KEY POINTS
- This year marks the 50th anniversary of the American Psychiatric Association’s removal of homosexuality from its Diagnostic Manual.
- The APA’s revision was the beginning of the end of organized medicine’s participation in the social stigmatization of homosexuality.
- Charles Silverstein, who was crucial in persuading the APA to change, recently died.
This year marks the 50th anniversary of the American Psychiatric Association’s removal of homosexuality from its Diagnostic Manual in 1973. The decision, and the reasoning behind it, made for was a culture-changing event. It led to an important shift in mental health practices as clinicians stopped asking questions like “What causes homosexuality?” and “How can we change it?” nd focused instead on the health and mental-health needs of LGBTQ patient populations. January 2023 saw the passing of Charles Silverstein, Ph.D., an important figure who participated in persuading APA to bring about this diagnostic change.
Why Change Was Needed
In 1973...:- Homosexual behavior was criminalized in most U.S. states.
- Openly gay men and women were banned from serving in the U.S. military. If a gay person in the military came out or was outed by someone else, they could be court-martialed and discharged.
- Being gay was grounds for being fired from a U.S. government job. This is what happened to Frank Kameny, who, in 1957, lost his job as an astronomer with the U.S. government after it was discovered that he had once pleaded guilty to a legal charge of homosexual activity. Kameny, both a scientist and an activist, would go on to become a leader in persuading APA to make diagnostic changes.
- An openly gay physician, psychiatrist, or other mental-health professional could lose their state license to practice.
- Most Americans were unlikely to approve of gay marriage, otherwise known as marriage equality. The question of how Americans felt about marriage equality did not even appear in major polls and surveys until the 1980s.
How Diagnostic Change Happened
Psychiatric diagnosing of homosexuality as a mental disorder began in the 19th century, most prominently in the work of Richard von Krafft-Ebing, who thought it was due to “degeneration” of the nervous system—degeneracy being a now-disproven medical theory of that era.Sigmund Freud directly disagreed with Krafft-Ebing’s concept of homosexuality as an illness and instead saw it as a “developmental arrest,” a kind of psychological immaturity. However, by the middle of the 20th century, the belief that homosexuality was a mental disorder was the prevailing view among psychiatrists and most of Freud’s psychoanalytic followers. Thus, in 1952, when the APA published the first edition of its Diagnostic and Statistical Manual (DSM-I), it classified “homosexuality” as a “sociopathic personality disturbance.” In the DSM-II, published in 1968, homosexuality was classified as a “sexual deviation.”
These psychiatric perspectives on homosexuality were drawn from a skewed sample of patients seeking treatment for homosexuality or other difficulties and studies of prison populations. Sexologists, on the other hand, conducted field studies that recruited large numbers of non-patient subjects in the general population. Most prominent among them was Alfred Kinsey, whose team surveyed thousands of people who were not psychiatric patients. They found homosexuality to be more common in the general population than was generally believed—a finding at odds with psychiatric claims of the time that homosexuality was extremely rare in the general population.
However, American psychiatry mostly ignored the growing body of sex research that saw homosexuality as normal. In Kinsey's case, they expressed extreme hostility to any findings that contradicted their own pathologizing theories. All this changed in the wake of the 1969 Stonewall riots in New York City, an event that energized gay and lesbian activists who believed psychiatric diagnosis to be a major contributor to anti-homosexual social stigma.
What did the activists do? They disrupted the normally staid 1970 and 1971 annual meetings of the APA. In doing so, they succeeded in getting the APA’s attention, leading to unprecedented educational panels at the group’s next two annual meetings. A 1971 panel, entitled “Gay is Good” featured Kameny, Barbara Gittings, and Ron Gold, who explained to psychiatrists, many of whom were hearing it for the first time, the stigma caused by the “homosexuality” diagnosis. Kameny and Gittings returned in 1972, this time joined by John Fryer, who appeared as Dr. H Anonymous, a “homosexual psychiatrist" who, given the realistic fear of adverse professional consequences for coming out at that time, disguised his true identity from the audience and spoke of the discrimination gay psychiatrists faced in their own profession.
