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Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual

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The American Psychiatric Association (APA) is in the process of revising its Diagnostic and Statistical Manual (DSM), with the DSM-V having an anticipated publication date of 2012. As part of that ongoing process, in May 2008, APA announced its appointment of the Work Group on Sexual and Gender Identity Disorders (WGSGID). The announcement generated a flurry of concerned and anxious responses in the lesbian, gay, bisexual, and transgender (LGBT) community, mostly focused on the status of the diagnostic categories of Gender Identity Disorder (GID) (for both children and adolescents and adults). Activists argued, as in the case of homosexuality in the 1970s, that it is wrong to label expressions of gender variance as symptoms of a mental disorder and that perpetuating DSM-IV-TR's GID diagnoses in the DSM-V would further stigmatize and cause harm to transgender individuals. Other advocates in the trans community expressed concern that deleting GID would lead to denying medical and surgical care for transgender adults. This review explores how criticisms of the existing GID diagnoses parallel and contrast with earlier historical events that led APA to remove homosexuality from the DSM in 1973. It begins with a brief introduction to binary formulations that lead not only to linkages of sexual orientation and gender identity, but also to scientific and clinical etiological theories that implicitly moralize about matters of sexuality and gender. Next is a review of the history of how homosexuality came to be removed from the DSM-II in 1973 and how, not long thereafter, the GID diagnoses found their way into DSM-III in 1980. Similarities and differences in the relationships of homosexuality and gender identity to psychiatric and medical thinking are elucidated. Following a discussion of these issues, the author recommends changes in the DSM-V and some internal and public actions that the American Psychiatric Association should take.
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ORIGINAL PAPER
Queer Diagnoses: Parallels and Contrasts in the History
of Homosexuality, Gender Variance, and the Diagnostic
and Statistical Manual
Jack Drescher
Published online: 25 September 2009
American Psychiatric Association 2009
Abstract The American Psychiatric Association (APA) is
in the process of revising its Diagnostic and Statistical Man-
ual (DSM), with the DSM-V having an anticipated publica-
tion date of 2012. As part of that ongoing process, in May
2008, APA announced its appointment of the Work Group on
Sexual and Gender Identity Disorders (WGSGID). The ann-
ouncement generated a flurry of concerned and anxious res-
ponses in the lesbian, gay, bisexual, and transgender (LGBT)
community, mostly focused on the status of the diagnostic
categories of Gender Identity Disorder (GID) (for both chil-
dren and adolescents and adults). Activists argued, as in the
case of homosexuality in the 1970s, that it is wrong to label
expressions of gender variance as symptoms of a mental dis-
order and that perpetuating DSM-IV-TR’s GID diagnoses in
the DSM-V would further stigmatize and cause harm to trans-
gender individuals. Other advocates in the trans community
expressed concern that deleting GID would lead to denying
medical and surgical care for transgender adults. This review
explores how criticisms of the existing GID diagnoses par-
allel and contrast withearlier historical events that led APA to
remove homosexuality from the DSM in 1973. It begins with
a brief introduction to binary formulations that lead not only
to linkages of sexual orientation and gender identity, but also
to scientific and clinical etiological theories that implicitly
moralize about matters of sexuality and gender. Next is a
review of the history of how homosexuality came to be re-
moved from the DSM-II in 1973 and how, not long thereafter,
the GID diagnoses found their way into DSM-III in 1980.
Similarities and differences in the relationships of homo-
sexuality and gender identity to psychiatric and medical th-
inking are elucidated. Following a discussion of these issues,
the author recommends changes in the DSM-V and some in-
ternal and public actions that the American Psychiatric Asso-
ciation should take.
Keywords American Psychiatric Association DSM-V
Gender variance Gender identity disorder Homosexuality
Transgender
It was six men of Hindustan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind)
That each by observation
Might satisfy the mind.
The first approached the Elephant
And happening to fall
Against his broad and sturdy side
At once began to bawl:
‘Bless me, it seems the Elephant
Is very like a wall’’.
The second, feeling of his tusk,
Cried, ‘‘Ho! What have we here
So very round and smooth and sharp?
To me ‘tis mighty clear
This wonder of an Elephant
Is very like a spear’’.
The third approached the animal,
And happening to take
J. Drescher (&)
Department of Psychiatry and Behavioral Sciences,
New York Medical College, 440 West 24th St., Suite 1A,
New York, NY 10011, USA
e-mail: jadres@psychoanalysis.net
123
Arch Sex Behav (2010) 39:427–460
DOI 10.1007/s10508-009-9531-5
The squirming trunk within his hands,
Then boldly up and spake:
‘I see,’ quoth he, ‘‘the Elephant
Is very like a snake.’
The Fourth reached out an eager hand,
And felt about the knee.
‘What most this wondrous beast is like
Is mighty plain,’’ quoth he;
‘‘Tis clear enough the Elephant
Is very like a tree!’
The Fifth, who chanced to touch the ear,
Said: ‘‘E’en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a fan!’
The Sixth no sooner had begun
About the beast to grope,
Than, seizing on the swinging tail
That fell within his scope,
‘I see,’ quoth he, ‘‘the Elephant
Is very like a rope!’
