Archive for March 22nd, 2010

Posted on March 22, 2010 - by David

Not Sick: The 1973 Removal of Homosexuality from the DSM

81 Words, a 2002 episode of NPR’s This American Life that was recently rebroadcast, tells the story behind the removal of the homosexuality diagnosis from the DSM-II in 1973. You can download the audio or read a transcript of the show here: part 1, part 2.

The report is given by Alix Spiegel, whose grandfather, Dr. John P. Spiegel, was president-elect of the American Psychiatric Association in 1973 when this historic change took place. Alix describes the family myth – that grandpa had single-handedly changed the APA’s position on homosexuality and removed one of the major barriers to equal rights for homosexuals in America. The truth, she says, is actually much more complicated. Though he did play a role in this historic change, ‘grandpa’ was not the driving force his family believed him to be, nor were his motives simply those of dedicated psychiatrist and champion of human rights. In Alix Spiegel’s words:

… this version of events was discarded anyway. Discarded after the family went on vacation to the Bahamas to celebrate my grandfather’s 70th birthday. I remember it well. I also remember my grandfather stepping out from his beach front bungalow on that first day followed by a small well-built man, a man that later during dinner my grandfather introduced to a shocked family as his lover, David. David was the first of a long line of very young men that my grandfather took up with after my grandmother’s death. It turned out that my grandfather had had gay lovers throughout his life, had even told his wife-to-be that he was homosexual, two weeks before their wedding. And so in 1981 the story that my family told about the definition in the DSM changed dramatically.

According to Alix Spiegel, from the 40’s through the early 60’s, the APA was a very conservative organization, largely uninterested in “weighing in on the issues of the day.” In her interviews with psychiatrists who were members of the APA in 1970, when the forces behind the definition change began to take shape, she was told that the overwhelming majority of the APA believed that homosexuality was indeed a mental illness – “even the ones of us who were gay,” added Dr. John Fryer.

Fryer was not alone in the APA. Because homosexuals were not allowed to practice psychiatry, Fryer and others like him had to hide their sexual preference, but they began to meet informally at APA conventions, calling themselves the Gay PA. There may have been a sense of solidarity among them, but they were not questioning the official psychiatric stance on homosexuality. Fryer told Spiegel, “because of our own internalized homophobia, most of us probably agreed that it was OK to be a disease.”

The idea that homosexuality was a form of insanity rather than a ‘moral abomination’ was first put forth in the 19^th century, and Spiegel notes that many homosexuals actually saw this as a step forward.  In the early 70’s, psychoanalysis, Freud’s great gift to psychiatry, was still the dominant form of therapy and mode of theoretical understanding in the profession. The two psychoanalytic authorities on homosexuality were Dr. Irving Bieber and Dr. Charles Socarides. Bieber, who was later demonized by gay activists, actually became interested in the subject of homosexuality after working as an army psychiatrist during WWII, when soldiers who were found to be homosexual were dishonorably discharged.  Bieber believed they should receive treatment instead of being discharged, and because of this position, he was never promoted from his rank of Captain during his four years of service. Returning home, he began to research and write about this topic, which culminated in the 1962 publication of Homosexuality: A Psychoanalytic Study. As Spiegel says, this book, which analyzes the work of 77 doctors and over 100 of their gay patients, “concluded that the cause of homosexuality was a combination of what they termed close-binding mothers – which is overprotective women who made their children weak and feminine – and detached, rejecting fathers.”

Of course, there was other data used to argue against the idea of homosexuality as a mental illness. Alfred Kinsey’s famous and highly controversial report on male sexuality, published in 1948, found that 37% of American men had had physical contact to the point of orgasm with another man. Some opponents of the diagnosis used Kinsey’s work to claim that an experience so common could not be reasonably considered pathological.

The work of Evelyn Hooker, a psychologist from UCLA, was first made public in 1956, and addressed one of the main criticisms leveled against psychiatrists like Dr. Irving Bieber, whose study subjects consisted only of homosexuals who were imprisoned, in mental hospitals, had been discharged from the military, or had otherwise sought treatment on their own. Hooker’s aim was to examine gay men who weren’t troubled by their own sexuality. She administered psychological tests to 30 homosexuals who had never sought therapy, as well as 30 heterosexuals who were matched for comparable age, IQ, and education. The disguised results were then given to three experienced psychiatrists who were asked to identify the homosexuals. They were unable to distinguish between the two groups, and categorized two-thirds of both groups as “perfectly well-adjusted, normally functioning human beings.”

In 1970, the APA held their convention in San Francisco, probably an ill-advised choice of location. Gay rights activists showed up, some of whom had apparently obtained press passes from people within the APA, and made their feelings known. Bieber was a particular target, and they effectively broke up the meeting where he was trying to give a talk. The ’71 convention was much the same story.

