“Gay Is Good”: History of Homosexuality in the DSM and Modern Psychiatry

In the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published in 1952, homosexuality was classified under “sociopathic personality disturbance” (1). The last 70 years have brought psychiatry a long way, but it is only in the most recent version of the DSM that the last pieces of evidence of pathologizing homosexuality were removed (2). Although the DSM-I’s primary objective was to standardize nomenclature and criteria for psychiatric conditions, the current DSM-5 also attempts to explore cultural considerations (1, 2). In short, “Judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them” (2). It is, at least in part, this consideration of culture that allows for advancement in our understanding of psychopathology (2). Sixty years of work by gay rights activists, psychiatrists, psychologists, and leaders in the mental health community have shaped our current views about individuals from sexual minority communities and the care that they receive. This article examines the progression of classification of homosexuality in various editions of the DSM, factors influencing this progression, and implications for sexual and other minority communities.

In 1952, the American Psychiatry Association (APA) Committee on Nomenclature and Statistics developed the first version of the DSM, which served as the first manual of mental health focused on clinical diagnoses and care and provided a glossary and description of psychiatric illnesses (3). The category of sociopathic personality disturbance included subcategories, such as antisocial reaction, sexual deviation, and addiction. Sexual deviation included different types of behavior classified as pathologic, including “homosexuality, transvestism, pedophilia, fetishism, and sexual sadism including rape, sexual assault, mutilation” (1). Given the current societal acceptance of homosexuality in many countries—and while it may be difficult to imagine today that homosexuality truly fits into “pathologic behavior”—it is important to understand that inclusion of homosexuality in the DSM served to move same-sex sexual behavior from being regarded as a moral sin and into the secular world of medicine by recognizing it not as a sin but instead as a disorder (4). Placed within the context of mental health, this formed the foundation for future study of homosexuality by clinicians and for a modern-day understanding of health disparities faced by persons from sexual minority groups.

The publication of the DSM-II in 1968 saw the inclusion of homosexuality again, but in this edition, the heading read simply “personality disorders” (5). However, it is in this period of history when the push for change began. In 1969, a series of violent uprisings began between police and patrons of a bar in Greenwich Village known as the Stonewall Inn. The Stonewall riot is often viewed as the catalyst for the gay rights movement that resulted over the following years (6). In 1970, gay rights activists protested at the annual APA meeting in San Francisco. They argued that the psychiatric theories about homosexuality and need for treatment or a cure for their sexuality fueled social stigma around homosexuality. These protests gained the attention of the APA, and at the 1971 meeting, a panel discussion entitled “Gay Is Good” invited gay rights activists to speak on the topic of the stigma and discrimination that they had encountered because of their diagnosis. These activists returned the following year for another panel discussion with Dr. H. Anonymous. Dr. Anonymous was a homosexual psychiatrist who appeared in an oversized suit and mask and spoke into a microphone to disguise his voice. He agreed to appear only with this disguised identity, fearing the impact that it could have on his career (7). Other influential members of this panel, such as APA Vice President Judd Marmor, would argue that “psychiatry is prejudiced” against homosexual people and that “moral values” of society contributed to the inclusion of homosexuality as a psychiatric condition. He argued for removal of homosexuality from the DSM (8).

Along with pressure from gay rights advocates, internal debate was occurring as to whether homosexuality met the criteria for a psychiatric disorder. At the APA annual meeting in 1973, a symposium led to the conclusion that “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” (9). Following this meeting, and likely many more undocumented hours of debate among members of the APA Committee on Nomenclature and Statistics, the sixth printing of the DSM-II, in 1973, saw a change in language from “homosexuality” to “sexual orientation disturbance” (4). Sexual orientation disturbance was defined not just as same-sex attraction but as a conflict caused by this attraction or a desire to change it.

This shift in focus from homosexuality itself being pathologized to the internal conflict or desire to change one’s sexuality would set the theme for the following three editions of the DSM. The DSM-III published in 1980 renamed this condition “ego dystonic homosexuality” and recategorized it not as a personality disorder but as a psychosexual disorder (10). The DSM-III-R in 1987 categorized marked distress about one’s sexual orientation under “sexual disorder, not otherwise specified” (11). This deemphasis on homosexuality as a psychiatric disorder would allow for its eventual removal from the DSM-5 entirely in 2013 (4). This shift in focus highlights the impact of cultural context in which a diagnosis is being made. As noted in DSM-5, “Cultural norms” have an impact on what is considered pathological, and as norms shifted during the gay rights movement, so did the conceptualization of homosexuality. The level of functional impairment attributed to sexuality decreased as society became more accepting of sexual minority groups, which is mirrored by the depathologizing of homosexuality in the DSM (4).

Psychiatry’s views on homosexuality today are vastly different than they were 70 years ago. Today, Dr. Anonymous, now identified as Dr. John Fryer, is honored with an APA annual award given in his name to an individual who has contributed to the mental health of sexual minority communities. Professional organizations, such as the Association of Gay and Lesbian Psychiatrists and the APA’s caucus of Gay and Lesbian Psychiatrists, exist to help support psychiatrists from sexual minority groups and care for patients from sexual minority groups. Journals are devoted to the study of other mental health conditions in sexual minority populations and how the field of psychiatry can best address the disparities that exist (12). Some of these disparities include increased rates of depression, anxiety, substance use, and suicidality, compared with heterosexual peers. In fact, suicide attempts are around three to five times higher for individuals from sexual minority groups than for their heterosexual counterparts (13). Persons from sexual minority groups continue to have decreased access to mental health services and experience stigma and bias when able to obtain these services (14). Despite advancements that have been made, there is obviously still much work to be done in this population.

In addition to sexual minority groups, it is important to consider the impact that the evolution of homosexuality in the DSM has for gender minority groups. Regarding homosexuality, the progression moved from pathologizing homosexuality itself to pathologizing the stress associated with being homosexual to its ultimate removal from the DSM (4). As previously noted, cultural norms and increased societal acceptance of homosexuality has allowed for its removal from the DSM (4). Pathology related to gender identity first appeared in the DSM-III, under the term “gender identity disorder” (10). In DSM-5, focus was shifted from pathologizing some forms of gender identity to instead focusing on the distress related to gender identity, renaming the condition “gender dysphoria” (2). This shift mirrors the change regarding homosexuality between DSM-II and DSM-III, in which emphasis is placed not on the identity of the individual but instead on distress associated with the identity (4, 10). If this trajectory continues and society continues to become more accepting of transgender individuals and of other forms of gender identity, perhaps the associated distress will continue to decrease, allowing for the removal of gender dysphoria from the DSM entirely. Although at present, gender dysphoria is still considered a pathology, it is possible that individuals from gender minority communities might one day see their existence not as a psychiatric pathology but as simply their identity.