And so these men of Hindustan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right
And all were in the wrong.
John Godfrey Saxe, The Blindmen and the Elephant
(1873)
Introduction
‘We are in a new era in which diagnosis has such social
and political implications that one is constantly on the
front lines fighting on issues our forebears were spared.’
Robert Stoller, M.D.
1
The American Psychiatric Association (APA) is in the pro-
cess of revising its Diagnostic and Statistical Manual (DSM),
with the DSM-V having an anticipated publication date of 2012
(Kupfer, First, & Regier, 2002; Phillips, First, & Pincus, 2003).
As part of that ongoing process, in May 2008, APA announced
the appointment of the members of the Work Group on Sexual
and Gender Identity Disorders (WGSGID),
2
one of 13 Work
Groups participating in the DSM-V revision process.
Prior to the WGSGID appointments, media interest in the
DSM process had primarily focused on possible conflicts of
interests of psychiatrists with financial ties to the pharma-
ceutical industry (Garber, 2007). However, the announce-
ment of the WGSGID appointments and the group’s charge
generated a flurry of concerned and anxious responses in the
lesbian, gay, bisexual, and transgender (LGBT) community
and blogosphere, mostly focused on the status of the diagnos-
tic categories of Gender Identity Disorder (GID) of Adoles-
cence and Adulthood and GID of Childhood (GIDC).
3
These
controversies were subsequently taken up in the LGBT press
(Chibbaro, 2008; Osborne, 2008) and, shortly afterwards, the
mainstream media (Carey, 2008) and professional newslet-
ters (Melby, 2009) began reporting about them as well. The
issues LGBT activists raised related to GID and the DSM are
summarized below:
1. As in the case of homosexuality in the 1970s, it is wrong
for psychiatrists and other mental health professionals to
label expressions of gender variance
4
as symptoms of a
mental disorder and perpetuating DSM-IV-TR’s GID
diagnoses in the DSM-V would further stigmatize and
cause harm to transgender individuals, already a highly
vulnerable and stigmatized population.
2. Some members and advocates of the trans community
expressed concern that deleting GID from the DSM-V
would lead third party payers to deny access to care for
those transgender adults already struggling with inade-
quate private and pubic sources of healthcare funding for
medical and surgical care.
3. Retention of the GID diagnoses would eventually lead to
putting the diagnosis of ‘homosexuality,’ removed from
the DSM-II in 1973, back into the psychiatric manual.
4. Clinical efforts with gender variant children aimed at getting
them to reject their felt gender identity and to accept their
natal sex were unscientific, unethical, and misguided. Act-
ivists labeled such efforts a form of ‘‘reparative therapy.’
1
Cited in Bayer (1981, p. 10).
2
The13WGSGIDmembers areKennethJ.Zucker,Ph.D.(Chair),Irving
M. Binik, Ph.D., Ray Blanchard, Ph.D., Lori Brotto, Ph.D., Peggy T.
Cohen-Kettenis, Ph.D., Jack Drescher, M.D., Cynthia Graham, Ph.D.,
Martin P. Kafka, M.D., Richard B. Krueger, M.D., Niklas La
˚
ngstro
¨
m,
M.D., Ph.D., Heino F. L. Meyer-Bahlburg, Dr. rer. nat., Friedemann
Pfa
¨
fflin, M.D., and Robert Taylor Segraves, M.D., Ph.D.
3
In DSM-IV-TR, there is only one diagnosis—GID—with separate
criteria sets for children vs. adolescents/adults.
4
Following Meyer-Bahlburg (2009), ‘The nomenclature in the area of
gender variations continues to be in flux, in regard to both the descriptive
terms used by professionals, and, even more so, the identity terms adopt-
ed by persons with GIV [Gender-Identity-Variants].’’ Where possible,
this author will use the term ‘gender variance’ to refer to individuals
with gender atypical behavior or self presentations.
428 Arch Sex Behav (2010) 39:427–460
123
5. Internet bloggers and petitioners widely circulated ad homi-
nem accusations and attacks against individual members of
the WGSGID who were characterized as prejudiced against
transgender individuals (i.e., transphobic).
5
Some profes-
sionals petitioned the APA to ‘balance’ the work group
appointments with more ‘trans positive’ members.
6
Fears
were raised that these individuals would use their position to
influence the Work Group in ways that would further exac-
erbate stigma and prejudice against the trans community.
There is no factual basis to the rumors that APA, which
issued a 2005 position statement supporting civil marriage
equality for gay people,
7
might restore homosexuality to the
DSM nor have these assertions been made by anyone affili-
ated with APA or the DSM process (Osborne, 2008). What
constitutes a reparative therapy is addressed briefly later in
this review. Meyer-Bahlburg (2009), in a related DSM re-
view, takes up the issue of how medical treatment of gender
variance might be conceptualized with or without the GID
diagnosis in greater detail. Also in related reports, Cohen-
Kettenis and Pfa
¨
fflin (2009) and Zucker (2009) review the
diagnostic criteria of the existing GID diagnoses. Although
this author questions the utility of ad hominem and ad fem-
inam attacks by activists opposed to researchers with whom
they disagree, that is a discussion for another paper.
