Courageous Actions Led to Removal of Homosexuality as a Diagnosis in DSM

Who was that masked man?

One of the most memorable moments in APA history came when the 1972 Annual Meeting in Dallas included a certain “Dr. H. Anonymous,” his face hidden behind a rubber Halloween mask, in the session “Psychiatry: Friend or Foe to the Homosexual? A Dialogue.”

“I am a homosexual,” announced the mysterious figure. “I am a psychiatrist.”

It was a stunning public admission for a member of a profession that had officially diagnosed homosexuality as psychopathology.

At prior Annual Meetings, gay activists had protested prevailing psychiatric thinking as a contributing to the social stigmatization of homosexuals. The year before, Franklin Kameny, Ph.D., an astronomer who had been fired from a federal government job after his homosexuality became known, demanded that APA delete its description of homosexuality as a mental illness. Kameny was also a member of the 1972 Annual Meeting panel, along with gay advocate Barbara Gittings and APA Vice President (and later APA President) Judd Marmor, M.D.

“We object to the sickness theory of homosexuality tenaciously held with utter disregard for the disastrous consequences of this theory to the homosexual, based as it is on poor science,” wrote Kameny in a follow-up letter to the editor of Psychiatric News published in the July 7, 1971, issue.

Profound stigma against homosexuality then existed within the psychiatric profession as well.

“I think it was impossible at that time to be openly gay and to be a psychiatry resident in any good program in America—or, as far as I know, to be, in the 1960s, an excellent and respected bisexual or gay analytic psychiatrist,” said former APA President Lawrence Hartmann, M.D., in a 2004 interview.

The masked psychiatrist in 1972 also said he had to keep his sexual orientation secret because of the bias and rejection he would encounter. “My greatest loss is my honest humanity,” he said. “How incredible that we homosexual psychiatrists cannot be honest in a profession that calls itself compassionate and helping.”

It was 22 years later that John Fryer, M.D. (1938-2003), revealed that he was the masked man on the APA panel. Fryer had been forced to leave his psychiatry residency at the University of Pennsylvania when it was discovered that he was gay. He eventually became a professor of psychiatry at Temple University. In tribute to his courage, in 2005 APA created the John Fryer Award, which is presented annually to an individual who has contributed to improving the mental health of sexual minorities.

The roots of psychiatry’s view of homosexuality as pathology were varied, Jack Drescher, M.D., former chair of APA’s Gay, Lesbian, and Bisexual Issues Committee and a clinical professor of psychiatry at Columbia University, said in an interview. The 19th century German psychiatrist Richard Krafft-Ebing saw homosexuality as a “degenerative” disorder, employing a term that was then a popular explanation for mental illness. Later, Sigmund Freud viewed homosexuality as a matter of arrested psychosexual development. By mid-19th century, prevailing psychoanalytic dogma recorded same-sex behavior as a “sociopathic personality disorder” in DSM-I (1952) and a “sexual deviation” in DSM-II (1968).

The seeds for change had been planted decades before. Alfred Kinsey’s work in the 1940s and 1950s revealed that same-sex behavior was more common than generally believed. An elegant experiment by Evelyn Hooker, published in 1957, tested 60 men without psychiatric diagnoses. Half were gay, and half were heterosexual. Blinded evaluations by experts found no difference between the two groups, lending support to the view that homosexuality was not inherently pathological.

A resolution developed by Hartmann, Richard Pillard, M.D., and colleagues in the Northern New England District Branch in March 1973 called for deletion of the homosexuality diagnosis from DSM and an end to discrimination against gays. The proposal was approved by APA’s Assembly in November 1973 with a proviso retaining a diagnosis of “sexual orientation disturbance” for individuals unhappy with their same-sex orientation. The decision was confirmed by the full Board of Trustees that December.

The APA Task Force on Nomenclature and Statistics, in preparation for DSM-III, noted that to be considered a mental disorder, “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual” had to be associated with symptoms of distress or significant impairment of functioning.

“It is now clear that homosexuality often is not associated with distress,” wrote Robert Spitzer, M.D., chair of the DSM-III Task Force on Nomenclature and Statistics, in an article in the February 1981 American Journal of Psychiatry. “Furthermore, many claim that if there were no societal discrimination against homosexuality and no societal expectation of heterosexuality, homosexuals would never be distressed by their sexual orientation.”

“The decision to remove homosexuality was made over the objections of the analysts and that in turn only accelerated the decline of psychoanalysis within APA,” said Drescher. “At the same time, there was an increasing generational shift in APA as younger members pushed to have the organization become more involved in social issues.”

Opposition to the designation of homosexuality as a mental disorder also coincided with an era of change across American society that saw the rise of the civil rights, feminist, and anti-war movements, said Drescher.

APA was in the throes of similar generational change. Hartmann and others were already working to turn a “guild-directed, conservative APA” into “an organization that looked for and embraced social psychiatric issues,” electing younger members (like Alfred Freedman, Judd Marmor, John Spiegel, Jack Weinberg, Viola Bernard, E. Fuller Torrey, and ultimately Hartmann) to high posts within APA.

“There was a climate of change, and there were a lot of people who came together and did a lot of cooperative work, sometimes without talking to each other, sometimes aware of one another, sometimes not,” recalled Hartmann.

There was an immediate backlash within APA. Proponents of tradition called for a referendum on the Board’s decision, which was upheld by 58% of the APA members who voted. The fact that a designation of illness could be decided by majority vote would serve for decades afterward as an argument for psychiatry’s opponents.

The nomenclature change would make homosexuals feel more free to seek psychiatric aid if they wanted it, APA President Alfred Freedman, M.D., was quoted as saying in the January 2, 1974, Psychiatric News. He and Spitzer, then a member of the APA Task Force on Nomenclature and Statistics, suggested that those who felt comfortable with their sexual orientation could concentrate on other problems without feeling that their homosexuality itself was a sign of psychopathology, and those who felt in conflict with their sexuality would no longer feel that the ultimate goal of psychiatric treatment would be to become heterosexual.

“APA took leadership in 1973 by removing homosexuality as a DSM diagnosis, which was the essential basis of the movement to ensure that discrimination against homosexual individuals would end. This has led to positive outcomes from workplace protection to marriage equality,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. “We must continue to push forward to ensure those civil rights won are not eroded and win protections for members of other sexual minorities.”

“While discrimination still exists, APA’s decision removed the cover of other entities for discriminating against homosexuals,” said Drescher. “Change doesn’t happen immediately.”

As a reminder, as late as 1989, the U.S. government blocked the entry of homosexuals into the country on grounds of their “mental illness.” In 1993, controversy arose initially about the inclusion of gays in the U.S. armed forces, leading to the infamous “Don’t Ask, Don’t Tell” policy. Eventually, simply being a homosexual was no longer a bar to serving one’s country, although recent moves to block transgender service members have marked a retrograde step.

The lesson, said Drescher, is that DSM is not carved in stone. “The DSM is not a Bible; it’s a user’s manual, and it can change as the field changes.” ■