The APA also engaged in a slow, internal deliberative process to consider the question of whether homosexuality should remain a psychiatric diagnosis. In February 1973, Silverstein addressed the committee charged with making recommendations to APA’s Board of Trustees (BOT), introducing the committee to the science of the time that challenged the existing illness model. After noting some humorous aspects of historical diagnoses, he concluded, “To continue to classify homosexuality as a disorder is as valid today as was the diagnosis of masturbation in the 1942 edition. What we hope to convey to you is that we have paid the price for your past mistake. Don’t make it again.”
The committee wrestled with the question of what constitutes a mental disorder. Robert Spitzer, who chaired the subcommittee looking into the issue, finally concluded that a mental disorder had to cause subjective distress or impairment in social functioning. Having arrived at a novel definition of mental disorder—one that would change future DSM editions until the present—the committee agreed that homosexuality per se was not one.
Several other APA committees and deliberative bodies then reviewed and accepted their work and recommendations. As a result, in December 1973, APA’s Board of Trustees voted to remove homosexuality from the DSM. Psychiatrists from the psychoanalytic community, however, objected to the decision. They petitioned the APA to hold a referendum asking the entire membership to vote either in support of or against the BOT decision. A 58% majority of 10,000 voting members upheld the decision to remove. It should be noted that psychiatrists did not vote, as is often reported in the popular press, on whether homosexuality should remain a diagnosis. What APA members voted on was to either “favor” or “oppose” the APA BOT decision and, by extension, the scientific process the Board had set up to make the determination.
Since then, opponents of the 1973 removal have tried to discredit the referendum’s outcome by declaring, “Science cannot be decided by a vote.” Yet, in 2006, the International Astronomical Union voted on whether Pluto was a planet, demonstrating that even in a hard science like astronomy, the interpretation of facts is always filtered through human subjectivity.
The Impact of Diagnostic Change
APA’s diagnostic revision was the beginning of the end of organized medicine’s official participation in the social stigmatization of homosexuality. Similar shifts gradually took place in the international mental health community as well. For example, in 1990, the World Health Organization removed homosexuality per se from the International Classification of Diseases (ICD-10). In the ICD revision of 2019, the F66 diagnoses that still pathologized same-sex expression were removed from ICD-11.Without a medical or scientific rationalization for discrimination, debates about homosexuality gradually shifted away from medicine and psychiatry and into the moral and political realms of religion, government, the military, the media, and educational institutions. As a result, cultural attitudes about homosexuality changed in the U.S. and other countries as those who accept scientific authority on such matters gradually came to accept the normalizing view.
The reasoning behind acceptance went like this: If homosexuality is no longer considered an illness, if one does not literally accept biblical prohibitions against it, and if gay people are able and prepared to function as productive citizens, then what is wrong with being gay? Further, if there is nothing wrong with being gay, what moral and legal principles should society endorse in helping gay people openly live their lives?
The result, in many countries, eventually led to..:
- the repeal of sodomy laws that criminalized homosexuality—in 2003, the U.S. Supreme Court ruled that sodomy laws still on the books in thirteen states were unconstitutional.
- the enactment of laws protecting the human rights of lesbian, gay, bisexual, and transgender (LGBT) people in society and the workplace.
- the ability of LGBT personnel to serve openly in the military.
- marriage equality and civil unions in an ever-growing number of countries; in most recent polls, more than 70% of Americans support marriage equality.
- the facilitation of gay parents’ adoption rights.
- the facilitation of gay spouses’ rights of inheritance.
- an ever-increasing number of religious denominations allowing openly gay people to serve as clergy.
- a pathway had been paved for the emerging movement for transgender rights; echoing the 1973 APA decision, the World Health Organization revised its ICD-10 diagnosis of transsexualism to Gender Incongruence in the ICD-11 and moved the diagnosis out of the mental disorders section.
References
A more detailed history of how change occurred can be found in Ronald Bayer’s Homosexuality and American Psychiatry: The Politics of Diagnosis (1987). Princeton, NJ: Princeton University Press.
Drescher, J. (2015). Out of DSM: Depathologizing homosexuality. Behavioral Sciences, 5:565-575.
Drescher, J. & Merlino, J.P., eds. (2007). American Psychiatry and Homosexuality: An Oral History. New York: Routledge.
