Abstract
At the time that I commenced formal training in psychiatry, in February 1973, homosexuality was a recognized mental disorder in both the second edition of the Diagnostic and statistical manual of mental disorders (DSM), published by the American Psychiatric Association in 1968, and in the Index and glossary of mental disorders published by the National Health and Medical Research Council of Australia in September 1972, based on the Glossary of mental disorders published by the World Health Organization for use with the eighth revision of the International classification of diseases (ICD). In December 1973, the Board of Trustees of the American Psychiatric Association (APA) voted to remove homosexuality from the DSM; that decision was ratified by a referendum of members of the APA. (For the record, 58% of the 10 091 who voted in the referendum supported the decision of the Board of Trustees.)
Homosexuality as a specific diagnostic category was retained in Chapter V of the ICD, listing mental disorders, in the ninth revision published in 1978, but was subsequently removed from ICD-10 Classification of mental and behavioural disorders published in 1992.
In this brief review I shall describe the status of homosexuality as a distinct diagnosis in several systems of psychiatric classification both prior to and after 1973, with an emphasis on the ICD and DSM systems. Discussion of the social and political factors that contributed to the removal of homosexuality from psychiatric classifications, whether or not it falls within the definition of ‘mental disorder’, as well as a consideration of the clinical arguments advanced by proponents and opponents of that change, is outside the scope of this review. The interested reader is referred to the select bibliography at the end of this article.
Early classifications
In his book The Vital Balance, Karl Menninger included an extensive appendix in which he reviewed ‘the psychiatric nosologies of all times’. As he observed: ‘they are a noble heritage. From them grew the concepts of today.’
Menninger divided the classifications into the ‘primitive’ (2600 −500 BCE), ancient Greek and Roman (460 BCE −700 CE), those of the Middle Ages (864 −1274 CE), of the Renaissance period (1450 −1600 CE), and those from the seventeenth century onwards, about which much more is known.
On perusing Menninger's account of these early psychiatric classifications, the first reference to homosexuality occurs in his mention of the work of Caelius Aurelianus, thought to date from the fifth century CE. Aurelianus translated into Latin some of the works of Soranus of Ephesus; among Soranus’ treatises were a number on psychiatric conditions, including phrenitis, lethargy, satyriasis, epilepsy, mania, melancholy, and homosexuality (‘seen as an affliction of a diseased mind, in both males and females’). Soranus, who is best known for his writings on the diseases of women and children, practised medicine in Rome during the first and second centuries CE.
In classical Greece, attitudes towards homosexuality were generally accepting. As noted by Simon, in Sparta the:
aristocratic culture of the fifth and fourth centuries [BCE] institutionalized homosexuality as a formal part of the education and rearing of adolescent boys. In Athens the homosexual relationship was not a formal institution. Indeed, Athens had laws against homosexual relations between older men and adolescent boys which were not sanctioned by the boy's family. But a sensual and erotic homosexuality was not only common in Athens, but quite public.
Hippocrates included ‘Scythian disease’ (transvestism) among the mental illnesses mentioned in his writings, but there was no reference to homosexuality. Similarly, although Plato discussed various types of ‘madness’ (mania) – including ‘erotic madness’ – in the Phaedrus there was no mention, perhaps not surprisingly, of homosexuality.
Avicenna (980 −1037 CE), in the Canon of Medicine, included mental disorders in the chapter on diseases of the head. Among the conditions listed was ‘passive male homosexuality’. Menninger commented, in relation to Avicenna, that ‘notable is the introduction of sexual pathology in the psychiatric nosology (possibly under the influence of the Hippocratic description of the “Scythian disease”)’.
Menninger's survey makes no further mention of the place of homosexuality in psychiatric nosology until the first edition of Kraepelin's Compendium published in 1883. As noted by Bayer, the scientific study of homosexuality began in the 19th century. During the preceding nine centuries it had been regarded as an ‘abomination’, and denounced by religious authorities and by the law, attracting the penalty of death until the first half of the 19th century.
