically transition.

Many transgender clients found their treatment in the hands of the Clarke Institute degrading and offensive, feelings which were greatly magnified by the Institute’s main mission of treating sex offenders. Transgender clients often describe inappropriate and degrading tests and experiences at the institute. In fact, feelings run so deeply about the Clarke Institute that some transgender advocates have dubbed it “Jurassic Clarke.”, while others append the adjective “notorious” in front of the Institute’s name so routinely that one might be tempted to think that its official name was “The Notorious Clarke Institute.”

Because of the Clarke Institute’s history, virtually anything emanating from the Centre for Addiction and Mental Health is suspect among the transgender community, and those suspicions often radiate to the rest of the LGBT community.

Associations with the Clarke Institute however isn’t the only source of transgender advocates’ concerns. Also controversial are some of Blanchard’s theories on MtF transgender etiology that he calls “autogynephilia,”which many people find deeply offensive and off the mark. (Blanchard, on the other hand, is a leading researcher into what he believes to be the biological causes of male homosexuality.) Also controversial is Zucker’s approach to treating transgender clients, which involves counseling the client to take on behaviors and attitudes which are considered to be more socially appropriate to that person’s biological sex. This is an approach which raises alarm bells among gays and lesbians who recognize the parallels to sexual reorientation therapies, which may be the source of the rumors concerning homosexuality and sexual reorientation therapy that I mentioned earlier.

Today, we have a statement from four Transgender advocacy groups, which will hopefully provide some clarification on Zucker’s and Blanchard’s role in the DSM-V revision.

Statement from:

National Center for Transgender Equality (NCTE)
Transgender Law and Policy Institute (TLPI)
Transgender Law Center (TLC)
Transgender Youth Family Allies (TYFA)

On May 1, 2008, the American Psychiatric Association (APA) announced the composition of work groups to review scientific advances and research-based information to develop the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The composition and scope of the work group on Sexual and Gender Identity Disorders and two subgroups are of great interest to transgender people and therefore to our organizations.

Though no consensus exists among transgender people about whether and how a GID diagnosis should be in the DSM-V, there is certainly agreement that decisions made by the APA about transgender and gender non-conforming people will deeply affect the lives of millions of transgender adults, adolescents and children.

We have met with and strongly encouraged the APA to closely adhere to its stated commitment to scientific process regarding diagnosis of transgender people. We are confident that a fair, unbiased review of current knowledge can result in a DSM-V that can move society toward a more rational and humane understanding of transgender people.

We encourage our transgender brothers and sisters to approach this issue with thoughtful consideration of all available information. To that end, we encourage transgender people and allies to remember that:

The naming of this working group on May 1 was not the commencement of advocacy around rethinking or revision of the GID diagnosis. Thoughtful advocates, within and without the APA, have been working on this issue for several years and they will continue to do so for several more, through at least 2012 when the DSM-V is finalized. We look forward to strengthening our relationships and positive communication channels with the many APA-affiliated professionals who are knowledgeable and understanding of transgender issues.

It is inconceivable that in the 21st century any credible scientist or medical professional would recommend any discredited treatment that would attempt to change a person’s core gender identity or sexual orientation. Such treatments have no empirical basis and are harmful. Importantly though, the DSM consists of diagnoses and not treatments. As such, the DSM-V will not offer any treatment recommendations for transgender people of any age.

The APA has created several mechanisms for thoughtful input into the DSM revision process from mental health professionals as well as laypeople affected by the DSM. We encourage transgender people and allies, especially mental health professionals, to utilize these systems to appropriately impact the process. In particular the APA has created a website through which written comments can be submitted. Additionally, as the DSM-V development process advances, working groups are charged with seeking the counsel and input of various advisers who will be selected from various clinicians, academics and other stakeholders. We will advocate for the inclusion of fair-minded advisors who are committed to providing only scientific, fair, reasonable and humane input. We are hopeful that these systems will help provide sufficient information to assure a fair and scientific process for the creation of the DSM-V.

Public acceptance of transgender people and anti-discrimination protections have been advancing swiftly. This is in large part due to scientific and medical advances, but also to the assertive, vigilant and intelligent activism of thousands of transgender people and our allies. While transgender people’s history with the psychiatric and medical professions has been, at times, fraught with misunderstanding and tainted by bigotry, we are optimistic that current and developing scientific research and clinical data will further the understanding of transgender issues among health care professionals and the public.

National Center for Transgender Equality (NCTE)

Transgender Law and Policy Institute (TLPI)

Transgender Law Center (TLC)

Transgender Youth Family Allies (TYFA)


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