Psyhotherapists went from classifying homosexuality as a sociopathic mental disorder to a paraphilic disorder, then to a paraphilic disorder provided that a homosexual was uncomfortable with his homosexuality but not if he was comfortable with it, and subsequently to a mentally normal condition, but here are some curious finds...

Some curious finds

5 years after the American Psychiatric Association ( APA) removed ego-syntonic (comfortable with orientation) homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), Garfinkle and Morin asked some psychotherapists to evaluate a patient’s description.1 Some were told that the patient was a homosexual and others were told that the patient was a heterosexual. Psychotherapists described the homosexual patient as more severely mentally ill.

It may be argued that the participants in Garfinkle and Morin's study were still influenced by the fact that only a short time ago homosexuality was classified as a mental disorder. However, 20 years after the APA declassified homosexuality as a mental illness, Rubinstein repeated Garfinkle and Morin’s study and found similar results.2 Rubinstein’s subjects were 417 predominantly secular, politically liberal, and young psychotherapists who had never been acquainted with the old versions of the DSM.

Both results turned out to be inconsistent with the declared attitude of psychotherapists regarding homosexual patients,3, 4 or the official position of the APA.5, 6 In addition, Rubinstein reported that a survey of psychological literature revealed the declaration of psychologists that nonpatient homosexuals are not less well-adjusted than heterosexuals,7, 8, 9 or even that homosexuals are better adjusted than heterosexuals.10, 11 Some psychotherapists declare that homophobia is the problem that should be treated.12, 13

In 1995, Lilling and Friedman14 obtained results similar to that of Garfinkle and Morin, and Rubinstein, in a sample of psychoanalysts. Therefore, with respect to homosexuality, what psychotherapists really believe is different from what they think they believe. It appears that many psychotherapists are in denial and have deluded themselves into believing what is official dogma.

The APA decision to remove homosexuality from the DSM (1973) did not immediately influence psychiatrists in many countries. For instance, in 1988, Kachaev and Ponomarev wrote the following in a Russian Journal:15

“A comprehensive clinical and psychological investigation was performed in 240 homosexual men. Various factors were established as playing a role in the development of homosexual drive. Therapeutic and preventive methods were designed. Homosexual men were found to have increased sexuality at the age of 5 to 7. First signs of homosexual settings were evident since the age 14-16 and their final shape acquired by 18-20. Parts played by individual partners were largely determined by personality traits (extroversion prevailing in “active” group and introversion in “passive” one). Homosexual orientation was primarily due to psychopathological development of the personality, asociality and external cues providing first sexual impression. In the forced confinement homosexual settings could be easily suppressed with Chlorpromazine and then with Sulfadiazin treatment. The prevention of homosexuality should be arranged as a complex of means effected through a differentiated medicolegal approach.”

Consider also the published comments of Bardenshtein et al., who, in 1995, explained the rationale behind the necessity of diagnosing homosexuality and how one may do so:16

“In social terms homosexuality is one of the most dangerous sexual perversions, for it is subject to a strong social disapproval, affects the personality core, leads to social disadaptation, growth of anxiety, development of neurotic and depressive states, suicidal inclination, is conducive to the spread of syphilis and AIDS, forms the basis for numerous crimes (violence, aggression, murder). Homosexuality virtually cannot be corrected and is carefully concealed. In single-sex groups (soldiers, students of military schools, convicts) the prevalence of homosexuality may be as high as 30 to 50%. The proposed complex method for the diagnosis of homosexuality in men has been developed on the basis of methods of sexology, anthropometry, verbal and nonverbal psychodiagnosis, multidimensional mathematical statistics. The method consists of several independent blocks representing different aspects of sexuality. It is conductive to a flexible and rapid solution of numerous practical problems from singling out a risk group in screening examinations to full expert evaluation of the sexual sphere with a resulting differential diagnosis.”

Russian psychiatry no longer considers homosexuality to be a mental illness. Let us address the circumstances that lead to the removal of homosexuality as a diagnosis in the DSM.