Prior to 1883 there were, however, indications in other sources that well before the publication of Kraepelin's textbook homosexuality was considered to be a mental disorder. In 1838, Alexander Morison published The physiognomy of mental diseases, with 108 plates ‘of insane patients’. Five of the patients illustrated had been diagnosed as ‘monomania with unnatural propensity’; as noted by Hunter and MacAlpine ‘in a less squeamish age called homosexuality – which gave Morison the opportunity of mentioning this subject in an English psychiatric text’.
According to Morison, ‘monomania with unnatural propensity… is a variety of partial insanity, the principal feature of which is an irresistible propensity to the crime against nature. This offence is so generally abhorred, that in treatises upon law it is termed peccatum illud horribile inter christianos-non-nominandum, the punishment of which is death, formerly rendered more dreadful by burning or burying alive the offender.’
In 1840, John Gideon Millingen published Aphorisms on the treatment and management of the insane. Employing language more robust than that of Morison only two years earlier, Millingen wrote: ‘When religious monomaniacs are addicted to sodomy – a very frequent complication – the case is incurable, more especially if they show much apparent devotion, and constantly talk on religious subjects. The case is still more hopeless, when they select idiots for the indulgence of their vices.’
In the first edition of Kraepelin's textbook, among what were termed ‘states of psychological weakness’ were listed ‘idiocy, cretinism, feeble-mindedness’ and ‘“conträre Sexualempfindung” (i.e., homosexuality)’. Menninger did not translate the German term, which means ‘contrary sexual feeling’.
The phrase ‘contrary sexual feeling’ had been earlier used by Karl Westphal, in 1869; it was also referred to as ‘sexual inversion’. Among those who studied homosexuality were Jean Martin Charcot, Paul Moreau, Richard von Krafft-Ebbing, Magnus Hirschfeld, and Havelock Ellis.
While Hirschfeld and Ellis argued that homosexuality was ‘inborn and therefore natural’, the psychoanalytic study of sexuality pioneered by Freud held that ‘heterosexuality represented the normal end of psychosexual development’. Freud himself wrote that homosexuality ‘cannot be classified as an illness’. The view that homosexuality was ‘abnormal’ prevailed over those that regarded homosexuality as a normal variant of human sexuality, and it was the dominance of such views that maintained homosexuality within psychiatric nosology during most of the 20th century.
Kraepelin's textbook evolved through eight editions; the final edition was published in four volumes during the years 1909–1915. In the successive editions homosexuality was transferred from its initial 1883 listing among ‘states of psychological weakness’ to that of a ‘developmental abnormality’ (2nd edn. 1887), and later to ‘psychopathic conditions (degeneracy insanity)’ (5th edn. 1896). In the seventh and eight editions of Kraepelin's textbook homosexuality was included among ‘mental conditions of constitutional origin’.
The international classification of diseases
During the 1950s the World Health Organization (WHO) invited Ernest Stengel, at that time Professor of Psychiatry at the University of Sheffield, ‘to survey all the currently used classifications, to establish principles of classification and to ponder the prospects and requirements of an international system’. Stengel's report described a variety of national psychiatric classifications, and laid the foundation for the development of an official WHO classification of mental disorders, which became part of the International classification of diseases.
Following the publication of Stengel's report, an international group met annually at seminars held between 1965 and 1972. That group prepared the Glossary of mental disorders and guide to their classification that was issued in 1974 for use in conjunction with the eighth revision of the ICD (Chapter V). The expert group also made recommendations that served as the basis for the revision of Chapter V that was published in 1978, with the ninth revision of the ICD.
The Glossary of mental disorders prepared for use with the eight revision of the ICD had been also published in Australia during September 1972, as noted previously.
This glossary and classification included the category of ‘sexual deviation’ (code 302) among the ‘Neuroses, personality disorders and other non-psychotic mental disorders’. ‘Sexual deviation’ was described as:
Deviant sexuality which is not indicative of more extensive mental disorders, such as schizophrenia or obsessive-compulsive neurosis, are included here. These individuals show persistent anomalies of the sexual impulse manifesting, inter alia, as homosexuality, transvestitism, fetishism, exhibitionism, sadomasochism, bestiality. These deviations provide the main if not the only means of achieving sexual excitement or gratification.