8
The bulk of this report explores how criticisms of the exist-
ing GID diagnoses compare with earlier historical events that
led APA to remove homosexuality from the DSM in 1973.
The definitive chronicle of events leading up to that decision
is Bayer’s (1981) Homosexuality and American Psychiatry:
The Politics of Diagnosis in which he lays out some ‘deep
and fundamental questions’ regarding the relationship be-
tween psychiatry and homosexuality that were heatedly de-
bated four decades ago. As the added comments in brackets
below indicate, today society is debating similar questions
about gender as well:
What is normal sexuality [or normal gender]? What is
the role of sexuality [or the role of gender] in human
existence? Do the brute requirements of species sur-
vival compel an answer to the question of whether ho-
mosexuality [or whether gender variance] is a disorder?
How should social values influence psychiatry and help
to define the concept of mental illness? What is the app-
ropriate scope of a nosology of psychiatric disorders?
How should conflicts over such issues be resolved?
How should the opposing principles of democracy and
authority be brought to bear in such matters? (Bayer,
1981,p.4)
As in the case of homosexuality, arguments for removal of
the ‘‘trans diagnoses’’ include societal intolerance of differ-
ence, the human cost of diagnostic stigmatization, using the
language of psychopathology to describe what some consider
to be normal behaviors and feelings and, finally, inappropri-
ately focusing psychiatric attention on individual diversity
rather than opposing the social forces that oppress sexual and
gender nonconformity.
9
In consideration of the question of removal versus reten-
tion, this review begins with a brief introduction to binary
formulations that lead not only to linkages of sexual orien-
tation and gender identity, but also to scientific and clinical
etiological theories that implicitly moralize about matters of
sexuality and gender. Next is a review of the history of how
homosexuality came to be removed from the DSM-II in 1973
and how, not long thereafter, the GID diagnoses found their
way into DSM-III in 1980. Although the DSM-IV-TR diag-
nosis of Transvestic Fetishism also falls under the transgen-
der umbrella—and the history of that diagnosis is worthy of
similar review—this paper confines its discussion to the his-
tory and issues surrounding the GID diagnoses and their intro-
duction to the psychiatric nomenclature in the DSM-III.
10
This paper goes on to elucidate some similarities and
differences in the relationships of homosexuality and gen-
der identity to psychiatric and medical thinking. Although
this paper primarily focuses on adolescent and adult GID, it
briefly addresses the question of whether efforts to convert a
child’s gender identity (as opposed to an individual’s sexual
orientation) are a form of reparative therapy. This is followed
by a discussion leading to this author’s recommendations for
changes in the DSM-V in particular as well as some internal
organizational and public policy actions that should be taken
by the American Psychiatric Association.
5
For example, see http://www.thepetitionsite.com/2/objection-to-dsm-v-
committee-members-on-gender-identity-disorders; retrieved February
9, 2009.
6
For example, see http://professionals.gidreform.org/samples.html;
retrieved July 10, 2009.
7
Retrieved November 9, 2008 from http://www.psych.org/Departments/
EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/
200502.aspx.
8
Severalyearsago, members ofthe LGBTcommunity protested thecon-
tent of Northwestern University’s J. Michael Bailey’s (2003)book,The
Man Who Would be Queen. While there were activists who primarily
criticized the author’s arguments regarding transgenderism, some activ-
ists attacked Bailey’s character, reputation, and family members. Dreger
(2008) has summarized an account of those events. Critics of Dreger’s
account of those events include Bettcher (2008), Gagnon (2008), Lane
(2008), Mathy (2008), McCloskey (2008), and Nichols (2008)among
others. Also see Archives of Sexual Behavior, Volume 37(3), 2008 for a
broad range of discussions of the Dreger article.
9
See Karasic and Drescher (2005).
10
In a classic text on the subject, Benjamin’s (1966) The Transsexual
Phenomenon takes pains to distinguish transvestitism from transsexu-
alism. The current DSM-IV-TR diagnosis of ‘transvestic fetishism,’ in
one form or another, has been found in all editions of the DSM. It is be-
yond the scope of this paper to go into that history, although, as Benjamin
(1966) noted, touching upon transvestitism can be helpful in clarifying
one’s understanding of transsexualism.
Arch Sex Behav (2010) 39:427–460 429
123
Although the author is a member of the DSM-V Work
Group on Sexual and Gender Identity Disorders,this paper and
its recommendations do notnecessarily represent the positions
of either the Work Group or of the APA. It is just the author’s
ownperspective.The aim ofthis reviewis to further discussion
of substantive issues in the debates surrounding possible re-
moval, modification or retention of the DSM GID diagnoses.
