Dr Sean Naughton considers the troubled history of the Psychiatric profession and the LGBT community. (December 2017)
Through advocacy, civil action, and the support of the wider population, the LGBT community has made great strides in recent decades to resolve the historical prejudices and marginalisation to which they have been subjected. Much work remains to be done. Psychiatry has had a role to play in this course, at times supportive, at other times greatly obstructive. Perhaps more than any other aspect of Psychiatry’s history, our relationship with the LGBT community represents rich ground for reflection on our profession’s relationship with wider society, a chronical of how inter-professional debates on diagnosis and mental illness can have far reaching consequences.
Condemnation of homosexual behaviour has been an unfortunate facet of human society for quite some time. In common with other behaviour which deviated from socially prescribed orthodoxies, homosexuality initially attracted the moral repudiation of religious groups. As a gradual societal shift to secular authorities progressed through the 19th century, it fell to professional and civil organisations – doctors, judges and politicians to pass judgements of moral rectitude.
Legislators, for their part, saw a raft of laws introduced across Europe in the 19th century which criminalised homosexuality – the so-called “sodomy laws”. In fact, some of the early pseudo-psychiatric theories of homosexuality were defences against such criminalisation. Karl Henirich Ulrichs, a mid-19thcentury intellectual, proffered the theory that homosexuality was inborn and unchangeable, and thus it was unethical to criminalise. His supporting theory may have been somewhat abstract (that homosexual men were born with a woman’s spirit trapped inside their body, and vice-versa for homosexual women), but this principle formed the bases for much historical and contemporary resistance towards such laws. He found support in the Psychiatric community through, amongst others, Magnus Hirschfeld, a German Psychiatrist, who was himself an openly homosexual physician and sex researcher. It could not be claimed, however, that such a supportive position was unanimous in the profession and in 1886 Hirschfeld’s fellow German Psychiatrist, Richard von Krafft-Ebing, published Psychopathia Sexualis. This book did much to frame homosexuality as a degenerative disease and mental illness, gaining considerable influence well into the 20thcentury.
The early American diagnostic manuals were principally Psychoanalytic works and it is from this community that assumptions of pathology endured for some time. It is curious then, that Freud’s conception of homosexuality was hardly one of condemnation. While it is true that Freud viewed homosexuality as pathological, in that he saw it as a state of arrested development of ‘normal’ heterosexual development, still he argued against it being considered a degenerative condition as, amongst other reasons, it was “found in people whose efficiency is unimpaired, and who are indeed distinguished by specially high intellectual development and ethical culture”. Towards the end of his life Freud became more conciliatory toward homosexuality, writing “homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation; it cannot be classified as an illness; we consider it to be a variation of the sexual function, produced by a certain arrest of sexual development.” Yet, his Psychoanalytic successors vigorously pursued the search for ‘cures’ that they believed had eluded Freud.
The 1973 delisting of homosexuality from the DSM was not a revolutionary change, but rather was preceded by a number of evolutionary revisions. DSM-I listed it rather pejoratively as “sociopathic personality disturbance”. By DSM-II it was listed as a “sexual deviation”. Support for its inclusion was drawn from a small number of studies and case reports, often self-selected groups from Psychiatric inpatient units, prisons, or men who had specifically sought treatment for their sexual orientation. These ‘studies’, unsurprisingly, tended to demonstrate elevated rates of distress and maladjustment than found in the general population. Yet by the 1950s, works such as Evelyn Hooker’s exploration of rates of psychological disturbance among non-patient homosexual men compared to heterosexual controls were failing to show a difference between the groups. The professional Psychiatric community was slow to shift, however.
Ultimately, it was this emerging scientific counterpoint combined with forces outside of Psychiatry that precipitated change. In the wake of the 1969 Stonewall riots, the LGBT community mobilised against much of the discrimination they faced in US civil society. Representatives were invited to the American Psychiatric Association’s (APA) educational panels at annual assembles. The first in 1971, entitled “Gay is Good”, explained to a group of Psychiatrists the stigma caused by a homosexuality ‘diagnosis’, many of whom had been seemingly naive to this fact. The 1972 meeting saw activists joined by a homosexual Pyschiatrist, Dr John Fryer, who appeared as Dr H Anonymous for fear of adverse professional consequences, discussing discrimination within his own profession.
It was finally at the APA meeting in 1973 that the Board of Trustees voted to remove homosexuality from DSM, reasoning that it did not cause “subjective distress or was associated with generalised impairment in social effectiveness or functioning”. This vote was challenged, however, by the psychoanalytic division of the APA who petitioned the Board to hold a referendum on whether to support this decision. It was upheld by a 58% majority of the 10,000 voting members. This was not the end of the story with a successor diagnosis relating to distress over sexual orientation to be found in the DSM until 1987 and it would take until 1990 for the ICD-10 to make similar changes. It was, however, the beginning of the end of Psychiatry’s involvement in the pathologising of homosexuality.
Thus the relationship between Psychiatry and the LGBT community has been a difficult one and more complex than is frequently portrayed. There is no doubt that the profession’s involvement in classifying homosexuality as a mental illness led to much unnecessary suffering and stigmatisation. However, by understanding the origins of this relationship, we can move towards focusing on the health and mental health needs of the LGBT population we serve, guided by the successes and mistakes of the past. As William Lund said: “study the past to understand the present… to guide the future”.
References
Drescher J. Out of DSM: Depathologizing Homosexuality. North C, Suris A, eds. Behavioral Sciences. 2015;5(4):565-575.
Freud S. Three Essays on the Theory of Sexuality. Hogarth Press; London, UK: 1953 [1905].
Spitzer R.L. The diagnostic status of homosexuality in DSM-III: A reformulation of the issues. Am. J. Psychiatr. 1981;138:210–215.
