The DSM, the Diagnostic and Statistical Manual of Mental Disorders (used primarily in the United States), has had a rocky past, to say the least. The thing about deciding what is and is not a mental disorder is that it can quickly become dangerously subjective, and deviant can become disordered. The DSM works to diagnose issues people deal with that cause them distress in their everyday life. However, As anyone who has studied the social model of disability can tell you, distress is not always caused from an internal source but rather from an external (societal) source. That hiccup, combined with personal and social opinion, can create some dangerous diagnoses. Many people have heard of diagnosing women with hysteria whether something was actually wrong, or whether their husbands or family members had simply had enough of them.1 Less well known is the time period in which there was an official psychiatric diagnosis, before the DSM, for Black enslaved people who escaped from their enslavers.2 The DSM has always been reflective of the time, and there are many criticisms that people can and do make of it. One of our most historically recent battles in the DSM has been the many phases of pathologizing queerness in all its forms: romantic, having to do with gender, and sexual.
Portraits of a woman with hysteria. Source: https://commons.wikimedia.org/wiki/File:Hysteria.jpg
Queerness is not new. Though some might claim that many of the identities people are open about today did not exist in the past, this is not true. Sometimes they were more covert, sometimes they were less so, but these identities were and are real. However, existence does not always predicate acceptance. In America, when homosexuality became impossible to ignore, the general populace labeled it deviant and, soon thereafter, a mental illness. It is important here to note that the label of mental illness itself should not be seen as bad or something to be ashamed of. However, it does hold the implication that something is not as it should be, and it opens the door for others to try to “treat” the perceived problem. Homosexuality is not an illness or something that inherently causes distress, and the attempts to “treat” it are simply poorly disguised intolerance wielding dangerous power. Similarly, being transgender or asexual are not disorders or something to be fixed.
Participants of a staged men's wedding on January 15, 1921 in a private apartment at 6 Simeonovskaya Street. Police raided the event, and all 95 guests went to the jail for an inquiry.
Homosexuality has been most famously treated as diagnosably pathological, so we have a considerable amount of historiography regarding that. Homosexuality was a part of the DSM from its first edition in 1952 under “Sociopathic Personality Disturbance,” and then in 1968 in the DSM-II it was classified as a sexual deviance, lumped together with pedophilia.3 Generally for DSM diagnoses, there is a diagnostic criteria for there to be some indication of significant distress for the person. In this case, that idea was used improperly. Psychologists claimed that being homosexual was causing significant distress to their patient, resulting in anxiety and depression, when the truth is that a discriminatory and hateful society was causing these things - not the act of being homosexual in itself. This means that when gay people were being “treated,” the actual issue was never addressed. They were instead being conditioned to suppress their gayness, rather than there being a societal push for acceptance.
Today, conversion therapies are generally condemned. This is for good reason, as many gay people suffer worsened mental health after such therapies, sometimes to the point of attempting suicide.4, 5 Our modern idea of what conversion therapy is, may be a very sanitized one - those who are not familiar might think of it as intense one on one therapy. This is not the case, especially in the height of anti-gay psychiatry. Treatment avenues included talk therapy and reeducation therapy, multiple angles of aversion therapy (including electroshock), drugs, castration, and lobotomies.6, 7 Articles from the time on “treating” homosexuality allude clearly to the idea that being homosexual is wrong and being heterosexual is both the norm and healthy.8 They “allude” to it, not because they don’t want to say it outright, but because they don’t need to. For them it is just a fact, and about as useful in a scientific paper as clarifying that the grass was green. Articles are available detailing the experiments with electroshock, and what set-ups were most effective - including one that would administer up to 15 shocks within 125 seconds for each slide shown during aversion therapy.9,10 For those doing the math at home, that’s about one shock every eight seconds. We know now that these efforts are in vain, and a person’s sexual orientation is not changed so easily, but there are still those who support conversion therapy.
These were the treatment options for being diagnosed as homosexual, but this is not where the ramifications ended. Employers could get psychologists to come in and try to determine which of their employees might be homosexual.11 In many states this information would be enough to fire someone.12 There may be people who read about the conversion therapies that were offered and think that while they were perhaps drastic, people went through them of their own free will. Even ignoring the fact that societal and familial pressures can cloud consent considerably, this is still not always true. There were many states that held homosexuality on the same level as rape and child molestation, and could mandate that anyone found to be homosexual could be forcibly institutionalized and held until they were “cured”.13 The diagnosis was not only used as a pretext in psychological circles to try to eradicate homosexuality in those who were “distressed” - it was used for social control.14
Image from the Operative Notes on [name redacted]. In this autopsy brain section, holes in either side of the central brain are from prefrontal lobotomy. Source: Grant, Francis C., M.D., “Autopsy photo of brain post prefrontal lobotomy.,” The College of Physicians of Philadelphia Digital Library, accessed June 22, 2021, https://www.cppdigitallibrary.org/items/show/4396.