In preparing this review, this author was unable to find any
one perspective that adequately tied together the disparate
threads of understanding gender. The issuesinvolved are com-
plexanddo not lend themselves to easy solutions. The author’s
own efforts to fashion such a synthesis left him pondering
anew the proverbial blind men inadequately describing an ele-
phant by touching just one of itsbodyparts. In fact, many of the
authors cited in this review have put forward some element of
truth,albeita partial one.Asinthecaseoftheblindmenandthe
elephant, the metaphors evokedby the parts offer only a partial
understanding of the whole of gender variance, gender diag-
noses and the social construction of gender. In acknowledg-
ment of gender’s multiplicity, this author makes no claim of
having a more acute vision than others who have theorized or
written about the matter. Hopefully, readers will accept this
limitation and be patient as this review takes them through the
subject’s complexity.
Gender Binaries, Sexual Orientation, and Gender
Variance
It is not altogether surprising that questions about the proper
place of gender variance in a psychiatric manual would re-
semble those regarding the placement of sexual orientation as
well. ‘Both historically and cross-culturally, transgender
people have been the most visible minority among people
involved in same-sex sexual practices. As such, transgen-
dered [sic]
11
people have been emblematic of homosexuality
in the minds of most people’ (Devor, 2002, p. 5). In addition,
‘atypical gender behavior’ is not an infrequent finding in the
histories of gay men and women (Bell, Weinberg, & Ham-
mersmith, 1981; Mathy & Drescher, 2009).
Many cultures routinely conflate homosexuality with trans-
gender identities because they rely upon several beliefs that
use conventional heterosexuality and cisgender
12
identities as a
frame of reference. Once regarded as synonymous, it is only
relatively recently that sexual orientation (denedasanindi-
vidual’s erotic response tendency or sexual attractions) and
gender identity (defined as one’s sense of oneself as being either
male or female) have been regarded as separate categories.
History offers many examples of this conflation. For exam-
ple, in the mid-19th century, Ulrichs (1994) hypothesized that
some men were born with a woman’s spirit trapped in their
bodies. He believed these men constituted a third sex and
named them urnings.
13
While historians of homosexuality
unremarkably and routinely seem to regardUlrichs’urnings as
homosexual men (Bullough, 1979; Chauncey, 1994;Green-
berg, 1988), a female spirit in a male body bears a narrative
kinship with 20th century theories of transsexualism. Like
many theories about homosexuality and transgenderism, Ul-
richs drew upon longstanding gender beliefs, employing im-
plicit cultural ideas about the ‘essential’ qualities of men and
women (Drescher, 1998a, 2007; Drescher & Byne, 2009).
People express gender beliefs, their own and those of the
culture in which they live, in everyday language as they either
indirectlyorexplicitlyacceptandassigngendered meaningsto
what they and others do, think, and feel. Gender beliefs touch
uponalmosteveryaspectofdaily life,includingsuchmundane
concerns as the kind of shoes men should wear or ‘‘deeper’
questions of masculinity such as whether men should openly
cry. Gender beliefs are embedded in questions about the kind
of career a woman should pursue and, at another level of dis-
course, what it would mean if a professional woman were to
forego rearing children or pursue her career more aggressively
than a man. ‘Real men’ and ‘real girls’ are powerful cultural
myths with which everyone must contend.
Gender beliefs draw upon gender binaries that usually
refer to a most ancient one, that of male/female, but can also
include the 19th century binary of homosexuality/heterosex-
uality and, perhaps in the future, the emerging 21st century
binary of transgender/cisgender. Furthermore, these binaries
are not confined to popular usage. Many scientific studies of
homosexuality contain implicit (and often explicit) binary
gender beliefs as well. For example, the intersex hypothe-
sis of homosexuality (Byne, 1995; Drescher & Byne, 2009)
maintains that the brains of homosexual individuals exhibit
characteristics that would be considered more typical of the
other sex. The essentialist gender belief implicit in intersex
hypotheses is that an attraction to women is a masculine trait,
which in the case of Freud (1920) led to his theorizing about
lesbians as having a masculine psychology, while biological
researchers have presumed that gay men have brains that
11
The use of ‘transgendered as an adjective has begun to fall out of fa-
vor and has been replaced by ‘transgender,’ as in ‘transgender people.’
12
Historically, the term ‘homosexual’ preceded and necessitated the
creation of the term ‘‘heterosexual’’; the latter term emerged as a more
specific signifier of what people used to think of as ‘normal.’ Similarly,
members of the transgender community have coined the term ‘‘cisgen-
der’ to describe those whose psychological gender is concordant with
their anatomical sex and who usually think of their gender identity as just
‘normal.’ ‘The word has its origin in the Latin-derived prefix cis,
meaning ‘on the same side’ as in the cis–trans distinction in chemistry.
In this case, ‘cis’refers tothe unityof a gender identity with a genderrole’
Footnote 12 continued
(http://en.wikipedia.org/wiki/Cisgender). Some trans writers (Serano,
2007) prefer cissexual rather than cisgender.
13
Ulrichs defined a woman who we would today call a lesbian as urn-
ingin, a man’s spirit trapped in the body of a woman.
430 Arch Sex Behav (2010) 39:427–460
123
more closely resemble those of women (LeVay, 1991) or are
recipients of extra fragments of their mothers’ X (female)
chromosomes (Hamer & Copeland, 1994).
14
Gender beliefs usually only allow for the existence of two
sexes.