While there was obvious pressure coming from the gay community to change the DSM, there was also something happening inside the APA.  It seems from Spiegel’s story that the psychiatrists of the Gay PA were for the most part content to gather in secret and accept the traditional designation of homosexuals as sick, but others had begun to mobilize. In Dr. John P. Spiegel’s Cambrige, MA home, a small group of psychiatrists, ‘the young turks,’ began to meet:

The young turks were all psychiatrists, all members of the APA and all liberal-minded easterners who had decided to reform the American Psychiatric Association from the inside. Specifically they had decided to replace all the grey-haired conservatives who ran the organization with a new breed of psychiatrist; more sensitive to the social issues of the day with liberal opinions on Kent State, Vietnam, feminism. They figured that once they got this new breed into office they could fundamentally transform American psychiatry. And one of the things this group was keen to transform was American psychiatry’s approach to homosexuality.

Spiegel is quick to clarify that this group and others like it by no means constituted a “homosexual cabal,” but “several of the key players were gay,” and the young turks were able to use their influential positions as members of the Committee for Concerned Psychiatry to propose candidates for office. Despite all the visible and colorful protests of the APA by gay activists, Spiegel maintains that if it weren’t for the internal changes set into motion by these psychiatrists, the DSM diagnosis would have gone untouched.

At the 1972 convention, the efforts of those working for change both inside and outside the APA were joined for the first time. Gay psychiatrist Dr. John Fryer, recently ousted from his job at UPenn and apparently unemployable due to the rumors of his homosexuality, was recruited by activists to give a speech about the damaging effects of the DSM diagnosis. Though he initially refused the offer, after being rejected by one university after another as he looked for a new job, Fryer accepted the second request on the condition that his identity remain a secret. He appeared as ‘Dr. Anonymous,’ wearing a loud suit several sizes too big, his face hidden behind a distorted Nixon mask, hair covered by a wig, speaking into a special microphone to alter his voice.  “He explained to his fellow psychiatrists how these [81] words had harmed him, and others like him,” and when he was through, received a standing ovation.

Independent of the changes already underway on the inside, there was another chance encounter involving an APA psychiatrist and a gay activist which proved to be instrumental in this process. During a behavioral therapy conference in New York City in ‘72, Dr. Robert Spitzer, a member of the APA’s committee on nomenclature and subscriber to the standard psychiatric view of homosexuality, was sitting in a meeting when Ron Gold stood up and spoke out against psychiatry’s oppression of gays. Spitzer made a point of speaking to Gold after the meeting ; he wanted to express his annoyance at the inappropriateness of the interruption. But when Gold discovered that Spitzer was on the nomenclature committee – the group that first decides what should and shouldn’t end up in the DSM – the conversation went in a different direction. The two men parted ways with Spitzer agreeing to set up a meeting for Gold with the committee as well as a panel discussion at the next convention where gay activists could participate.

At the 1973 APA convention in Honolulu, a few months after the requested audience with the nomenclature committee left the psychiatrists at a loss as to what should be done about the diagnosis, “The old guard, Charles Socarides and Irving Bieber, publicly met the new school, Ronald Gold, Judd Marmor [a future president of the APA] and several other psychiatrists in front of a room filled to capacity.”  The showdown was a resounding victory for the gay activists. Even Socarides admits that the reception to his speech, (which Gold referred to as “his ‘they’re betraying their mammalian heritage’ number”), hardly qualified as warm.  “A lot of people booed,” he told Spiegel, “some people clapped.”

Perhaps the most surprising part of this story, the last shove leading to the change, came later that night in a Honolulu bar. Gold, as the hero of the day, was invited to a covert Gay-PA celebration, and decided to bring Spitzer, who still didn’t personally know of any gay psychiatrists, along with him. Spitzer was supposed to be playing the role of a closeted gay man, but when he realized some of the big names who had been part of this underground group for years, he was shocked, and started asking questions that gave his true identity away.  A psychiatrist Gold described as “the grand dragon of the Gay PA” wanted Spitzer out of there, but Gold refused on the grounds that Spitzer was actually doing something to help homosexuals, while the Gay PA had done nothing. In the middle of this encounter, a man in full army uniform walked into the bar, looked around, and fell weeping into Gold’s arms. As Gold tells Spiegel:

Well I had no idea who he was. It turned out he was a psychiatrist, an army psychiatrist based in Hawaii who was so moved by my speech, he told me, that he decided he had to go to a gay bar for the first time in his life. And somehow or other he got directed to this particular bar and saw me and all the gay psychiatrists and it was too much for him, he just cracked up. And it was a very moving event, I mean this man was awash in tears. And I believe that that was what decided Spitzer, right then and there, let’s go. Because it was right after that that he said, ‘Let’s go write the resolution.’ And so we went back to Spitzer’s hotel room and wrote the resolution.

