41 years ago this month, homosexuality ceased to be a mental illness. Amid growing opposition from gay activists, and dissent within its own ranks, the American Psychiatric Association was begrudgingly forced to expunge homosexuality from the DSM-II. Paradigmatic of the social nature of psychiatric diagnosis, the purging of homosexuality from the psychiatric nomenclature highlights the instability of the psychiatric sign: once signifying disease and perversion, homosexuality came to be recognized by the establishment as a normal variant of human sexuality. The ‘coming out’ of homosexuality from the DSM-II allows us to reflect on the following: (1) change in the concept of mental disorder is slow; (2) diagnosis-making is a social act; (3) the construct of illness and disorder, ‘mental’ or otherwise is a social one; (4) the construct of illness has social consequences; and (5) shifts in the concept and nature of disorder reflect wider social, political and economic forces more than scientific advancement.
The slow demise of homosexuality as disease
Although the removal of homosexuality from the DSM is often heralded as a radical and rapid sea-change in how sexual orientation was viewed, the reality is more sobering. Homosexuality was not actually removed from the diagnostic nomenclature of the revised DSM-II. Instead, it was shifted into parentheses of the new diagnosis of sexual orientation disturbance. The change in diagnosis was supposed to create as little disruption to psychiatric practice as possible, and the position statement about this change notes that ‘hardly anyone can disagree’ that ‘Modern methods of treatment enable a significant proportion of homosexuals who wish to change their sexual orientation to do so.’ While noting that homosexuality does not fulfill criteria for a psychiatric disorder, the same position statement goes on to note “no doubt, homosexual activists will claim that psychiatry has at last recognized that homosexuality is as “normal” as heterosexuality. They will be wrong.” The same year, 1973, a number of publications discuss diagnostic and treatment aspects of homosexuality, including aversive conditioning, use of electric shocks and even lobotomy. Further, the diagnosis of ‘sexual orientation disturbance’, later to become ‘ego-dystonic sexual orientation’ was only applicable to same-sex attraction. The implicit assumption is that it is not possible for those with opposite-sex attraction to feel negatively about this. Whether true or not, the assumption goes unchallenged.
It was not until 1987 that homosexuality completely disappeared from the DSM, but the concept of ego-dystonic sexual orientation persists in the World Health Organization’s International Classification of Diseases. More recently we have seen a similar shift with transgendered individuals. It is interesting to note as homosexuality came out of the DSM, transsexualism was making its debut. This transformed into gender identity disorder, and most recently, to gender dysphoria in DSM-5.
Diagnosis making as a social act
The ritual of making a diagnosis is a performance that occurs within the social space. Making a diagnosis, as Arthur Kleinman has pointed out, is a semiotic act. It involves transforming experiences into ‘symptoms’ and ‘signs’ that signify disease or disorder. These diagnoses confer social meaning not just for those labeled so, but also come to signify what it means to be without disease or disorder. Taking the example of homosexuality, its appearance as a social and medical concept at the end of the 19th century, also coincided with the invention of heterosexuality. Psychiatry was thus instrumental in creating and polarizing sexual identities in a way that persists today despite the demedicalization of sexual orientation. Diagnoses thus convey not only information about the treatability and prognosis of particular states, they also create identities, confer recognition, or conversely erode personhood, and our ability to construct meaningful narratives beyond the medico-psychological discourse. Schizophrenia is not just a diagnosis, but signifies a particular identity that shifts with cultural convenience – once capturing the attractive delicate white woman who has been trampled by society, to the imposing, aggressive black man who poses a threat to social order.
The social construction of ‘mental illness’
Whilst the concept of the sodomite dates back to biblical times, the concept of the homosexual did not emerge until the late 19th century. At once, sexual behaviors were transformed into a diagnosis and a sexual identity. That this transformation occurred when it did, is no accident, but accompanied the tacit acceptance that sex was not simply procreative but pleasurable, the increasing prominence of the physician-as-expert, and the need for physicians to ‘prescribe a healthy sexuality.’ Similarly, the demise of homosexuality as disorder came at a time when pleasure could be celebrated over duty, with the rise of anti-authoritarianism, and psychiatry’s grand venture into solving the social ills of our time. Whether homosexuality or psychosis have some biological basis, does not detract from the role of psychiatrists as agents of social control. For example, in 1972, just a year before the DSM expunged homosexuality, John Feighner and colleagues proposed diagnostic criteria for various mental disorders to be used in research. Among the ’14 psychiatric illnesses’ was homosexuality defined so:
- This diagnosis is made when there are persistent homosexual experiences beyond 18 (equivalent of Kinsey 3 to 6)
- Patients who fulfill the criteria for transsexualism are excluded.
