"Gay activism was clearly the force that propelled the APA to declassify homosexuality."
Source: Simon LeVay, Queer Science, MIT Press, 1996, p. 224
An excerpt from: The A.P.A. Normalization of Homosexuality, and the Research Study of Irving Bieber
"Dr. Bieber was one of the key participants in the historical debate which culminated in the 1973 decision to remove homosexuality from the psychiatric manual.
His paper describes psychiatry's attempt to adopt a new "adaptational" perspective of normality. During this time, the profession was beginning to sever itself from established clinical theory--particularly psychoanalytic theories of unconscious motivation--claiming that if we do not readily see "distress, disability and disadvantage" in a particular psychological condition, then the condition is not disordered.
On first consideration, such a theory sounds plausible. However we see its startling consequences when we apply it to a condition such as pedophilia. Is the happy and otherwise well-functioning pedophile "normal"? As Dr. Bieber argues in this article, psychopathology can be ego-syntonic and not cause distress; and social effectiveness-‹that is, the ability to maintain positive social relations and perform work effectively--"may coexist with psychopathology, in some cases even of a psychotic order."...
Dr. Bieber describes the deletion of homosexuality from the American Psychiatric Association's diagnostic and statistical manual as "the climax of a sociopolitical struggle involving what were deemed to be the rights of homosexuals."
Gay activist groups believed that prejudice against homosexuals could be extinguished only if, as homosexuals, they were accepted as normal. "They claimed that homosexuality is a preference, an orientation, a propensity; that it is neither a defect, a disturbance, a sickness, nor a malfunction of any sort." To promote this aim, Dr. Bieber reports, "Gay activists impugned the motives and ridiculed the work of those psychiatrists who asserted that homosexuality is other than normal."
A task force was set up to study homosexuality, but the members chosen included not a single psychiatrist who held the view that homosexuality was not a normal adaptation. There followed riots at scientific meetings by gay activists who increased the pressure on the Psychiatric Association.
Will preventive therapy for homosexuality be prohibited, Dr. Bieber wondered, when homosexuality is normalized?
Furthermore is it the proper domain of psychiatry to remove diagnoses to eliminate prejudice?
Dr. Bieber pointed out that there were several other conditions in the DSM-II that did not fulfill the "distress and social disability" criteria: voyeurism, fetishism, sexual sadism, and masochism. A.P.A.'s Dr. Spitzer replied that these conditions should perhaps also be removed from the DSM-II -- and that if the sadists and fetishists were to organize as did the gay activists, they, too, might find their conditions normalized.
Summary
The factors that determined the decision of the APA to delete homosexuality from DSM-II were summarized as follows:
- Gay activists had a profound influence on psychiatric thinking.
- A sincere belief was held by liberal-minded and compassionate psychiatrists that listing homosexuality as a psychiatric disorder supported and reinforced prejudice against homosexuals. Removal of the term from the diagnostic manual was viewed as a humane, progressive act.
- There was an acceptance of new criteria to define psychiatric conditions. Only those disorders that caused a patient to suffer or that resulted in adjustment problems were thought to be appropriate for inclusion in the Diagnostic and Statistical Manual."
An excerpt from: Psychology's sexual dis-orientation, by MIT Psychologist Gerald E. Zuriff, Ph.D:
"DIAGNOSING HOMOSEXUALITY
In 1952 the American Psychiatric Association formalized its system of diagnosis and published the Diagnostic and Statistical Manual of Mental Disorders (DSM). Today, a DSM listing has practical consequences; whether treatment for a problem is paid for by health insurance companies or a psychological problem qualifies as a disability under various laws often depends on whether it is listed in DSM.
Not surprisingly, given the psychoanalytic theory shared by most clinicians, the DSM listed homosexuality as a psychiatric disorder. Interestingly, it was classified as a sociopathic personality disturbance, meaning that the diagnosis could be made purely on the basis of the homosexuality alone, despite the absence of subjectively experienced distress. In the 1968 revision of the DSM, homosexuality was still included as a disorder but classified more descriptively under "sexual deviations" along with disorders such as fetishism and pedophilia. What followed is unprecedented in the annals of medicine.
The publication of DSMII coincided with the founding of a militant gay liberation movement whose goals included the normalization of homosexuality as a legitimate "lifestyle." Gay activists mounted a furious attack on the American Psychiatric Association for designating homosexuality a disease. Their most effective form of protest consisted of demonstrations at several professional conventions, most critically the 1970 disruptions in San Francisco. Over the next three years, the association was forced to reconsider not only the inclusion of homosexuality in DSMII but also the entire conceptual basis for defining a mental disorder.