Luckily, due to lobbying, protests, and some scientific articles and studies, homosexuality was removed from the DSM-II in 1973.15 A win! Right? Well, it’s more complicated than that. Sure, it was removed - and replaced by “sexual orientation disturbance,” and then “ego-dystonic homosexuality”.16 In the DSM-III-R it was relabeled as “sexual disorder not otherwise specified”.17 What this means is that, while homosexuality itself was no longer listed as a pathological disorder, distress regarding being homosexual was. This was attributed to being gay, rather than being in a society configured against you. In short, this replacement diagnosis gave psychologists a workaround to still “treat” homosexuality and use conversion therapy.
In the DSM-III, which is usually touted as the edition that removed homosexuality as a diagnosis, other diagnoses rose to take its place. Instead of removing the pathology around sexuality and gender, the DSM broadened the scope. More paraphilias were added, along with a section on psychosexual dysfunctions, and, of course, one for gender identity disorders.18 This was not the first pathologization of transgender and intersex people. Transvestism was in the first edition of the DSM, and the wording of the classification simply changed over time with the occasional addition of more categories.19 However, with the apparent success in removing homosexuality, a new focus was put on gender. Gender identity disorder remained in the DSM until the DSM-V, when it became listed as Gender Dysphoria.20 The idea was to shift away from seeing being transgender as the issue, and instead address the distress that being transgender can cause. If this sounds familiar, then you’ve been paying attention. At the end of the day, diagnoses like these still create a pathology surrounding a characteristic of who you are, rather than focusing on what the actual problem is.
Tying being transgender to a diagnosis has a few specific impacts. First, it attaches the stigma of being mentally ill to being transgender. We know that the stigma against mentally ill people is dangerous by itself, but when combined with the already salient stigma against being transgender, that danger rises.21 Secondly, it allows the medical profession to uphold traditional binaries and gendered standards of behavior.22 Some of the diagnostic criteria for Gender Dysphoria include a desire to be the other gender, to dress as is typical of the other gender, a desire to have the anatomy of the opposite sex, and distress in social situations as a result of this, all for at least a six month period.23 This is clearly a very narrow definition of what it means to be transgender. You must want to fully transition completely to the “opposite” sex in order to qualify for this diagnosis, and have the stereotypical transgender story (i.e. knowing your whole life that you were born in the wrong body).
Reality is much less clearly defined than that. Gender is not either/or, as this diagnosis would have you believe. But if the existence of the diagnosis and being labeled with it is bad, then why does it matter? That brings us to the third point - if you want any major gender affirming body modification, you need a diagnosis for it to be covered by insurance.24 The assessment for this can take months or even years, and can include both a medical assessment and an invasive social assessment.25 In order to get affirming surgery for their own body, people do not only have to be psychologically assessed to make sure they are mentally stable enough to make a permanent decision like this (which is its own can of worms) - they must also submit to being diagnosed with a mental illness.
For those keeping track, the DSM has pathologized who you are sexually or romantically attracted to and your gender. To round things out, they also pathologize whether you have sexual attraction at all. Being asexual is often seen as an identity that flies under the radar, because it is focused on not doing something and people think this is easily kept to oneself. However, in a society obsessed with sex, just because being asexual flies under the radar to allosexual people (people who experience sexual attraction) does not mean it doesn’t face troubles. When sex began to be seen as a positive and necessary aspect of a healthy relationship, any variation from that acceptable parameter of sexual activity was seen as a pathology.26 It began as “Inhibited Sexual Desire,” later becoming “Hypoactive Sexual Desire Disorder” (HSSD).27 In the DSM-IV the language surrounding this left room for a diagnosis to be made even if the individual in question did not experience distress, but this changed in the DSM-V.28
This stack of all five DSM editions showcases the ever increasing pathologizing of human behaviour. The pathologization of queerness directly contributed to this increase.
Having a low sex drive, especially if it is a new development, can be a side effect of medications or a symptom of some other condition. However, it is not in and of itself something negative. Not being sexually attracted to people does no harm, and would cause limited distress in a society that did not center sex in all romantic relationships. Experiencing distress over your sex drive or sexual attraction does not mean that there is something wrong with that part of you, just like how experiencing distress over your romantic orientation does not mean that having that orientation is the thing that is wrong.29 In good news surrounding this, the DSM-V did specify that identifying as asexual is nonclinical and not the same as a pathological disorder.30 However, it cannot be ignored that this means there is still a diagnosis that hinges entirely on whether or not someone wants to have sex with people. Someone who has never heard of asexuality and thinks there is something wrong with them may go to be “treated” rather than being given the opportunity to accept themself and understand that there is nothing inherently wrong with what they are experiencing. Given this, it is important to remain critical of the DSM’s diagnoses.
