Wednesday, December 18, 2013

Elimination of Homosexuality from the DSM - An Old But Important Story

I follow Michael Blumenfield's blog Psychiatry Talk and his most recent post reminds us that homosexuality was eliminated as a diagnostic category from the DSM 40 years ago.  Incredibly he interviewed the President of the American Psychiatric Association at the time of this decision and has these interviews posted on his blog.  Many years ago, I encountered a piece done on This American Life that documented another side to the process.  In that discussion Robert Spitzer one of the main architects of the DSM was directly influenced by his attendance at a parallel meeting of gay and lesbian psychiatrists - informally self titled the GAYPA.  He was apparently struck by the fact that homosexuality did not confer any disability in terms of psychiatric careers or social functioning and advocated for eliminating it from the DSM.

Dr. Freedman's interview (especially recording 2 and 3) starts to talk about the issues raised by the Committee for Concerned Psychiatry.(paragraph 4).  The major issues of the day were opposing the Vietnam War and homosexuality as a disease.  Dr. Freedman accepted their offer to be a petition candidate to oppose the "old boy's club" approach to APA presidency.  He describes the 1972 APA Annual Meeting in Dallas where a  gay APA member gave a talk wearing a disguise about how the DSM definition had harmed him.  He received a standing ovation.

Dr. Freedman refers to Spitzer as the Chair of a Task Force to look into homosexuality.  He prepared a document that supported dropping homosexuality as a diagnosis.  At the same time the APA Board and members were strongly in favor of it.  It was debated in committees on nomenclature, research and reference committees in a process similar to the recent DSM-5 process.  The evidence to maintain the homosexuality was found to be unscientific, based on highly selected samples and it was rejected.  The decision was front page news in both the New York Times and Washington Post.  On December 16, 1999 the Washington Post selected the APA decision as one of the "stories of the century."

There was not complete consensus and two psychoanalysts insisted on a referendum at the next election and their petition was defeated by a margin of 2:1.  Dr. Freedman provided this information because of criticism that the APA Board and not the membership favored the elimination of homosexuality.  He points out in retrospect that there were other issues that he was focused on at the time including the theft of psychoanalytic records during the Watergate scandal and the reaction to that incident.  He also raised the issue of psychiatric abuse in the Soviet Union and interview detainees who had been inappropriately placed in psychiatric hospitals.  The APA contingent refused to travel to the USSR unless they would have access to patients in psychiatric hospitals and could interview them.  The Soviets sandbagged the process by presenting cases of severe chronic mental illness and not allowing interviews.  

The 81 Words piece is given primarily by Alix Spiegel, the granddaughter of John Spiegel a past President of the APA.  At the time of this decision he was President Elect of the APA.  She waxes rhetorical at times about psychiatry but I won't dwell on those details.  They are minor in comparison with a well researched human interest story about the parallel stories that factored into this decision. She also discusses a parallel story within her family based on the occurrences at the time.

At the time that Dr. Spitzer decided to eliminate homosexuality as a diagnostic category he was probably early in his career in terms of designing diagnostic criteria and extending the DSM technology. He has described that process as basically reviewing literature, talking with experts and trying to type up a notecard with the criteria for that disorder. The MPR piece described his process with regard to the homosexuality question as more complex. He first met with a gay activist and wanted to understand that viewpoint. Several months later he arranged for three gay activists to present their case to the DSM nomenclature committee. A forum was organized at the 1973 APA Convention in Honolulu with an open debate between the analysts supporting homosexuality as a diagnosis, a faction of psychiatrists who did not, and Ronald Gold, the gay activist who befriended Spitzer. The event that led to the redraft that evening was Spitzer's attendance at the GAYPA party later that evening. After stating that he did not know any gay psychiatrists, he saw many notable psychiatrists at that meeting and went back to his hotel and redrafted the DSM criteria.

I have an interest in flagging these resources for future reference.  Listen to the This American Life piece and the interviews by Dr. Blumenfield.  This is a compelling story and clearly a decision that the APA and its membership got right.  A common criticism of psychiatry is that it is unscientific or pseudoscientific and yet one of the main points in this historic decision was the rejection of psychoanalytic research that was considered unscientific.  Dr. Freedman's commentary points out that the decision went through a process that seems to be very similar to the current DSM-5 process.  Contrary to the flurry of criticisms of the DSM-5 before the recent release, this decision was precedent setting.  It preceded most state laws regulating gay marriage by nearly 40 years.  It was hailed as recently as 1999 as being a story of the century.  And yet the press image of the DSM process suggested that the organization was socially inept and could not be trusted with similar decisions without close monitoring by non-medical organizations.

If anything this decision combined with precedent setting decisions on confidentiality, commenting on public figures, and banning psychiatry from participating in torture and capital punishment suggests that psychiatry should be one of the first professional organizations consulted.  Anyone reading this blog gets the message that the APA is far from perfect, but at times they get it very right.  This is a forty year decision that has stood the test of time and is also a good example of activism within the organization as a driving force.  Activism and political tension within the organization can be as important as the science behind the position.

George Dawson, MD, DFAPA

1.  This American Life.  81 Words.  January 18, 2002.  The NPR story of how the American Psychiatric Association decided that homosexuality was no longer a mental illness.

2.  Michael Blumenfield, MD. 40th Anniversary of "Homosexuality" Being Removed from DSM.

3.  DSM-II Change - The actual DSM-II change involved the category "Sexual Deviations".  The introductory paragraph was 81 words long and "302. Homosexuality" was removed from the list.  It begins with the sentences:

"This category is for individuals whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances as in....."


4 comments:

  1. The APA did not get it right in DSM-5 with regards to transexuality. It is still (wrongly) classified as a mental illness - disease of the mind.

    The parallels between transsexualism and homosexuality are stunning if you ignore the need in today's medical industrial complex to feign a mental condition in order to access pharmaceuticals and surgery for a purpose of ensuring long term patient satisfaction.

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  2. "A common criticism of psychiatry is that it is unscientific or pseudoscientific and yet one of the main points in this historic decision was the rejection of psychoanalytic research that was considered unscientific."

    To be brutally honest, many critics saw the inclusion of "Gender identity disorder" in the DSM3 to be continuation of homosexuality under a different name.

    The APA has chosen to continue it as 'Gender dysphoria' in the DSM5.

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  3. For readers unfamiliar with the concepts raised in the intial two posts I would suggest taking a look at the document: "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People". Version 7 was last updated in 2011 and it is available in full text as both the original journal article and .pdf form from the WPATH web site at: http://www.wpath.org/

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  4. Science? Science was never the basis for putting in the manual nor pulling it out. Like most DSM Dx, it was reliable (we could agree on who was a homosexual) but not valid (not a taxonomic disease state). If we were going to be scientific, 90% of DSM would be eliminated along with homosexuality.

    The reason it was in to begin with is that at the time it was socially acceptable to call it a disorder, and by the beginning of the seventies it wasn't. Spitzer can rationalize at as science all he want, but the real reason he did this was obvious. Sacorides and the opponents obviously thought the diagnosis was very scientific but they thankfully lost a political battle.

    So once again, we see APA for what it is, a political guild (and a bad one at that, as you pointed out), not a scientific organization. Please read Ghaemi's latest op-ed at Psychiatric Times, in which he talks about pragmatism, not science as the guiding hand of DSM.

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