15
To maintain this gender binary, most cultures tra-
ditionally insisted that every individual be assigned to the
category of either man or woman at birth and that individuals
conform to the category to which they have been assigned
thereafter (Drescher, 2007). The categories of ‘man’ and
‘woman’ are considered to be mutually exclusive. Iran, in
contrast to Western beliefs and practices, offers a dramati-
cally startling example of how a contemporary society equip-
ped with sufficient modern technology can reinforce its own
binary perspectives. While homosexuality is illegal there, it is
estimated that about 150,000 transsexuals live in Iran, which
hosts more sex-reassignment surgery (SRS) than any nation
besides Thailand:
Explainingtheapparent paradox,oneMuslimclericsays
that while homosexuality is explicitly outlawed in the
Qur’an,sex-change operations are not. They are no more
an affront to God’s will than, for example, turning wheat
intoflourand flour into bread. So while homosexualityis
punishable by death, sex-change operations are present-
ed as an acceptable alternative—as a way to live within a
set of strict gender binaries, as a way to, well, live like
others. The tragic aspect comes through in discussions
with patients and their reluctant parents in the waiting
room of Tehran’s pre-eminent sex-change surgeon, Dr.
Bahram Mir Jalali, where it becomesclear thatsome feel
pressured, not free, to become transsexuals. Asked if he
would be preparing for surgery were he living outside
Iran, one young man says, ‘No. I wouldn’t do it. I
wouldn’t touch God’s work.’ (Ellison, 2008)
Rigid gender beliefs often flourish in fundamentalist, reli-
gious communities where any information or alternative ex-
planations that might challenge implicit and explicit assump-
tions are unwelcome. Iran’s implementation of coercive SRS
to prevent some of its gay citizens from practicing homosex-
uality is an extreme application of a culture’s binary gender
beliefs. Yet this cultural need to maintain gender binaries can
also be found in the West where, since the last half of the 20th
century, intersex infants,
16
even in the absence of medical
necessity, have been routinely subjected to surgery for the
purposes of ‘confirming’ an earlier assignment to either
male or female genders (Colapinto, 2000; Diamond & Sig-
mundson, 1997;Dreger,1998, 1999; Fausto-Sterling, 2000;
Kessler, 1998; Money, Hampson, & Hampson, 1955a, 1955b,
1957).
As the case of Iran illustrates, it is common when entering
the realms of gender and sexuality to encounter another form
of binary thinking: ‘morality tales’ about whether certain
kinds of thoughts, feelings, or behaviors are ‘good or bad’ or,
in some cases, whether they are ‘good or evil (Drescher,
1998a, 2002a). The good/bad binary is not confined to religion
alone as the language of morality is inevitably found, for
example,in theories about the ‘causes’ of homosexuality.For
in the absence of certitude about homosexuality’s ‘etiology,
binary gender beliefs and their associated moral underpin-
nings frequently play a role in theories about the causes and/or
meanings of homosexuality. When one recognizes the narra-
tive forms of these theories, some of the moral judgments and
beliefs embedded in each of them become clearer.
Homosexuality as Psychiatric Diagnosis
Nowhere are the moral implications of etiological theories
more apparent than in the modern history of homosexuality’s
status as a psychiatric diagnosis. As noted elsewhere (Dre-
scher, 1998a, 2002a), it is possible to formulate a descriptive,
empirical typology of etiological theories of homosexual-
ity
17
in which they generally fall into three broad categories:
normal variation, pathology, and immaturity.
18
1. Theories of normal variation treat homosexuality as a
phenomenon that occurs naturally. Such theories typi-
cally regard homosexual individuals as born different,
but it is a natural difference, like left-handedness. The
contemporary cultural belief that people are ‘born gay’
14
‘But every once in a whilethe X and Y chromosomes get jumbled
up, and this little strip of DNA from a Y chromosome is ‘mistakenly’
passed to a daughter (or a bit of the X goes to a son). That means boys are
getting a tiny bit of ‘female’ chromosome and girls are getting a bit of a
‘male’ chromosome. This raised the intriguing possibility that a genetic
crossover between the male and female sex chromosomes is related to
the behavioral ‘crossover’ between heterosexuality and homosexual-
ity’’ (Hamer & Copeland, 1994, p. 128).
15
There are exceptions, as in Plato’s Symposium and some Native
American cultures (Williams, 1986). Also see Fausto-Sterling (1992,
1993, 2000) for a scientist’s thoughtful criticisms of gender binaries.
16
Historicallyreferred toas‘hermaphroditism’ and lateras‘intersex,
the recent term ‘disorders of sex development’ (DSD), like ‘gender
identity disorder,’ has also divided intersex activists between those who
see this medical terminology as stigmatizing and those who see it as
necessary for providing informed treatment.
17
The exact ‘causes’ of heterosexuality are also unknown, but as a
dominant cultural narrative regarded as ‘normal,’ heterosexuality rare-
ly requires explanation. Yet as Freud (1905) noted, ‘‘from the point of
view of psycho-analysis the exclusive sexual interest felt by men for
women is also a problem that needs elucidating and is not a self-evident
fact based upon an attraction that is ultimately of a chemical nature (pp.