Riddled with issues as the DSM’s history may be, it might seem as though things are moving in a positive direction overall for the LGBTQ+ community. Homosexuality is no longer a diagnosis, pathologizing being transgender point blank is no longer the go-to, and asexuality is recognized as something nonpathological. All of these things are true, and they are positive. However, it is important to keep in mind that the only reason any of these changes took place was via lobbying and pressure, mainly from the affected groups. The American Psychiatric Association did not change these diagnoses out of the goodness of their hearts, they changed them because they were called out on the harm being done and the unscientific nature of the diagnoses. Even now, those fights continue. There are transgender rights groups who are still fighting to end the medicalization of transgender bodies and experiences.31 Dangerous research is being done to find a way to purportedly safely and effectively change a person’s sexual orientation, via potential avenues such as drugs, deep brain stimulation, or germline genetic engineering, which could be catastrophic for the community as a whole.32 Progress does not mean the fight is over, or that we can lower our guard. As long as society sees who we are as deviant, they will attempt to pathologize us to give justification to their intolerance and hatred.
1- Riggs, Damien W., Ruth Pearce, Carla A. Pfeffer, Sally Hines, Francis White, and Elisabetta Ruspini. “Transnormativity in the Psy Disciplines: Constructing Pathology in the Diagnostic and Statistical Manual of Mental Disorders and Standards of Care.” American Psychologist 74, no. 8 (2019): 912-924.
2- DiAngelo, Robin. “What Does it Mean to Be White: Developing White Racial Literacy.” Counterpoints 398, (2012): 79-86.
3- Bray, Sean. “Gender Dysphoria, Body Dysmorphia, and the Problematic of Body Modification.” The Journal of Speculative Philosophy 29, no. 3 (2015): 424-436.
4- Sobocinski, Michael R. “Ethical Principles in the Counseling of Gay and Lesbian Adolescents: Issues of Autonomy, Competence, and Confidentiality.” Professional Psychology: Research and Practice 21, no. 4 (1990): 240-247.
5- Wyatt-Nichol, Heather. “Sexual Orientation and Mental Health: Incremental Progression or Radical Change?” Journal of Health and Human Services Administration 37, no. 2 (2014): 225-241.
7- Herek, Gregory M. “Sexual Orientation Differences as Deficits: Science and Stigma in the History of American Psychology.” Perspectives on Psychological Science 5, no. 6 (2010): 693-699.
8- Mintz, Elizabeth E. “Overt Male Homosexuals in Combined Group and Individual Treatment.” Journal of Consulting Psychology 30, no. 3 (1966): 193-198.
9- Haynes, Stephen N. “Learning Theory and the Treatment of Homosexuality.” Psychotherapy: Theory, Research & Practice 7, no. 2 (1970): 91-94.
10- Callahan, Edward J., and Harold Leitenberg. “Aversion Therapy for Sexual Deviation: Contingent Shock and Covert Sensitization.” Journal of Abnormal Psychology 81, no. 1 (1973): 60-73.
11- Marston, Albert R. “Reflections After a Confrontation with the Gay Liberation Front.” Professional Psychology 5, no. 4 (1974): 380-384.
12- Herek (2010)
14- Brown, Phil. “Naming and Framing: The Social Construction of Diagnosis and Illness.” Journal of Health and Social Behavior Extra Issue: Forty Years of Medical Sociology: The State of the Art and Directions for the Future, (1995): 34-52.
15- Weinstein, Deborah. “Sexuality, Therapeutic Culture, and Family Ties in the United States After 1973.” History of Psychology 21, no. 3 (2018): 273-289.
17- Wyatt-Nichol (2014)
18- Lewis, Abram J. “‘We Are Certain of Our Own Insanity’: Antipsychiatry and the Gay Liberation Movement, 1968-1980.” Journal of the History of Sexuality 25, no. 1 (2016): 83-113.
19- Riggs et. al (2019)
21- Tompkins, Tanya L., Chloe N. Shields, Kimberly M. Hillman, and Kadi White. “Reducing Stigma Toward the Transgender Community: An Evaluation of a Humanizing and Perspective-Taking Intervention.” Psychology of Sexual Orientation and Gender Diversity 2, no. 1 (2015): 34-42.
22- Ault, Amber, and Stephanie Brzuzy. “Removing Gender Identity Disorder from the ‘Diagnosticand Statistical Manual of Mental Disorders’: A Call for Action.” Social Work 54, no. 2 (2009): 187-189.
23- Abel, Brendan S. “Hormone Treatment of Children and Adolescents with Gender Dysphoria: An Ethical Analysis.” The Hastings Center Report 44, no. 5 (2014): S23-S27.
24- Davis, Georgiann, Jodie M. Dewey, and Erin L. Murphy. “Giving Sex: Deconstructing Intersex and Trans Medicalization Practices.” Gender and Society 30, no. 3 (2016): 490-514.
26- Gupta, Kristina. “Compulsory Sexuality: Evaluating an Emerging Concept.” Signs 41, no. 1 (2015): 131-154.
27- Emens, Elizabeth F. “Compulsory Sexuality.” Stanford Law Review 66, no. 2 (2014): 303-386.
29- Chasin, CJ DeLuzio. “Reconsidering Asecuality and Its Radical Potential.” Feminist Studies 39, no. 2 (2013): 405-426.
30- Emens (2014)
31- Riggs et. al (2019)
32- Aas, Sean, and Candice Delmas. “The Ethics of Sexual Reorientation: What Should Clinicians and Researchers Do?” Journal of Medical Ethics 42, no. 6 (2016): 340-347.