Professional Papers

  • Even Psychiatry Can Profit from its Past Mistakes. Originally presented before the Nomenclature Committee of the American Psychiatric Association, February 8th 1973.

Published in the Journal of Homosexuality, Volume 2, No. 3, Spring 1976/1977 2,000 words.

Members of the committee:
The 1968 edition of the Diagnostic and Statistical Manual of the Psychiatric Association, and its presence in ICDA-8, is heir to a long tradition in medical practice of diagnosing the ills that plague us. Indeed, diagnosis is the fulcrum upon which rests the investigation of the etiology and the treatment of all diseases.

The recent edition of the APA statistical manual is a far cry, however, from the earlier manuals. The first attempt in the United States to classify our emotional ills was made in 1871 by the Association of Medical Superintendents of American Institutions for the Insane. Then 1917 the American Medico-Psychological Association (later to become the APA) and the National Committee for Mental Hygiene collaborated in the adoption of an informative pamphlet entitled "Statistical Manual for the Use of Hospitals for Mental Diseases." The present APA published its diagnostic manual in 1952, and its first revision in 1968. ICDA, as you know, has gone through eight editions.

It is extremely informative to read through the consecutive editions of these classificatory manuals. We find a general and clear trend emerging. Each revision of the diagnostic manual enlarges upon and subdivides the diagnostic categories of the previous edition. What was a subdivision of a disorder in one edition becomes a new gross classification with subdivisions of its own in the next. Compare the 1942 statistical manual with the 1968 edition with regard to drug usage. In 1942 under the general category "Conduct Disturbance" is a minor entry, "Use of Drugs." Compare this with the long list of drug dependencies in the 1968 edition. The 1942 list under "Pathologic Sexuality" has four subcategories. In 1968 there are nine. As you follow each personality disorder through consecutive editions, as Parkinson's Law predicts, the list grows ever larger and broader, so that the 1968 list includes almost every foible imaginable.

Just for fun I would like to mention some of the more quaint "illnesses" from the official manual of the APA published just one year after Pearl Harbor. For seven years after World War II it was possible to suffer from such "mental illnesses" as "Syphilophobia,” ȁVagabondage,” and “Pathologic Mendacity,” under the category "Asocial Trends," which should not be confused with "Untruthfulness" which is listed under "Conduct Disturbance." And less I be accused, under the 1942 list, of being either "Misanthropic" to this committee or "Cruel," by throwing back at you these immorally inspired inclusions to the medical nosology, let me share with you some thoughts on how these changes came about.

Every society has had rules of conduct and societal institutions, such as religion, and civil laws to enforce them. Indeed, society must develop techniques for social control. The concept of deviance seems to be necessary for a society so that it can provide a clear cut and recognizable threshold between permissible and impermissible behavior. Deviance, then, is a reaction of the major group in society in their perception of a minority group. As some sociologists have suggested, deviance is not in the behavior of the offender, but in the perception of his audience.

Around the turn of the century, psychiatry became a new force. It was inspiring. It had different kinds of answers to old problems, but its inspiration was also its trap. All the so-called problems of society were heaped upon the new practitioners. With the concomitant decline in religion, the process of transferring society's problems to medical people was accelerated. If our penologists were incapable of dealing with criminality, then let the psychiatrists do it; if social behavior was offensive, let the psychiatrists correct it; and most certainly if there was immoral sexual behavior like homosexuality, let the psychiatrists change it. Psychiatry and the medical model were placed in the position of having to solve every problem that other institutions had failed to solve. Other institutions neatly avoided all responsibility by getting the psychiatric establishment to accept responsibility for every possible violation of social norms.

In fact, diagnostic labeling came to serve two conflicting masters: the psychiatrists genuine concern to treat psychiatric disorders, and the needs of social control. Homosexuality, we suggest, is not a diagnostic label. It is a social, religious, and pejorative label slipped in for moral reasons. We feel very strongly that there is an orthogonal relationship between the psychological health (the purpose of diagnosis) and social uniqueness (pejorative labeling), and the inclusion of homosexuality in the diagnostic manual serves the purpose of social control (with appropriate penalties), not psychiatric diagnoses.

Now if we are correct that social labeling and psychological health are orthogonal, then we should be able to demonstrate their independence by psychological research. Let us briefly review the research available to us.

The "old" research with which you are familiar is the subjective psychoanalytic theory. Our position here is simple. Unless these authors can establish the veracity of their theories through the established techniques of scientific research, their theories remain creative, but unsubstantiated. They are, in effect, adult "fairy" tales. How can a treatment be evaluated without a comparison with appropriate control groups? Where has there been the concern for experimenter bias and placebo affects that mandates so much double-blind research in drug testing? Indeed, every psychoanalytic investigator has already been taught the so-called etiology of homosexuality before he met his first patient. Selective perception takes over from there. If you wish, we are prepared to discuss specific psychoanalytic theories and writers, but for the moment I would like to turn to the objective evidence.