- Patients who perform homosexual activity only when incarcerated for a period of at least one year without access to members of the opposite sex are excluded.
Here we see a psychiatric definition of homosexuality that is operational and wholly arbitrary, with the long-term incarcerated given a free ticket to buggery, unencumbered by psychiatric labeling. All medical diagnoses, psychiatric or otherwise are socially constructed, but psychiatric illnesses also confer identities – wanted or unwanted – that other medical illnesses seldom do.
The social consequences of illness
Illnesses can be stigmatizing, and although such diseases including leprosy, TB, cancer, and AIDS have carried stigma for sufferers at some point in history, they rarely alter the experience of the self in the way that psychiatric diagnoses do. The pathologization of homosexuality convinced some individuals that they were sick, and that in itself may have made them (feel) sick! The removal of homosexuality from the psychiatric canon has undoubtedly facilitated the rights of those who identify as lesbian, gay, or bisexual. Adoption rights, same-sex marriage, the repeal of Don’t Ask Don’t Tell, would never have occurred if homosexuality continued to be seen as the developmental end-point of deep psychopathology. In the same way, diagnoses of mental illness, confer individuals with a sense of otherness, that they are somehow different than other people, perhaps less important, less deserving, or of less worth. With a diagnosis of schizophrenia, if internalized, comes the erosion of personhood, lowered self-esteem, shattered dreams, and a sense of disenchantment. The psychiatrist Richard Warner has even suggested that those who reject the diagnosis of severe mental illness may have better outcomes as they retain the right to construct their own narrative of personhood and define what really matters for them. Despite public education campaigns (or perhaps because of them), the stigma of mental illness is as enduring as it was 50 years ago.
The rise of illness: scientific advancement or commercial cash cow?
As discussed above, the removal of homosexuality from the DSM was the result of sociopolitical forces, and not a reflection of scientific advancement. Even within psychiatry, the mass proliferation of psychiatric diagnoses is viewed as something commercial. Up until the 1970s psychiatric diagnoses were not necessary to treat individuals with a wide range of problems, and psychiatrists had little competition from other mental health professionals. With the growth of clinical psychology and other mental health professions who could provide psychotherapy more cheaply, psychiatrists needed to maintain their moral authority over the mental life that had come under their purview. What psychiatrists, as physicians, could do that others could not was make diagnoses. Thus the medical profession created new diagnoses for the range of mental life that psychiatrists were already seeing in their offices; and these became the signifiers that these patients had a medical illness that required treatment. The growth of psychopharmacology allowed the boundaries for these new diagnoses to expand, creating new markets, not only for the pharmaceutical industry but also for the mental health field. There was no problem too small to warrant pharmaceutical relief.
But what of the social and political forces that facilitated the growth of mental illness? At the same time that homosexuality was losing its status as mental disorder, the US was in the midst of a deepening economic crisis. By 1980, the year of publication of DSM-III, a new republican government headed by Ronald Regan entered the White House. Rather than draw attention to the psychiatric casualties that would amass under neoliberal policies, it became convenient to locate mental illness within the self – in brain, cell, and molecule – rather than as a product of community, society, and state. It is for this reason that psychiatrist Joanna Moncrieff has suggested that a “marriage of convenience” exists between biopsychiatry and the politics of neoliberalism. A biological model that was gaining ascendance was fortified by the political expedience of supporting a paradigm of psychic discontent that obfuscated the wider social, economic and political forces at play. In the same way the removal of homosexuality from the DSM was not the result of scientific advancement but political will, the solidifying of disease status of minor psychiatric diagnoses and their biological basis are more the result of these same forces than scientific triumphalism.
- Disturbance: Proposed Change in DSM-II, 6th Printing Page 44 Position Statement. http://dsm.psychiatryonline.org/data/PDFS/dsm-ii_homosexuality_revision.pdf (accessed 12/24/13)
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The Psychopathology of American Life: A British physician explores how the concept of mental disorder has vastly expanded over the past century, reporting from the front lines of American psychiatry.