History of Homosexuality in Diagnostic Manuals

Scholars originally thought sexual orientation was a decision, which first led to the placement of homosexuality in DSM-I and DSM-II. Theories of homosexuality throughout history and culture generally fall into pathology or immaturity categories. Pathology theories regard adult homosexuality as a disease, a condition deviating from ?normal' heterosexual development. The presence of atypical gender behavior or feelings are symptoms of the disease or disorder to which mental health professionals need to attend. These theories hold that some internal defect or external pathological agent causes homosexuality, and such events can occur before or after birth. Theories of pathology tend to view homosexuality as a sign of a defect, or morally bad, with the belief homosexuality is socially evil. Theories of immaturity regard expressions of homosexual feelings or behavior at a young age as a normal step, often identified in the ?experimentation stage' toward the development of adult heterosexuality. Ideally, homosexuality is a passing phase an individual outgrows. However, as a developmental arrests, adult homosexuality is equated with stunted growth.

For much of Western history the meanings of same-sex behaviors viewed by religions deemed homosexuality to be morally bad. However, as 19th century Western culture shifted power from religious to secular authority, same-sex behaviors, like ?sins' received increased spherical scrutiny from: law, medicine, psychiatry, and human rights activism.

Richard von Krafft-Ebing, a German psychiatrist, offered an early theory of pathology, describing homosexuality as a ?degenerative' disorder. Krafft-Ebing believed although one might be born with a homosexual predisposition, such inclinations should be considered a congenital disease. Krafft-Ebing was influential in disseminating among the medical and scientific communities both the term ?homosexual' as well as its author's view of homosexuality as a psychiatric disorder. This theory influenced many of pathological assumptions regarding human sexuality in psychiatric diagnostic manuals of the mid-20th century.

Freud believed everyone is born with bisexual tendencies; expressions of homosexuality could be a normal phase of heterosexual development. Freud argued homosexuality could not be a degenerative condition as Krafft-Ebing maintained because, among other reasons, it was found in people whose efficiency is unimpaired, and who are indeed distinguished by specially high intellectual development and ethical culture. Freud saw expressions of adult homosexual behavior as caused by ?arrested psychosexual development,' a theory of immaturity.

Most psychoanalysts of the next generation came to view homosexuality as pathological. They offered a revised understanding of homosexuality as well as psychoanalytic ?cures.' In the mid-20th century, American psychiatry was greatly influenced at the time by these psychoanalytic perspectives. Consequently, in 1952, when APA published the first edition of the Diagnostic and Statistical Manual (DSM-I), it listed all the conditions psychiatrists then considered to be a mental disorder. DSM-I classified homosexuality as a sociopathic personality disturbance. In DSM-II, published in 1968, homosexuality was reclassified as a sexual deviation.

Kinsey's research found homosexuality to be more common in the general population than was generally believed, and found in nature. Researchers and activists started to reject the pathological model as a major contributor to the stigma associated with homosexuality. It was this latter group that brought modern sex research theories to the attention of APA. In the wake of the 1969 Stonewall riots in New York City, gay and lesbian activists, believing psychiatric theories to be a major contributor to anti-homosexual social stigma, disrupted the 1970 and 1971 annual meetings of the APA.

The APA started to question what constitutes a mental disorder. They reviewed the characteristics of the various mental disorders and concluded that, with the exception of homosexuality and perhaps some of the other ?sexual deviations', they all regularly caused subjective distress or were associated with generalized impairment in social effectiveness of functioning, (p. 211). Having arrived at this novel definition of mental disorder, the Nomenclature Committee agreed that homosexuality per se was not one. As a result, in December 1973, APA's Board of Trustees (BOT) voted to remove homosexuality from the DSM.

Psychiatrists did not vote, as is often reported in the popular press, on whether homosexuality should remain a diagnosis. As a result, opponents of the 1973 removal have repeatedly tried to discredit the outcome by declaring, science cannot be decided by a vote. The events of 1973 did not immediately end psychiatry's pathology of some presentations of homosexuality. For in homosexuality's place, the DSM-II contained a new diagnosis: Sexual Orientation Disturbance (SOD). SOD regarded homosexuality as an illness if an individual with same-sex attractions, which caused them distress and wanted to change. The new diagnosis legitimized the practice of sexual conversion therapies, even if homosexuality per se was no longer considered an illness. SOD was later replaced in DSM-III by a new category called Ego Dystonic Homosexuality (EDH). However, it was obvious to psychiatrists more than a decade later that the inclusion first of SOD, and later EDH, was the result of earlier political compromises, and neither diagnosis met the definition of a disorder. As a result, ego-dystonic homosexuality was removed from the next revision, DSM-III-R, in 1987. In so doing, the APA implicitly accepted a normal variant view of homosexuality in a way that had not been possible fourteen years earlier. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695779/

In 1948, WHO published ICD-6(International Classification of Diseases), which was the first ICD version to include a classification of mental disorders. ICD-6 classified homosexuality as a sexual deviation presumed to reflect an underlying personality disorder. Later in 1992, the ICD-10 defined sexual orientation by itself is not to be considered a disorder. Nevertheless, the descriptions of the categories suggest mental disorders exist that are uniquely linked to sexual orientation and gender expression.https://www.who.int/bulletin/volumes/92/9/14-135541/en/

The World Health Organization (WHO) only removed homosexuality from its ICD classificationwith the publication of ICD-10 in 1992, although ICD-10 still carries the construct of "ego-dystonic sexual orientation". In this condition, the person is not in doubt about his or hersexual preference, but "wishes it were different because of associated psychological and behavioral disorders". https://www.psychologytoday.com/us/blog/hide-and-seek/201509/when-homosexuality-stopped-being-mental-disorder. In June 2018, the IDC-11 removed gender incongruence from mental disorders into sexual health conditions. The rationale being that while evidence is now clear that it is not a mental disorder, and indeed classifying it in this can cause enormous stigma for people who are transgender or gender non-binary.

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