Among the specific diagnoses listed was homosexuality, as well as fetishism, paedophilia, transvestitism, and exhibitionism. There was also a ‘mixed sexual deviation’ diagnosis, together with ‘other’ and ‘unspecified’.
In 1978 the WHO published Mental disorders: Glossary and guide to their classification in accordance with the ninth revision of the International classification of diseases.
This included the category of ‘Sexual deviations and disorders’ (code 302), again within the group of ‘Neurotic disorders, personality disorders and other nonpsychotic mental disorders’.
An expanded glossary entry described ‘sexual deviations and disorders’ as:
Abnormal sexual inclinations or behaviour which are part of a referral problem. The limits and features of normal sexual inclination and behaviour have not been stated absolutely in different societies and cultures but are broadly such as serve approved social and biological purposes. The sexual activity of affected persons is directed primarily either towards people not of the opposite sex, or towards sexual acts not associated with coitus normally, or towards coitus performed under abnormal circumstances. If the anomalous behaviour becomes manifest only during psychosis or other mental illness the condition should be classified under the major illness. It is common for more than one anomaly to occur together in the same individual; in that case the predominant deviation is classified. It is preferable not to include in this category individuals who perform deviant sexual acts when normal sexual outlets are not available to them.
ICD-9 included the specific diagnosis of ‘homosexuality’ (code 302.0) without qualification, and the glossary entry stated that it is the ‘exclusive or predominant sexual attraction for persons of the same sex with or without physical relationship’. The entry also stated ‘Code homosexuality here whether or not it is considered as a mental disorder’. It was further noted that ‘homosexuality’ included ‘lesbianism’, but excluded ‘homosexual paedophilia’.
ICD-10, published in 1992, included ‘Psychological and behavioural disorders associated with sexual development and orientation’ (code F66) among the ‘Disorders of adult personality and behaviour’. It was noted that ‘Sexual orientation alone is not to be regarded as a disorder’.
Included in this group is ‘Sexual maturation disorder’ (code F66.0), in which ‘the individual suffers from uncertainty about his or her gender identity or sexual orientation, which causes anxiety or depression. Most commonly this occurs in adolescents who are not certain whether they are homosexual, heterosexual, or bisexual in orientation, or in individuals who after a period of apparently stable sexual orientation, often within a longstanding relationship, find that their sexual orientation is changing’.
The diagnosis of ‘Egodystonic sexual orientation’ (code F66.1) refers to persons whose ‘gender identity or sexual preference is not in doubt but the individual wishes it were different because of associated psychological and behavioural disorders and may seek treatment in order to change it’. In ‘Sexual relationship disorder’ (code F66.2) ‘the gender identity or sexual preference abnormality is responsible for difficulties in forming or maintaining a relationship with a sexual partner’.
In addition to the codes given above, an additional code may be used to indicate variations of sexual development or orientation that may be problematic for the individual and lead to the disorders coded under F66. The variations listed are heterosexual, homosexual, and bisexual.
DSM and its predecessors
The APA published its first edition of DSM in 1952. The DSM developed from previous American systems of classification, which were initially published during the early part of the 20th century. In 1886, the Association of Medical Superintendents of American Institutions for the Insane (which in 1892 became the American Medico-Psychological Association, and in 1921 was renamed the American Psychiatric Association) had adopted, with several modifications, the classification of the British Medico-Psychological Association.
American classifications used during the 19th century, as reproduced by Menninger in his book, made no specific mention of homosexuality as a diagnostic entity; it is possible that it was encompassed within what were later named personality disorders and sexual deviation. Thus, the classification proposed by Jeliffe and White during the 1920s included a ‘characterological defect group’ among which were ‘anomalies of the sexual instinct’.
In 1935, the Standard classified nomenclature of disease included a number of conditions under the term ‘pathological sexuality’ in the category of ‘psychopathic personality’. Homosexuality was specifically included in that category. During 1951 a Veterans’ Administration classification included ‘sexual deviate’ among ‘pathological personality types’, under the heading of ‘character and behaviour disorders’. Only one year later the first version of the APA's own diagnostic classification – DSM-I – was published.