While obviously we don’t have the original text composed by Gold and Spitzer in Honolulu– perhaps scrawled on some long lost sheets of hotel stationary –I’m guessing that much of what was written that night ended up here, in this position statement proposing a change in diagnosis from homosexuality to ‘Sexual Orientation Disturbance’ with homosexuality bracketed. This change was to be put into effect for the 6^th printing of the DSM II and read as follows:

302.0 Sexual orientation disturbance (Homosexuality)

 

This category is for individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation. This diagnostic category is distinguished from homosexuality, which by itself does not constitute a psychiatric disorder. Homosexuality per se is one form of sexual behavior and, like other forms of sexual behavior which are not by themselves psychiatric disorders, is not listed in this nomenclature of mental disorders.

 

In this paper, Spitzer basically states that homosexuality is a normal variant of human sexuality. He writes that “for a mental or psychiatric condition 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,” and because many homosexuals do not meet these criteria, homosexuality should not be considered an illness. Spitzer clearly understood that this change was in part a political action, stating that “we will be removing one of the justifications for the denial of civil rights to individuals whose only crime is that their sexual orientation is to members of the same sex.” However, he writes that the removal of the homosexuality diagnosis does not amount to “saying that it is ‘normal’ or as valuable as heterosexuality,” and maintains that “this change should in no way interfere with or embarrass those dedicated psychiatrists and psychoanalysts who have devoted themselves to understanding and treating those homosexuals who have been unhappy with their lot.” The idea, in the end, was that if someone was bothered by their own homosexual thoughts, impulses, or behavior, the DSM still had them covered.

This initial change, officially announced by Dr. Alfred Friedman, president of the APA, on December 15, 1973, may have allowed psychoanalysts to continue treating gay patients for a time, but in less than 15 years, the DSM would be wiped clean of the last traces of the idea that homosexuality could be a mental illness. Spitzer’s original change had been rewritten as ‘ego-dystonic homosexuality’ for the DSM-III, but was removed altogether in 1987.

Dr. Charles Socarides, the most prominent player on the losing team, responded to the change in a 1978 article titled ‘The Sexual Deviations and the Diagnostic Manual,’ published in the American Journal of Psychotherapy.  In protest of further proposed revisions for the soon to be published DSM-III, Socarides wrote, “these changes would remove from psychoanalysis and psychiatry entire areas of scientific progress, rendering chaotic fundamental truths about unconscious psychodynamics, as well as the interrelationship between anatomy and psychosexual identity.” In particular, Socarides objected to the fact that the heading ‘Sexual Deviations,’ under which the homosexuality diagnosis had once was fallen, was going to be entirely removed from the DSM-III. Proponents of this change pointed to reports like Kinsey’s, arguing that a phenomenon as common as homosexuality shouldn’t be understood as a deviation, but Socarides believed this was faulty reasoning:

To form conclusions as to the specific meaning of an event simply because of its frequency of occurrence is to the psychoanalyst scientific folly. Only in the consultation room, using the techniques of introspective reporting and free association, protected by the laws of medicine and professional ethics, will an individual, pressed by his suffering and pain, reveal the hidden (even from himself) meaning and reasons behind his acts.

When I read Socarides’ paper, I noticed that he repeatedly summons the name of science, even while his argument belies a dogmatic faith in psychoanalysis –an approach that has been waning in popularity for decades, suffering from the criticism that it lacks scientific validity. Regardless of who is right or wrong in this argument, (or any similar argument for that matter), what I find most interesting is how it is imperative for each party to claim the support of science. One of the last people Spiegel speaks to in her report is Ronald Bayer, a public health historian from Columbia who wrote a history of this change titled Homosexuality and American Psychiatry. Bayer tells Spiegel that “the nature of these controversies,” is that “both sides wrap themselves in the mantle of science and both sides charge that the other side is being unscientific.”

While developments in medicine and advances in genetic study and different brain imaging technologies have no doubt increased the importance of being aligned with “science” when it comes to psychiatric debate, this is not a new phenomenon, nor was it new in the ‘70’s. At the same time, stories like this one makes it plain that the progress of certain disciplines may be driven just as much by personal and political factors as it is by actual scientific progress. I wonder if the removal of the homosexuality diagnosis in 1973 wasn’t the beginning of the end for psychoanalysis, as well as the first move towards the more standardized, symptom-based diagnoses of the 1980 DSM-III. This seems reasonable, considering that Robert Spitzer was chairman of the task force responsible for creating the new edition and directed the development of the revised edition published in 1987 (DSM-III-R).

As the APA prepares for the publication of the DSM-V in 2013, I believe it’s worthwhile to keep this story in mind. Some of the proposed changes seem to have more to do with a desire to remove a stigmatizing label than real “scientific” evidence.  And like homosexuality, the pathology of which was for a many years assumed but never proven, the scientific understanding of some of the older DSM diagnoses is not particularly strong. Studying the history of psychiatry can’t necessarily prove or disprove the validity of a diagnosis, but it may help us to remain cautious as we go forward.