145–146n).
18
Among the key words in the morality tales embedded in etiological
theories are ‘socialbenefit’ and ‘social harm, ‘goodand evil,’ ‘health
and illness,’ ‘adaptive and maladaptive,’ ‘holy and sinful,’ or ‘mature
and childish.’
Arch Sex Behav (2010) 39:427–460 431
123
is a normal variation theory.
19
As these theories equate
the normal with the natural, they define homosexuality as
good (or, at baseline, neutral). Such theories see no place
for homosexuality in a psychiatric diagnostic manual.
2. Theories of pathology regard adult homosexuality as a
disease, a condition that deviates from ‘normal, hetero-
sexual development.Atypicalgender behavior or feelings
are symptoms of a ‘disease to which mental health pro-
fessionals need to attend. These theories hold that some
internal defect or external pathogenic agent causes homo-
sexuality and that such events can occur pre- or postna-
tally (intrauterine hormonal exposure, excessive mother-
ing, inadequate or hostile fathering, sexual abuse). Theo-
ries of pathology tend to viewhomosexuality as either bad
or as a sign of a defect and some of these theorists are quite
open about their belief that homosexuality is evil.
20
3. Theories of immaturity regard expressions of homosex-
ual feelings or behavior at a young age as a normal step
toward adult heterosexuality. Ideally, homosexuality is a
passing phase that one outgrows. However, as a ‘devel-
opmental arrest,’ adult homosexuality is equated with
stunted growth. Those who hold these theories tend to
regard immaturity as relatively benign, or at least not
as ‘‘bad’’ compared to those theorists of pathology who
have a tendency to emphasize the potentially malignant
meanings of homosexuality.
Throughout history, discourse about homosexuality has been
tied to cultural values. Thus, unsurprisingly, official pronounce-
ments on the meanings of same-sex behaviors were once pri-
marily the province of religions, many of which deemed homo-
sexuality to be ‘‘bad.’ However, as 19th century Western culture
shifted power from religious to secular authority, homosexuality
received increased scrutiny from, among others, the fields of law,
medicine, psychiatry, sexology, and human rights activism. In
1869, Hungarian journalist Ka
´
roli Ma
´
ria Kertbeny first coin-
ed the terms ‘homosexual’ and ‘homosexuality’ in a political
treatise against Paragraph 143, a Prussian law later codified in
Germany’s Paragraph 175 that criminalized male homosexual
behavior (Katz, 1995). Kertbeny put forward his theory that
homosexuality was inborn and unchangeable, arguments that it
was a normal variation, as a counterweight against the condemna-
tory moralizing attitudes that led to the passage of sodomy laws.
Richard von Krafft-Ebing, a German psychiatrist, offered a
theory of pathologythatdescribed homosexuality as a ‘degen-
erative’’ disorder. Adopting Kertbeny’s terminology, but not
his normalizing beliefs, Krafft-Ebing’s (1965) Psychopathia
Sexualis viewed unconventional sexual behaviors through the
lensof 19thcenturyDarwiniantheory:allnon-procreativesex-
ual behaviors, now subject to medical scrutiny, were regarded
as forms of psychopathology. In an ironic twist of the modern
‘born gay’ theory, Krafft-Ebing believed that although one
might be born with a homosexual predisposition, such inclina-
tions should be considered a congenital disease. Krafft-Ebing
was influential in disseminating among the medical and sci-
entific communities both the term ‘homosexual’ as well as its
author’s view of homosexuality as a psychiatric disorder.
21
Psychopathia Sexualis would presage many of the patholo-
gizing assumptions regarding human sexuality in psychiatric
diagnostic manuals of the mid-20th century.
In contrast to Krafft-Ebing, Havelock Ellis (1905), a British
sexologist, considered homosexuality a normal variation of
sexual expression. A normative view was also the position of
the German homophile movement led by openly homosexual
physician and sex researcher, Magnus Hirschfeld (1914), the
major torchbearer in his time of Ulrich’s (1994)19thcentury
third sex theories.
22
In contrast to Ellis and Hirschfeld’s the-
ories of normal variation and Krafft-Ebing’s theory of pathol-
ogy, Freud put forward a third kind of narrative, a theory of
immaturity, that would also find its way into the popular
imagination.
AccordingtoFreud(1905), as everyone is born with bisexual
tendencies, expressions of homosexuality can be a normal phase
of heterosexual development. His belief in innate bisexuality
did not allow for the possible existence of Hirschfeld’s third sex:
‘Psychoanalytic research is most decidedly opposed to any att-
empt at separating off homosexuals from the rest of mankind as
a group of special character’ (p. 145n).
23
Further, Freud argued
19
These theories say that gay people are born different, but their dif-
ferences are natural and intrinsic to who they are. Today, left-hand-
edness is an apt analogy, as its presence in a minority of people is not
defined as illness, although being left-handed may have disadvantages.
Yet, in the past, being left-handed did lead to social opprobrium (the
word sinister is derived from a Latin root connoting the left side) and
historically, analogous to gay men, left-handed children were often
treated as if they were abnormal and cured of their antisocial habit by
forcing them to write right-handed.