The gay liberation movement considered the psychiatric designation of homosexuality a major basis for antihomosexual attitudes in American society. It justified a wide variety of antihomosexual legislation, ranging from laws barring homosexuals from immigrating to the United States or serving in the military to regulations in New York requiring homosexual taxicab drivers to undergo semiannual psychiatric examinations. In a broader sense, the designation reinforced the prevalent attitude that homosexuality is an "illness." According to the activists, this stigmatization not only justified bigotry but also caused gay men and lesbians to turn against themselves in self-hatred. The DSMII diagnosis was seen as a societal attempt to control human sexuality under the guise of a medical diagnosis.
After intense lobbying and debate, in December 1973, the Board of Trustees passed the proposal to remove homosexuality from DSMII. Because of the sharp disagreements within psychiatry, however, the board, as a compromise, replaced homosexuality with "sexual orientation disturbance" for "individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation." This compromise allowed homosexuality to be dropped as a disorder, giving the gay lobby what it wanted, and, at the same time, it allowed psychiatrists to treat homosexuality under the new diagnosis.
The board's decision unleashed a storm of counterprotest from many psychiatrists. Opponents saw the board's decision as a capitulation to gay activism rather than a reasoned judgment based on medical evidence. They forced the leadership to submit its decision to a referendum of the organization's membership. After an intense campaign, of the approximately ten thousand votes cast, the proposal passed with 58 percent. In retrospect, it seems shocking that the question of whether a condition is a psychiatric disorder should be decided by a vote, but a closer look at the debate indicates that a vote is not as strange as it seems...
THE POLITICS OF HOMOSEXUALITY
Thus, the decision whether homosexuality is a psychopathology is really a social-cultural question rather than a scientific one, and settling the matter by debate and a vote is not as bizarre as it initially appears. Scientific studies may inform the discussion, but the final decision must be a societal value judgment. Accordingly, the continuing controversy in the mental health profession over this issue merely reflects the cultural divergences in our wider society over homosexuality, and politics within the profession have been critical in every stage of this debate.
With the decision voted upon, homosexuality was dropped in the seventh printing of DSMII, and "sexual orientation disturbance" was substituted. In DSMIII, further refinements were introduced. First, "sexual orientation disturbance" was replaced with "ego-dystonic homosexuality" as a term to diagnose clients persistently distressed by their homosexuality and wishing to have heterosexual relationships. This change clarified that only homosexuals were intended and emphasized the impairment in heterosexual functioning. Second, the stated causes of this disorder consisted of the negative attitudes of society toward homosexuality and/or desire for heterosexual life of family and children. Thus, contrary to psychoanalytic theory, the causes were presented as entirely social rather than internal conflicts or family dynamics.
Eventually, even this revised compromise was opposed. Critics charged that the new terminology singled out only homosexuality as an orientation that might lead to distress. Second, it suggested that homosexuality itself can still be considered a disorder rather than a normal variant of human sexuality. Third, it failed to recognize that in the United States, almost all people who are homosexual normally pass through a phase in which their homosexuality is ego-dystonic. Consequently, yet another compromise was devised. In DSMII-Revised, even ego-dystonic homosexuality was omitted. Clients with a "persistent and marked distress about sexual orientation" would now be diagnosed with "sexual disorder not otherwise specified." The term homosexuality no longer appeared..."
Panelists Recount Events Leading to Deleting Homosexuality As a Psychiatric Disorder From DSM
Twenty-five years ago APA leaders, in the glare of a national media spotlight, took the controversial step of deleting homosexuality from the Association's compendium of psychiatric disorders. That action launched APA on a quarter century of efforts to end discrimination against homosexuals and coincided with the increasing willingness of gay and lesbian psychiatrists to insist openly that APA must listen to them.
A panel of psychiatrists who played crucial roles in the fight to end the stigma attached to homosexuality both within and outside the mental health field came together at the APA annual meeting last month to provide insiders' perspectives on that initiative and more recent efforts to alter how psychiatry views gays and lesbians and their sexual orientation.
Melvin Sabshin, M.D., a member of the APA Board of Trustees in the early 1970s and chair of the Scientific Program Committee at that time, described how the alienation gay psychiatrists felt from their APA colleagues led in 1970 to the start of a concerted push for APA to include them in decision making and address their concerns and those of gay patients.
If there was an official kickoff for APA's newly energized gay psychiatrists, it was the 1970 annual meeting in San Francisco, Sabshin suggested, where Gay Liberation Front activists along with political protesters in support of other social and political causes disrupted the meeting. "It was guerilla theater" at that meeting and the one held in Washington, D.C., the next year, he said.
The onset in 1970 of a decline in psycho-analysis's dominance of the field also contributed to the change of mood in psychiatry about pathologizing homosexuality, he noted.
In 1972, for the first time, the annual meeting featured exhibits and discussions spotlighting positive aspects of the lives of gay individuals. Also during that year well-known psychiatrists such as Richard Green, M.D., Judd Marmor, M.D., and John Spiegel, M.D., began openly challenging psychiatrists' attitudes toward and treatment of homosexual patients, Sabshin observed. Marmor, a psychoanalyst who would soon be elected APA president, played a particularly significant role in trying to bridge the chasm that existed between his psychoanalytic colleagues and psychiatrists who were convinced that homosexuality was not an illness.