DSM-I (1952) included the diagnosis of homosexuality under the rubric of ‘sexual deviation’, within the category of ‘sociopathic personality disturbances’. ‘Sexual deviation’ was as a diagnosis that was:
reserved for deviant sexuality which is not symptomatic of more extensive syndromes, such as schizophrenia and obsessional reactions. The term includes most of the cases formerly classed as ‘psychopathic personality with pathologic sexuality’. The diagnosis will specify the type of pathologic behavior, such as homosexuality, transvestism, paedophilia, fetishism and sexual sadism (including rape, sexual assault, mutilation).
In DSM-II (1968), ‘sexual deviation’ (code 302) was included within the ‘major subdivision V’ dealing with ‘personality disorders and certain other non-psychotic mental disorders’. The category of ‘sexual deviation’ was differentiated from ‘personality disorders’ (code 301) and was to be used:
… 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 such as in necrophilia, pedophilia, sexual sadism and fetishism. Even though many find their practices distasteful, they remain unable to substitute normal sexual behaviour for them. This diagnosis is not appropriate for individuals who perform deviant sexual acts because normal sexual objects are not available to them.
The category of ‘sexual deviation’ included homosexuality, fetishism, paedophilia, transvestitism, exhibitionism, voyeurism, sadism, masochism, and ‘other sexual deviations’.
The above description of ‘sexual deviation’ was published through six reprints between 1968 and October 1973. Following the vote of the Board of Trustees of the APA in December 1973, that was changed. It has been argued that, to some extent, the APA decision was influenced by studies of the prevalence of homosexual behaviour published by Kinsey, as well as the research by Evelyn Hooker. Hooker had published comparative studies of homosexual and heterosexual men, which did not support the view that homosexuality per se was pathological.
Reprints of DSM-II, from July 1974 onwards, referred to ‘sexual orientation disturbance [homosexuality]’. A ‘special note – seventh printing’ referred to the vote of the Board of Trustees in December 1973 ‘to eliminate Homosexuality per se as a mental disorder and to substitute therefore a new category titled Sexual Orientation Disturbance’. The note also referred to that decision having been ‘upheld by a substantial majority in a referendum of the voting members of the Association’ in May 1974.
The definition of ‘sexual orientation disturbance [homosexuality]’ in the seventh and subsequent reprints of DSM-II was:
This is for individuals whose sexual interests are directed primarily towards people of the same sex and who are either disturbed by it, 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 with other forms of sexual behavior which are not by themselves psychiatric disorders, are not listed in the nomenclature.
During the preparation of DSM-III, which was published in 1980, there was further debate among American psychiatrists over the inclusion of a diagnosis for homosexuals distressed over their sexual orientation. The edited correspondence in relation to that debate has been published. The final result was that in DSM-III, on Axis I, the diagnostic class of ‘Psychosexual Disorders’ included the category of ‘Ego-dystonic Homosexuality’ among the ‘Other psychosexual disorders’ group. The diagnostic criteria for ‘Ego-dystonic Homosexuality’ were:
A. The individual complains that heterosexual arousal is persistently absent or weak and significantly interferes with initiating or maintaining wanted heterosexual relationships. B. There is a sustained pattern of homosexual arousal that the individual explicitly states has been unwanted and a persistent source of distress.
Before the designation ‘ego-dystonic homosexuality’ was introduced in DSM-III, one of the alternatives considered by the relevant APA committee had been ‘dyshomophilia’. According to Bayer, it was also suggested that a new diagnostic category of ‘heterodysphilia’ be introduced for ‘heterosexuals… distressed by their sexual orientation’.
In DSM-III-R, published in 1987, the group of ‘Psychosexual Disorders’ was renamed ‘Sexual Disorders’. The diagnosis of ‘Ego-dystonic Homosexuality’ was dropped from the classification. There was only one diagnosis listed under the heading ‘Other sexual disorders’, namely ‘Sexual Disorder Not Otherwise Specified’ (code 302.90). It was described in the following terms:
Sexual Disorders that are not classifiable in any of the previous categories. In rare instances, this category may be used concurrently with one of the specific diagnoses when both are necessary to explain or describe the clinical disturbance. Examples: (1) marked feelings of inadequacy concerning body habitus, size and shape of sex organs, sexual performance, or other traits related to self-imposed standards of masculinity or femininity (2) distress about a pattern of repeated sexual conquests or other forms of nonparaphilic sexual addiction, involving a succession of people who exist only as things to be used (3) persistent and marked distress about one's sexual orientation.
