Deleting Homosexuality From the DSM: 50th Anniversary

“The normal outcome of male adolescent development is heterosexuality,” a child psychiatry professor told other trainees and I in 1989, during our residency education.

“What if you’re gay?” a fellow trainee asked.

The professor frowned. “The normal outcome of male adolescent development is heterosexuality,” he repeated with annoyance.

I was stunned because 16 years earlier, in 1973, the Board of Trustees of the American Psychiatric Association (APA) had, in fact, deleted homosexuality as a psychiatric condition from the Diagnostic and Statistical Manual, or DSM, the book that dictates what constitutes a mental health disorder.

“Just because homosexuality is no longer a disorder,” the professor continued, “doesn’t mean it isn’t a symptom.” To him, it was still pathological.

“Why is it so bad?” my fellow resident inquired.

“Homosexuality is a disease because it has an increased risk of morbidity and mortality,” due to AIDS. “Anything with an increased risk of morbidity and mortality is a disease.”

“But isn’t that partly because it has been seen as a disease? Because it is stigmatized?” the trainee asked.

“Mothers would not want their children to be born that way,” he said. “Why would you want your child to differ from others in a way that will induce ridicule?”

“What about left-handedness then?” the trainee pursued. “Shouldn’t that then be a disorder, too?”

The professor became irate. “Why are you being so recalcitrant and resistant?” he demanded. His voice rose. The resident decided not to push,

I have recently been thinking about this interchange for two reasons. First, over the past year, states are now passing record numbers of anti-LGBTQ+ bills, along with anti-abortion laws.

Secondly, this year marks the 50th anniversary of the APA’s Board of Trustees historic decision on December 15, 1973.

This anniversary marks an important moment for reflecting on how far we have come as a nation, but also how far we still have to go, and for assessing what insights and lessons we might learn about progress in these battles and overcoming obstacles.

Despite support on certain issues from the Pope and others, in 2023, state legislators introduced over 520 anti-LGBTQ+ bills, and enacted over 70. Large numbers of congregations are leaving the United Methodist Church and other denominations over LGBTQ+ issues, the Supreme Court allowed a website designer to refuse gay couples as clients, and hate crimes against LGBTQ+ individuals continue to rise. The spread of such anti-LGBTQ+ policies increasingly frustrates and depresses many members of the LGBTQ+ community.

The example of the APA is thus important, both to inspire us that change is possible and to remind us of barriers that can arise and ways of surmounting these.

The APA’s decision, occurring just four years after the Stonewall Riot, required courageous, concerted efforts by allies, both LGBTQ+ and straight. Since 1918, the APA had classified all homosexuality as a “disorder,” justifying so-called conversion therapy and discrimination in countless areas of life, preventing LGBTQ+ individuals from working in schools, the military, and innumerable jobs.

Slowly, scientific data helped begin to alter attitudes. In 1948, The Kinsey Report found high rates of LGBTQ+ activity among Americans. In the 1950s, the psychiatrist Evelyn Hooker began to meet with and publish studies about gay men who were not patients seeking psychiatric treatment and were instead well-adapted and satisfied with their sexual orientation.

Still, despite these scientific facts, psychiatry continued to categorize homosexuality as a disease.

Hence, in 1971, gay activists snuck into the annual APA convention and directly confronted psychiatrists who supported this classification. Only after these activists threatened to confront speakers again at the following year’s annual convention did the APA agree to invite gays and lesbians to speak on a panel.

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In 1972, this panel included, for the first time at an APA meeting, a self-identified gay psychiatrist. Yet he appeared only as “Dr. Harry Anonymous,” and wore a crude cartoon-like paper bag mask over his head to disguise his identity. Today, this protective measure sounds absurd, but it reveals the depth of the discrimination and fear at the time. Only several years later did Dr. Anonymous publicly reveal his name—John Freyer.

The following year, in 1973, APA Trustees cast their historic vote. Heralded on the front page of the New York Times and major newspapers, this decision aided millions of people throughout the U.S. and abroad, leading state governments to eliminate sodomy laws and prompting other professional and religious organizations to end discriminatory policies.

Nonetheless, other psychiatrists continued to fight the Trustee’s decision, arguing that it occurred only under pressure from gay rights groups. Opponents demanded a referendum on the entire APA. Such a vote was unprecedented, but the Trustees agreed, and the membership referendum passed, in 1974, by 58 percent, a decisive majority.

Some then demanded an investigation into the conduct of the referendum—asking whether a flyer sent to members and paid for by a gay organization had been “unethical.” An APA committee determined that the sponsorship should have been clearer, but was not unethical.

Yet, as I witnessed during my own training, homophobia persisted in psychiatry into the 80s and 90s. Gradually, through these years, additional LGBTQ psychiatrists spoke out and made themselves known, at times risking their careers. Eventually, resistance abated.

In responding to current political threats against the rights of LGBTQ+ Americans, the APA’s decision offers critical lessons.

First, it used scientific data, demonstrating that the supposed harms of heterosexuality were largely illusory.

Secondly, it took courageous individuals to step forward to engage opponents and tell their stories in panel discussions before wary, if not hostile, audiences.

Thirdly, it required hard work and allies, including researchers and APA leaders from both inside and outside the LGBTQ community.

Fourthly, this change took time, occurred slowly, and met resistance. In today’s battles, anticipating a realistic timeline can help set appropriate expectations.

Fifthly, it took brave activism and non-violent protests, following the examples of peaceful marches for civil rights.

When other psychiatric trainees and I heard our professor’s homophobic comments, we were unsure how to respond. Yet, history has shown the problems and errors of psychiatrists' homophobic arguments.

Especially given our nation’s current challenges, we should remember and celebrate the APA’s decision and how far we have come since then, and recall the courageous psychiatrists and others who fought, spoke out, and ultimately succeeded. Though restrictive policies are increasing in many realms, progress, even if it meets resistance and takes time, can ultimately succeed.