While many APA members welcomed the new openness and opportunities to reassess their thinking, the stubborn polarization and factionalism that dogged this issue did not suddenly retreat into a quiet corner.
Sabshin credited the chair of APA's Committee on Nomenclature in the early 1970s, Robert Spitzer, M.D., with playing a pivotal role in propelling the evolution of APA's position on homosexuality. That committee was charged with revising the initial version of DSM, and Spitzer-armed with research showing there were no valid data to link homosexuality and mental illness-advocated forcefully for the strategy of deleting homosexuality from the disorders list and replacing it with a new one called "sexual orientation disturbance."
In a key vote in December 1973, the Board of Trustees overwhelmingly endorsed Spitzer's recommendation. Opponents of the decision attempted to overturn it with a referendum of the APA membership in early 1974-just as Sabshin was beginning his 23-year tenure as APA medical director. The Board's decision to delete homosexuality from the diagnostic manual was supported by 58 percent of the membership.
At the same time the debates over sexual orientation and psychopathology were occurring, a small group of gay psychiatrists was holding informal meetings to explore forming an organization that would heighten their visibility and that of gay patients. This event, unthinkable two or three years earlier, explained Robert Cabaj, M.D., to the overflow audience, culminated in 1978 in the establishment of the organization that eventually became the Association of Gay and Lesbian Psychiatrists (AGLP), which now has more than 600 members.
Also in 1973 APA passed a position paper calling on psychiatrists to advocate for full civil rights for gays and lesbians and to work to end the discrimination they endure, noted Cabaj, who is medical director of the San Mateo County Mental Health System and coauthor of a textbook on homosexuality and mental health. He hailed that paper as "the cornerstone of everything that has happened since" in APA's relationship to homosexuality.
Gay Psychiatrists More Visible
Through the rest of that decade, while issues affecting gay and lesbian psychiatrists and patients continued to achieve greater visibility in clinical and scientific forums, the voices of openly gay and lesbian psychiatrists were still rarely heard in APA policy discussions. That changed in 1982 when the APA Assembly granted a formal vote to gay and lesbian psychiatrists as a minority/underrepresented group, a status similar to that already achieved by other minority groups.
In the mid 1980s APA formed a task force on homosexuality issues, and by that time, Cabaj emphasized, it was able to focus not on the psychopathology battle but on homophobia, discrimination, and stereotyping. The task force was eventually elevated to a permanent component, the Committee on Gay, Lesbian, and Bisexual Issues. One of its earliest chairs was San Francisco psychiatrist James Krajeski, M.D., who this month became editor of Psychiatric News.
One of that committee's earliest endeavors was to remedy once again a defect that gay psychiatrists and many others perceived in the way in which the latest version of the DSM labeled some homosexuals. With the introduction of DSM-III in 1980 the diagnosis of sexual orientation disturbance had been changed to ego-dystonic homosexuality, which applied to people persistently distressed by their sexual orientation and desperate to change it. With another revision under way in 1986, committee members focused their efforts on successfully convincing the DSM task force to remove any such designation that linked sexual orientation with psychopathology.
Next 25 Years
The next several years will likely be a time of "consolidation of gains as psychiatrists who are more comfortable and open about homosexuality come up through the ranks," predicted Howard Rubin, M.D. A "gay-affirmative psychiatry" that has emerged over the last few years will become more commonplace "as long as we don't become complacent," he said.
While gay psychiatrists "now have a place at the table," APA and psychiatry in general will still have to address several troubling issues related to homosexuality, said Rubin, a research fellow at UCLA and member of the APA Committee on Gay, Lesbian, and Bisexual Issues. Prominent on this list is the large number of psychiatry residency programs where nothing is taught about homosexuality or where the program is "gay for a day," that is, where a few hours are devoted to this topic often via a guest speaker. In addition, psychiatrists will be called upon to take a leadership role in discussions of the relative influence of biological factors on the development of sexual orientation, he said.
With psychiatry having depathologized homosexuality, he said, the field's next task is to acknowledge that there are real mental health consequences of being gay, but to address them as individual responses to homophobia and social prejudice.
Carolyn Robinowitz, M.D., who recently became dean of Georgetown University's medical school and is a former senior deputy medical director of APA, has long been an advocate and ally on the many of the issues discussed by the other panelists.
"Let's hope," she emphasized, "that we have learned valuable lessons about the harm that comes from imposing a blanket of psychopathology over any group."
Robinowitz added, "While the DSM action was but one of many changes in the past 25 years, and while many people still view homosexuality in value-laden and not always rational ways, the decision had a major impact on other health professionals and the general public. I wish it had more.
"We still have a long way to go," she said, until gays and lesbians gain full acceptance.-K.H.