DSM-IV, published in 1994, once more changed the name of the major grouping that had contained sexual disorders into ‘Sexual and Gender Identity Disorders’. With reference to the diagnosis of ‘Sexual Disorder Not Otherwise Specified’, it was stated that ‘it is important to note that notions of deviance, standards of sexual performance, and concepts of appropriate gender role can vary from culture to culture’.
The diagnosis of ‘Sexual Disorder Not Otherwise Specified’ (code 302.9) was retained in DSM-IV, with the following description:
This category is included for coding a sexual disturbance that does not meet the criteria for any specific Sexual Disorder and is neither a Sexual Dysfunction nor a Paraphilia. Examples include: 1 Marked feelings of inadequacy concerning sexual performance, or other traits related to self-imposed standards of masculinity or femininity 2 Distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used 3 Persistent and marked distress about sexual orientation.
The current edition, DSM-IV-TR (Text Revision), published in 2000, retained the category of ‘Sexual and Gender Identity Disorders’. Similarly, the diagnosis of ‘Sexual Disorder Not Otherwise Specified’ (code 302.9) was retained, with the clinical description that is identical with DSM-IV.
Other psychiatric classifications
The International classification of diseases, which is issued by the World Health Organization, is used worldwide, and for that reason the ICD, as well as the various editions of DSM – which have been translated into some 20 languages – have superseded national classifications that were in use prior to 1974. Thus, although most Australian psychiatrists are more familiar with DSM than with ICD-10, it is the latter classification that is used for the purpose of compiling statistical data that is subsequently collated and forwarded to the WHO, which collects and publishes such information.
As noted earlier, homosexuality as a distinct disease category was removed from DSM in 1973, and in 1978 the ICD-9 noted that it is not necessarily to be ‘considered as a mental disorder’.
In Norway, homosexuality continued to be considered a mental disorder until 1979.
A 1998 article published by the American Psychological Association stated that ‘psychiatric organizations in many countries, such as India, Poland, Brazil and Belarus, still label homosexuality as a mental disturbance, according to data compiled by the American Psychiatric Association a few years ago’.
In China, the third edition of the Chinese classification of mental disorders (CCMD), published in April 2001 to replace the previous edition issued in 1989, was described as having stated that ‘homosexuals are not patients suffering from mental diseases’. At the same time, homosexuality is retained in the CCMD, albeit it is emphasized that only those homosexuals who express distress are classified as having a mental disorder. (Interestingly, because aetiological factors can be important for treatment decisions and prognosis, the CCMD-3 approach to classification has been described as both ‘aetiologic and symptomatologic’, in contrast to the essentially phenomenological approach to diagnosis in the ICD and, particularly so, the DSM.)
According to the website of the International Lesbian and Gay Association (accessed 18 July 2003), the only country in which homosexuality remains ‘officially categorized as an illness’ is Belorus.
Summary
This brief survey has reviewed the changed approach over the past 30 years in the psychiatric nosology to the classification of homosexuality. Initially listed as a mental disorder in the official classifications of both the American Psychiatric Association (the DSM system) and the World Health Organization (in the ICD), it is no longer considered to be so.
The deletion of homosexuality from the psychiatric nosology was the result of a concatenation of social forces, including political pressure from homosexual organizations, involvement of the wider human rights movement, and epidemiological data that questioned the ‘scientific’ basis for considering homosexuality simpliciter a mental disorder.
At the same time, the current version of the ICD appears to show a somewhat ambivalent attitude, in that it has retained homosexuality within its classification albeit with the instruction ‘code homosexuality here whether or not it is considered as a mental disorder’. It can be argued, given that – with one notable exception – homosexuality is not considered a mental disorder in any member country of the World Health Organization, it should no longer be listed in the International classification of diseases.