20
The psychiatrist Edmund Bergler (1956) infamously wrote in a book
for general audiences, ‘I have no bias against homosexuals; for me they
are sick people requiring medical help Still, though I have no bias, I
would say: Homosexuals are essentially disagreeable people, regardless
of their pleasant or unpleasant outward manner[their] shell is a
mixture of superciliousness, fake aggression, and whimpering. Like all
psychic masochists, they are subservient when confronted with a stron-
ger person, merciless when in power, unscrupulous about trampling on a
weaker person’’ (pp. 28–29).
21
Psychopathia Sexualis also attracted innumerable lay readers who
were intrigued, and sometimes felt recognized, to finally read about
experiences analogous to their own. Such readers often submitted their
own accounts to Krafft-Ebing and, partly for this reason, the volume
grew larger in each subsequent edition (J. Kerr, personal communica-
tion, July 11, 2009).
22
Hirschfeld would also help some of his patients obtain early access to
sex reassignment surgery (Denny, 2002).
23
Freud’s earlier diplomatic rebuke of Hirschfeld’s theory can be
compared with his more contemptuous assessment several years later:
‘The mystery of homosexuality is therefore by no means so simple as it
is commonly depicted in popular expositions—‘a feminine mind, bound
therefore to love a man, but unhappily attached to a masculine body; a
masculine mind, irresistibly attracted by women, but, alas! imprisoned
432 Arch Sex Behav (2010) 39:427–460
123
that 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’’ (p. 139).
24
Instead, Freud saw expressions
of adult homosexual behavior as caused by ‘arrested’’ psycho-
sexual development.
In support of that claim, he wrote several papers attributing
the homosexuality of patients and historic figures to family
dynamics. For example, in Leonardo da Vinci and a Memory
of His Childhood (Freud, 1910), he attributed the artist’s
homosexuality to prolonged mothering and an absent father.
In The Psychogenesis of a Case of Homosexuality in a Wo-
man (Freud, 1920), he argued that his female patient, disap-
pointed by the birth of a younger brother during the pubertal
resurgence of her Oedipus complex, turned away from her
father and from men in general. ‘She foreswore her wom-
anhood and sought another goal for her libidoshe changed
into a man and took her mother in place of her father as a love
object’ (p. 215). Toward the end of his life, Freud (1935)
wrote ‘Homosexuality is assuredly no advantage, but it is
nothing to be ashamed of, no vice, no degradation; it cannot
be classified as an illness; we consider it to be a variation of
the sexual function, produced by a certain arrest of sexual
development’’ (p. 423).
25
Yet, by the early 20th century, psychiatrists mostly regarded
homosexuality as pathological. After Freud’s death in 1939,
many psychoanalysts of the next generation would come to echo
that position as well. With a few notable exceptions, they would
claim a new and improved understanding of homosexuality and
then proffer psychoanalytic ‘cures that had eluded their field’s
founder. They based their views on the theories of Rado (1940,
1969), a Hungarian e
´
migre
´
to the United States whose theories
had a significant impact on American psychiatric and psycho-
analytic thought in the mid-twentieth century.
26
Rado claimed,
in contrast to Freud, that there was no such thing as either innate
bisexuality or normal homosexuality. Heterosexuality was the
only biological norm and homosexuality a ‘‘phobic’ avoidance
of the other sex caused by inadequate parenting.
Freud had pessimistically written in a 1920 case report,
‘In general, to undertake to convert a fully developed homo-
sexual into a heterosexual does not offer much more prospect
of success than the reverse, except that for good practical
reasons the latter is never attempted’ (p. 151). In contrast, the
next generation of analysts viewed efforts to cure homosex-
uality as akin to treating other forms of unconscious anxiety.
Although retaining elements of Freud’s immaturity narra-
tive, focusing on presumed preoedipal ‘causes’ of homosex-
uality (Lewes, 1988), mid-20th century analysts regarded the
‘homosexual’s’ development arrest less benignly than did
Freud. Their pathologizing theories provided a rationale for
claims of ‘cure.’ However, despite theirtherapeutic optimism,
most of their efforts appeared to have been unsuccessful. In a
rare, controlled analytic study, Bieber et al. (1962) treated 106
homosexual men. They claimed a 27% ‘cure’ rate with psy-
choanalysis, but when challenged a decade later to produce a
‘cured’ patient, they were unable to do so (Tripp, 1987).
27
Although practitioners of aversion therapy in the 1960s also
claimed ‘cures,’ by the 1970s behavioral therapists admitted
thatfew of their patients managed to stay ‘converted for very
long (Bancroft, 1974; Davison, 1976).
While psychiatrists, physicians, and psychologists were
trying to ‘cure’’ and change homosexuality, sex researchers
of the mid-20th century instead studied a wider spectrum of
individuals that included non-patient populations. Psychia-
trists and other clinicians inevitably drew conclusions from a
biased sample of patients seeking treatment for their homo-
sexuality or other difficulties and then wrote up findings of
this self-selected group as case reports. Sexologists, on the
other hand, went out and recruited large numbers of non-
patient subjects for their studies.
