Medical News & Perspectives – August 12, 1998
Forum Honors Landmark 1973 Events
It’s been 25 years since the American Psychiatric Association (APA) voted to delete homosexuality from its official list of mental disorders and issued a strong statement of support for gay rights. A forum marking this anniversary drew a standing-room-only crowd at the APA’s annual meeting in Toronto, Ontario, in June,.
Speakers discussed the controversy that surrounded efforts to depathologize homosexuality, traced the evolution of psychiatric and psychoanalytic attitudes toward homosexuality and explored the significance of these changes for the mental health of gay, lesbian, and bisexual persons today.
Melvin Sabshin, MD, who recently retired after 23 years as medical director of the APA, recalled "tumultuous" demonstrations by gay activists objecting to the classification of homosexuality as an illness and by Vietnam War protesters at the APA’s annual meeting in San Francisco, Calif, in 1970, a year when he served as program director. "It was guerrilla theater," he said, "with lots of hard words," so disruptive, in fact, that the APA hired a security consultant to try to ensure more orderly demonstrations at future annual meetings.
"The screaming eased into discussion, said Sabshin, now adjunct professor of psychiatry at the University of Maryland School of Medicine, Baltimore. At the 1972 annual meeting, a gay psychiatrist, who feared professional repercussions if his identity were known, spoke while wearing a mask. By 1973, however, there were exhibits at the meeting on being "gay, proud, and healthy."
Scientific Evidence Was Impetus
The social and political impetus for change, Sabshin said, was supported by scientific evidence. The APA’s Committee on Nomenclature reviewed numerous studies that used standardized instruments and nonpatient populations and showed that most gay persons were satisfied with their sexual orientation and were not impaired in their social functioning.
Pressure to abandon the psychoanalytic view that the "homoerotic level" is simply a stage in development toward mature sexuality, Sabshin said, was part of a broader movement to reexamine ideas about psychopathology in general, "to accept that all of us have some problem or another," and to redefine what is and is not normal. "The development of a rational approach to pathology," Sabshin said, "was salient and helpful to the gay group."
Proposals to drop homosexuality from the Diagnostic and Statistical Manual of Mental Disorders, second edition (DSM-II; Washington, DC: APA; 1968) advanced within the APA from local to national levels. In December 1973, Sabshin said, the APA’s board of trustees voted in favor of the deletion. This event drew national media coverage. The New York Times headline, "Doctors Rule Homosexuality Not Abnormal," Sabshin said, focused squarely on the central issue of normalcy. A newspaper aimed primarily at gay readers cheered, "Gays Leave Psychiatric Sicklist."
The battle was not quite over. Psychiatrists objecting to the board’s decision mustered support for a referendum to be voted on by the full APA membership in 1974. Some 58% of the members favored the board, an indication, Sabshin said, that a turning point had been reached.
At the December 1973 meeting, the APA’s board also approved a statement on homosexuality and civil rights (see sidebar). This statement, according to Robert Cabaj, MD, medical director of the mental health services division of San Mateo County Health Services Agency in California and associate clinical professor of psychiatry at the University of California, San Francisco, "is a landmark and the cornerstone of all that has happened since." It fostered recognition, he said, that many of the problems gays and lesbians deal with are the result of societal homophobia."
"Gay and lesbian psychiatrists," Cabaj said, "have worked within the APA, some holding high elective offices, and within the medical and larger community, to raise awareness of gay and other minority concerns.
The APA created a gay and lesbian taskforce in 1978. That same year, a group now called the Association of Gay and Lesbian Psychiatrists was established. Ensuing years have brought more presentations at meetings on such professional issues as what it is like to be a gay or lesbian therapist or psychiatry resident.
When homosexuality was deleted as a disease category from the DSM-II, a new diagnosis, "sexual orientation disturbance," was added to describe persons attracted to members of the same sex "who are either disturbed by, in conflict with, or wish to change their sexual orientation." This diagnosis was renamed "ego dystonic homosexuality" in the third edition of the DSM, DSM-III (Washington, DC: APA; 1980).
"The category was controversial, Cabaj said, "since it’s normal for gays and lesbians to grow up wishing they were not hated and reviled." Presentations on the lack of empirical data to support this diagnosis were made to the work group charged with revising the manual in the mid 1980s, and the category did not appear in the DSM-IIIR. In the fourth and most recent edition of DSM, DSM-IV, there is no reference to homosexuality, Cabaj noted, except perhaps under "sexual disorder not otherwise specified" (Washington, DC: APA; 1994).
"Concerns persist, he said, about problems faced by gay persons in military service. Before "don’t ask, don’t tell" became standard practice, he said, persons in the military who told their psychiatrists that they were gay might have information put in their chart that could lead to their discharge. After lobbying unsuccessfully to keep military psychiatrists from being seated in the APA assembly because they did not adhere to the APA’s guidelines on gay rights, Cabaj said, the gay groups sought to educate military psychiatrists about the ethical bind they were in.
Attitudes toward homosexuality have changed more slowly in the psychoanalytic community than among psychiatrists in general, according to Diana Miller, MD, a child and adult psychiatrist and psychoanalyst, and assistant clinical professor of psychiatry at the University of California, Los Angeles.