History: the declassification of homosexuality as a mental illness

The APA stopped considering homosexuality as a mental disorder after prolonged social agitation and professional conflict.17 Homosexuals disrupted APA meetings and harassed psychiatrists. For instance, psychiatrist Nelson Borelli was at the 1972 APA convention, and noted the following:18

“Contrary to Dr. Mac Donald's statement, Dr. Judd Marmor did not do the “declassifying of homosexuality”. I was there in San Francisco at the 1972 APA convention when the “Gay and Lesbian” activists forced the APA leadership to promise to drop “Homosexuality” from the diagnostic manual or else there would be no APA Convention. Not only the scandal they were causing, but the activists had gained control of the infrastructure of the convention building. The APA kept the promise.”

The note above was in response to an editorial comment in the British Medical Journal, crediting Dr. Judd Marmor for playing an instrumental role in declassifying homosexuality as a mental illness.19, 20 Schaler noted that Dr. Marmor borrowed the idea that homosexuality was not a mental illness from psychoanalyst Thomas Szasz, without giving credit to Szasz.21 Szasz not only believed that homosexuality was not a mental illness, but also he believed that there was no such thing as a mental illness.22 In a 1965 book on homosexuality edited by Dr. Marmor, which included a chapter by Szasz,23 Dr. Marmor never argued that homosexuals were not mentally ill and continued to refer to homosexuals as “patients.” As of 1965, Dr. Marmor’s view of homosexuality concurred with the psychiatric view of homosexuality as a pathology.

The APA's Committee on Nomenclature decided to remove homosexuality from the DSM in 1973. It gave opponents 15 minutes to present a rebuttal.24 The APA membership can overrule committee decisions even on scientific matters. Some voices appealed to the APA membership. Homosexual activists quickly purchased the APA mailing list after the National Gay Task Force (NGTF) sent out a fund-raising appeal to its members, and then drafted a letter, got it signed by some psychiatrists, and sent it to over 30,000 APA members urging them to vote to retain the nomenclature change. The letter deliberately avoided mention that the NGTF had written and distributed it. All psychiatrist signatories publicly denied any role in the cunning move by the NGTF. Only a third of the APA membership responded, but most voted to support the nomenclature change, and the decision of the Board of Trustees was allowed to stand. Clearly, the decision did not reflect how most psychiatrists viewed homosexuality then. Besides, some methods used then to prove that homosexuals are as well-adjusted as heterosexuals, such as the Rorschach test, which involves interpretations of ink-blot patterns, are so ludicrous that no self-respecting psychiatrist would use them today.

Homosexuality was declassified in two phases. At first, ego-syntonic homosexuality was removed as a diagnosis; ego syntonic refers to comfortable with orientation. A couple of years later, ego-dystonic homosexuality (not comfortable with homosexual orientation) was also removed as a diagnosis; it was assumed (not proven) that discomfort with own same-sex attraction was a result of internalizing societal homophobia.

In 1994, the Board of Trustees of the APA proposed a change in the code of ethics where it would be a violation of professional conduct for a psychiatrist to help a homosexual client behave exclusively heterosexually, even at the client's request. This was remarkable since psychiatrists are expected to cater to maximal self-determination on the part of their clients. Therapists who help homosexuals change and a number of “ex-gays” threatened that if the resolution passed, they would file a lawsuit against the APA, forcing it to reopen the original basis on which homosexuality was excluded from the list of diagnoses. The activists retreated. However, it remains unethical for psychiatrists to attempt to change a homosexual based on the assumption that homosexuality per se is a mental disorder or the assumption that the patient should change to exclusive heterosexual behavior for his own good.25

The future

From the late 1990s onward, numerous random and population-based studies have forced psychotherapists to acknowledge that homosexuality and bisexuality are accompanied by increased odds of mental illnesses, but they are quick to point out that discrimination, stigma, prejudice and victimization are responsible. However, many studies in recent years have argued against this notion, and provided plenty of evidence that homosexual and bisexual outcomes are intrinsically associated with increased odds of mental illnesses. So it is a matter to time before psychotherapists are forced to acknowledge the latter.


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