Psychiatry’s Dark Days: Healthy Skepticism

Excerpts from the following paper highlight that we are not necessarily black sheep when we challenge the ‘status quo’. This piece illustrates the need for healthy skepticism and activism to achieve personal, social and political change. #HealingTrauma

Out of DSM: Depathologizing Homosexuality: “In 1973, the American Psychiatric Association (APA) removed the diagnosis of “homosexuality” from the second edition of its Diagnostic and Statistical Manual (DSM). This resulted after comparing competing theories, those that pathologized homosexuality and those that viewed it as normal.

Theories of pathology: viewed homosexuality as a sign of a defect, or even as morally bad, with some of these theorists being quite open about their belief that homosexuality is a social evil.

For example, psychiatrist and psychoanalyst Edmund Bergler infamously wrote in a book for general audiences, “I have no bias against homosexuals; for me they are sick people requiring medical help… Homosexuals are essentially disagreeable people…

Theories of Immaturity: homosexual feelings or behavior at a young age are a normal step toward the development of adult heterosexuality. Ideally, a passing phase that one outgrows. However, as a “developmental arrest,” adult homosexuality is stunted growth.

Theories of Normal Variation: These theories treat homosexuality as a phenomenon that occurs naturally. Such theories typically regard homosexual individuals as born different, but it is a natural difference affecting a minority of people, like left-handedness.

The contemporary cultural belief that people are “born gay” is a normal variation theory. As these theories equate the normal with the natural, they define homosexuality as good (or, at baseline, neutral). Such theories see no place for homosexuality in a psychiatric diagnostic manual.

The 1973 APA Decision: American psychiatry mostly ignored this growing body of sex research and, in the case of Kinsey, expressed extreme hostility to findings that contradicted their own theories.

It should be further noted that some mid-20th century homophile (gay) activist groups accepted psychiatry’s illness model as an alternative to societal condemnation of homosexuality’s “immorality” and were willing to work with professionals who sought to “treat” and “cure” homosexuality.

Other gay activists, however, forcefully rejected the pathological model as a major contributor to the stigma associated with homosexuality. It was this latter group that brought modern sex research theories to the attention of APA.

In the wake of the 1969 Stonewall riots in New York City, gay and lesbian activists, believing psychiatric theories to be a major contributor to anti-homosexual social stigma, disrupted the 1970 and 1971 annual meetings of the APA.

As Bayer has noted, factors both outside and within APA would lead to a reconceptualization of homosexuality’s place in the DSM. In addition to research findings from outside psychiatry, there was a growing anti-psychiatry movement,

not to mention cultural studies critics who held medicine’s history of diagnostic excess up for ridicule, citing the example of drapetomania, a 19th century “disorder of slaves who have a tendency to run away from their owner due to an inborn propensity for wanderlust”, (p. 357).

There was also an emerging generational changing of the guard within APA comprised of younger leaders urging the organization to greater social consciousness. Some psychoanalysts like Judd Marmor were also taking issue with psychoanalytic orthodoxy.

However, the most significant catalyst for diagnostic change was gay activism. Gay activist protests succeeded in getting APA’s attention and led to unprecedented educational panels at the group’s next two annual meetings.

A 1971 panel, entitled “Gay is Good,” featured gay activists Frank Kameny and Barbara Gittings explaining to psychiatrists, many who were hearing this for the first time, the stigma caused by the “homosexuality” diagnosis.

Kameny and Gittings returned to speak at the 1972 meeting, this time joined by John Fryer, M.D. Fryer 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.

APA engaged in an internal deliberative process of considering the question of whether homosexuality should remain a psychiatric diagnosis. This included a symposium at the 1973 APA annual meeting in which participants favoring and opposing removal debated the question, “Should Homosexuality be in the APA Nomenclature?”.

The Nomenclature Committee, APA’s scientific body addressing this issue also wrestled with the question of what constitutes a mental disorder. Robert Spitzer, who chaired a subcommittee “reviewed the characteristics of the various mental disorders and concluded that, with the exception of homosexuality and perhaps some of the other ‘sexual deviations’, they all regularly caused subjective distress or were associated with generalized impairment in social effectiveness of functioning”, (p. 211).

Having arrived at this novel definition of mental disorder, the Nomenclature 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 (BOT) voted to remove homosexuality from the DSM.

Psychiatrists from the psychoanalytic community, however, objected to the decision. They petitioned APA to hold a referendum asking the entire membership to vote either in support of or against the BOT decision. The decision to remove was upheld by a 58% majority of 10,000.