"In the past 5 years, American institutional psychoanalysis has finally begun in earnest to revise its long-standing positions about homosexuality and about training gay and lesbian therapists," Miller said. "The previous 20 years," she maintained, "were trying ones."
In 1984, Miller said, she applied for training to a nonmedical institute that practiced the "don’t ask, don’t tell" philosophy. That same year, she said, her partner, Maggie Magee, MSW, who also applied to a nonmedical institute, may have been the first openly lesbian or gay candidate to be accepted for psychoanalytic training in any institute. Magee, a member of the faculty of the Los Angeles Institute and Society for Psychoanalytic Studies, and Miller are coauthors of Lesbian Lives: Psychoanalytic Narratives Old and New (Mahwah, NJ: Analytic Press; 1997).
"In our training," Miller said, "we could not help noticing hostility toward gay men and lesbian women, and stereotyped and pathologizing views, even by supposedly liberal analysts." Proposals to the American Psychoanalytic Association, the nation’s largest psychoanalytic organization, to ratify the APA’s 1973 position on homosexuality were defeated. The association said, according to Miller, that it did not take a stand on social issues not directly affecting psychoanalysis.
In 1991, after 5 years of debate, the American Psychoanalytic Association passed a resolution opposing public and private discrimination against homosexual persons. The words "including training and supervising analysts," however, were not added until 1992, Miller said, after the group received a letter from the American Civil Liberties Union.
Efforts continue, Miller said, to update information on homosexuality in the analytic curriculum. Some signs of progress: Publications by gay and lesbian analysts offer new ways of understanding and working with gay and lesbian patients. The psychoanalytic "obsession" with finding the origin of homosexual identity, she said, is beginning to be replaced by efforts to explore clinical experiences of gay men and lesbian women, such as "coming out" (publicly acknowledging one’s homosexuality), and factors that ease or complicate this experience. The 1997 annual meeting of the American Psychoanalytic Association included a discussion group on the topic "a gay analyst presents a gay patient." Also in 1997, the organization endorsed same-sex marriage, a step the APA has yet to take.
Analysts with gay and lesbian children, Miller asserted, have not been forthcoming about acknowledging these children’s orientation. If they were to do so, she said, their colleagues might be less likely to attribute homosexuality to "abnormal" family dynamics.
"Straighten Out" or Help?
Carolyn Robinowitz, MD, former deputy medical director of the APA and now dean-designate and professor of psychiatry at Georgetown University School of Medicine, Washington, DC, used personal vignettes from her 30 years in psychiatry to illustrate the evolution in attitudes toward homosexuality during this time.
One of her first patients, she recalled, was a young woman referred by a therapist who had not been able to help her. The therapist had focused primarily on the woman’s homosexuality, hoping, as he said in his notes, "to straighten her out before it was too late." Robinowitz focused instead on what brought the woman to treatment: the loss of significant others who had died or moved away and career conflicts. Her success with this patient, she said, brought referrals of other gay patients whose therapists also had concentrated on their homosexuality at the expense of current issues.
In the early 1980s, Robinowitz represented the APA at meetings of the American Medical Association where she met physicians in other specialties who expressed surprise, she said, that "it was okay to be gay in the APA." They told her, she said, that in their specialties they could not be openly gay, that if they were they would lose many opportunities for advancement.
Today, she said, even in the conservative atmosphere of Georgetown University, it is possible for same-sex couples to appear at social events and for students to be openly gay. People who don’t like this, she said, know that it is not socially acceptable to say so.
An Eye to the Future
Looking toward the future, Howard Rubin, MD, health services research fellow at the University of California, Los Angeles, and a member of the APA’s Committee on Gay, Lesbian, and Bisexual Issues, ticked off educational needs at all levels of medical training. Many residency programs, he said, provide little information about homosexuality, often only "a day for the gay," with brief presentations and discussion. This situation may change, he said, as more gay persons in faculty positions openly acknowledge their sexual orientation.
More "gay-affirmative" medicine is needed, Rubin added, urging that all physicians adopt a gender-neutral approach in taking a patient’s sexual history. Residents and trainees, he said, want more information on working with gays and on issues of transference and countertransference. Gay psychiatrists want more information about the pros and cons of disclosing their sexual orientation to patients.
Psychiatrists also need to be involved, Rubin said, at the intersection of personal, political, and community issues. "The radical right," Rubin said, "has used homosexual issues to aid fundraising and to rally their forces, a stance that has a negative effect on gay physicians and on their patients." On an international level, he said, the APA was instrumental in having homosexuality deleted from the Japanese version of the current DSM.
"It was important 25 years ago," Rubin said, "for gays to say, ‘we’re not different, we’re like everyone else.’ " But today, he said, they are more willing to explore whether problems such as substance abuse are higher in the gay population and, if so, why that might be.
Gay psychiatrists are asking, he said, "Do we focus on gay-specific issues or just try to fit in? Are we a queer nation or just people who happen to be gay who are part of a larger nation?"
by Lynne Lamberg, JAMA (Journal of the American Medical Association) contributor