Previous to 1957 all objective psychological research dealt with two very specific samples of homosexuals: patients who were guilt ridden about their homosexual orientation and came to be cured, and prison inmates. The former were persons of low self-esteem, usually suffering from an unusual burden of guilt. The latter, by definition, were legal offenders. It is not surprising that the objective test results revealed many varieties of psychological impairment. Unfortunately, control groups were lacking in every case. Therefore, homosexual object choice was confounded with psychological pathology.

That was Hooker's contribution in 1957. A nonpatient sample of homosexual and heterosexual subjects was administered a battery of projective tests, the ones most often used to diagnose homosexuality. The test interpreters, all experienced diagnosticians, could not differentiate one group from the other better than chance. From that day on, control groups became mandatory, and the results of subsequent research change dramatically.

We have delivered to you a summary of some of this research. At the moment we wish to point out two significant aspects of the cited studies. First of all they do not place their emphasis on etiology as the "old" research did.

It seems perfectly logical to state that one does not to look for the etiology of a "mental illness" unless one can first establish that an "illness" exists.

So the first order of business was to test for pathology in subjects with a homosexual object choice. The second point is the variety of homosexual samples tested, and the varieties of test utilized. Never before have so many different samples of a so-called deviant group been tested with so many instruments.

The Weinberg study (1970) sampled man in homosexual organizations in New York, San Francisco, and Chicago. It also sampled patrons of homosexual bars in these cities. Comparing younger and older homosexual man, Weinberg found no evidence for pathology, and no evidence for the legend that older homosexuals are lonely people. As a matter of fact, he found that older homosexuals were better adjusted than younger ones.

In a set of studies by Saghir et al. (1970), psychiatric interviews were the instruments of evaluation. Once again the subjects, both male and female, came from gay organizations. When compared with control groups, there was no difference with respect to pathology in the men. For lesbians the results appear to be bimodal, with some lesbians experiencing great difficulties and others functioning on a par with or better than the heterosexual control group.

College students were the subjects in the Loney (1972) study, and a questionnaire was administered to assess background factors and sexual experience in two nonpatient samples. Homosexual men, with regard to sexual experiences, were found to be most similar to heterosexual men. The same was true for lesbians.

Evans (1970) used a personality questionnaire with American homosexual men and controls, and compared results previously cited for Australian men. In both samples of homosexual men, no significant pathology was found. The only difference found between the homosexual and heterosexual man was sexual orientation.

Using the Minnesota Multiphasic Personality Inventory, Dean and Richardson (1964) compared homosexual and heterosexual college students. No pathology was found in the homosexual group.

There is much more, but we think this is enough for now. To our knowledge there is not one objective study, by any researcher, in any country, that substantiates the theory of homosexual pathology. As a matter of fact, we might wonder at how remarkable the human psyche must be to avoid pathology in the face of such condemnation from societal institutions.

So until replicated research can demonstrate that there is an an priori pathology in homosexuality, we do not wish to argue etiological theories.

We submit to you a set of letters by noted authorities who agree with us that homosexuality should be removed from the diagnostic manual.

Dr. Seymour Halleck states, "Deletion of the diagnosis of homosexuality is not only a humanistic step, it is dictated by the best scientific information available."

There are two men who have interviewed more homosexuals then have other researchers. Dr. Wardell Pomeroy found no evidence of pathology in the Kinsey et al. (1948) study of the human male. At the moment Dr. Alan Bell of the Kinsey Institute is analyzing the data from the largest sample of homosexuals ever studied. He remarks that if we understood more about both sexual orientation's, "We would find certain types of homosexuals and heterosexuals reasonably free of pathological features and having more in common with each other than with other types belonging to either sexual orientation." His data indicate that homosexuality falls within the normal range of psychological functioning.

The last letter to be submitted to you is from the American Psychological Association. As you will notice, the annual survey of psychologists will no longer list "Homosexuality and Sexual Deviation." In addition, "Sexual Life-Styles" has been added to the study of social psychology.

The National Association of Social Workers at its last national conference not only went on record to state that homosexuality was not a disorder but also approved a set of resolutions to encourage homosexuals to enter the social work profession.

The point is not that times are changing, but that times have changed. For a long time you have listened to the "old" authorities in your field, whose theories were left behind because they stood still while the rest of the world moved ahead with replicated research. I suppose what we are saying is that you must choose between the undocumented theories that have unjustly harmed a great number of people, and which continue to harm us, or controlled scientific studies cited here and in our previous report to you. It is no sin to have made an error in the past, but surely you will mock the principles of scientific research upon which the diagnostic system is based if you turn your backs on the only objective evidence we have. To continue to classify homosexuality as a disorder is as valid today as the diagnosis of masturbation was in the 1942 edition. We echo the words of Dr. Pomeroy when he said, "I have high hopes that even psychiatry can profit by its past mistakes and can proudly enter the last quarter of the 20th century." What we hope to convey to you is that we had paid the price for your past mistake. Don't make it again.