It should be noted that psychiatrists did not vote on whether homosexuality should remain a diagnosis. What APA members voted on was to either “favor” or “oppose” the APA Board of Trustees decision and, by extension, the scientific process they had set up to make the determination, (p. 148).

Further, opponents of the 1973 removal repeatedly tried to discredit the outcome by declaring, “science cannot be decided by a vote”. However they neglected to mention that those favoring retention of the diagnosis were the ones who petitioned for a vote in the first place.

In any event, in 2006 the International Astronomical Union voted on whether Pluto was a planet, demonstrating that even in a hard science like astronomy, interpretation of facts are always filtered through human subjectivity.

In any event, the events of 1973 did not immediately end psychiatry’s pathologizing of some presentations of homosexuality. For in “homosexuality’s” place, the DSM-II contained a new diagnosis: Sexual Orientation Disturbance (SOD): an illness if an individual with same-sex attractions found them distressing and wanted to change.

The new diagnosis legitimized the practice of sexual conversion therapies (and presumably justified insurance reimbursement for those interventions as well), even if homosexuality per se was no longer considered an illness.

The new diagnosis also allowed for the unlikely possibility that a person unhappy about a heterosexual orientation could seek treatment to become gay. SOD was later replaced in DSM-III by a new category called “Ego Dystonic Homosexuality” (EDH).

However, it was obvious to psychiatrists more than a decade later that the inclusion first of SOD, and later EDH, was the result of earlier political compromises and that neither diagnosis met the definition of a disorder in the new nosology.

Otherwise, all kinds of identity disturbances could be considered psychiatric disorders. “Should people of color unhappy about their race be considered mentally ill?” critics asked. What about short people unhappy about their height? Why not ego-dystonic masturbation?

As a result, ego-dystonic homosexuality was removed from the next revision, DSM-III-R, in 1987. In so doing, the APA implicitly accepted a normal variant view of homosexuality in a way that had not been possible fourteen years earlier.

Conclusions: APA’s 1973 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.

In 1990, the World Health Organization removed homosexuality per se from the International Classification of Diseases (ICD-10). As a consequence, debates about homosexuality gradually shifted away from medicine and psychiatry and into the moral and political realms as religious, governmental, military, media, and educational institutions were deprived of medical or scientific rationalization for discrimination.

As a result, cultural attitudes about homosexuality changed in the US and other countries as those who accepted scientific authority on such matters gradually came to accept the normalizing view.

For if homosexuality was no longer considered an illness, and if one did 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?

Additionally, if there is nothing wrong with being gay, what moral and legal principles should the larger society endorse in helping gay people openly live their lives? The result, in many countries, eventually led, among other things, to

(1) the repeal of sodomy laws that criminalized homosexuality; (2) the enactment of laws protecting the human rights of lesbian, gay, bisexual and transgender (LGBT) people in society and the workplace; (3) the ability of LGBT personnel to serve openly in the military;

(4) marriage equality and civil unions in an ever growing number of countries; (5) the facilitation of gay parents’ adoption rights; (6) the easing of gay spouses’ rights of inheritance; and (7) an ever increasing number of religious denominations that would allow openly gay people to serve as clergy.

Most importantly, in medicine, psychiatry, and other mental health professions, removing the diagnosis from the DSM led to an important shift from asking questions about: “what causes homosexuality?” and “how can we treat it?” to focusing instead on the health and mental health needs of LGBT patient populations.”

What an inspiring piece for Australians and people from all around the world to see that you are not the black sheep and that it possible to achieve personal, social and political change.

Source: Drescher, J. (2015). Out of DSM: Depathologizing Homosexuality. Behavioural Science (Basel). 565–575. DOI: 10.3390/bs5040565 This post is not the entire article to be reader friendly.

Now you know the power of Trauma Informed Care. Let’s turn this framework into a mindset for personal, social and political change. If you are unable to, you might need help first, to get safe or become ‘unstuck’ from trauma. Reach out for trauma informed care. #YouBelong

With love,

Dr Louise Hansen
Psychologist
PhD in Psychology
Human Rights Activist

#HealingTrauma #Justice4Australia #YouBelong

Trauma Informed World was inspired by Kopika and Tharnicaa; two faces that remind us everyday of Australia’s cruel refugee system. One of many systems in Australia that remind us of the negative operation of power. #HomeToBilo

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