Most prominent among those studies was the research of
Kinsey and his collaborators: Sexual Behavior in the Human
Male (Kinsey, Pomeroy, & Martin, 1948)andSexual Behavior
in the Human Female (Kinsey, Pomeroy, Martin, & Gebhard,
1953). The Kinsey reports surveyed thousands of people and
found homosexuality to be more common in the general pop-
ulation than was generally believed. Kinsey’s now-famous
‘10%’ statistic, today believedtobecloserto14%(Laumann,
Gagnon, Michael, & Michaels, 1994),
28
was sharply at odds
with psychiatric claims of the time that homosexuality was
extremely rare in the general population. Ford and Beach’s
(1951) Patterns of Sexual Behavior, a study of diverse cultures
and of animal behaviors, confirmed Kinsey’s view that homo-
sexuality was more common than psychiatry maintained and
Footnote 23 continued
in a feminine body.’.If [psychoanalytic] findings are taken into ac-
count, then, clearly, the supposition that nature in a freakish mood
created a ‘third sex’ falls to the ground’’ (Freud, 1920, pp. 170–171).
24
Freud (1905), in The Three Essays, described Krafft-Ebing’s
‘pathological approach to the study of inversion’’ as being ‘‘displaced
by the anthropological. The merit for bringing about this change is due to
[Ivan] Bloch, who has also laid stress on the occurrence of inversion
among the civilizations of antiquity’’ (p. 139n).
25
Freud also signed a 1930 petition calling for decriminalization of
homosexuality in Germany and Austria (Abelove, 1993).
26
Rado was the founder of the Columbia Center for Psychoanalytic
Training and Research in New York City.
27
Responding to Tripp’s challenge of Bieber’s claims of therapeutic
success, rather than producing a patient, Bieber filed an ethics complaint
with the American Psychological Association for impugning his ‘scien-
tific honesty and credibility.’ The Committee on Scientific and Pro-
fessional Ethics and Misconduct found no evidence of unethical be-
havior (Tripp, 1987, p. 287).
28
In 1903, Hirschfeld surveyed 3,000 students in a technical school and
found 1.5% of the students identified as homosexual and 4.5% as bisex-
uals (Pfa
¨
fflin, 1997).
Arch Sex Behav (2010) 39:427–460 433
123
that it was found regularly in nature.
29
Inthelate1950s,Hooker
(1957), a psychologist, published a study that refuted psychiatric
beliefs of her time, as her study failed to find more signs of
psychological disturbances in a group of non-patient homo-
sexual men compared to non-patient heterosexual controls.
30
American psychiatry, influenced at the time by psycho-
analytic ego psychology, mostly ignored this growing body
of sex research and, in the case of Kinsey, expressed extreme
hostility to findings that contradicted their own theories (Lewes,
1988). This was the general state of affairs when, in 1952,
APA published its first edition of the Diagnostic and Statis-
tical Manual (DSM-I), listing 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 reclassi-
fied as a ‘sexual deviation.’ However, by 1970, the scientific
research arguing for a non-pathological view of homosexu-
ality was dramatically brought to the attention of the APA.
As Bayer (1981, 1987) has noted, factors both outside and
within APA would lead to a reconceptualization of homo-
sexuality’s place in the diagnostic manual. In addition to the
research findings from outside psychiatry, there was a grow-
ing anti-psychiatry movement (Szasz, 1960) and an emerging
generational changing of the guard within APA comprised
of younger leaders urging the organization to greater social
consciousness (Drescher, 2006a). A very few psychoanalysts
like Marmor (1965) were also taking issue with psychoana-
lytic orthodoxy regarding homosexuality (Drescher, 2006b;
Rosario, 2003). However, the most significant catalyst for
diagnostic change was gay activism. In the wake of the 1969
Stonewall riots in New York City (Duberman, 1994), gay and
lesbian activists, believing psychiatric theories to be a major
contributor to antihomosexual social stigma, disrupted the
1970 and 1971 annual meetings of the APA.
The protests were successful in getting organized psychi-
atry’s attention and led to unprecedented and groundbreaking
educational panels at the next two annual APA meetings. A
1971 panel, entitled ‘Gay is Good,’ featured gay activists
Frank Kameny and Barbara Gittings explaining to psychia-
trists, many who were hearing this for the first time, the stigma
caused by the ‘homosexuality’ diagnosis (Gittings, 2008;
Kameny, 2009; Silverstein, 2009). Kameny and Gittings re-
turned to speak at the 1972 meeting, this time joined by John
Fryer, M.D. Fryer appeared as Dr. H Anonymous, a ‘‘homo-
sexual psychiatrist’’ who, given the realistic fear of adverse
professional consequences for coming out at that time, dis-
guised his true identity from the audience and spoke of the
discrimination gay psychiatrists faced in their own profes-
sion (Gittings, 2008; Scasta, 2002).
Asthese protestsand panelstookplace,APAalsoembarked
upon an internal deliberative process of considering the ques-
tion of whether homosexuality should remain a psychiatric
diagnosis. At a session of the 1973 APA annual meeting, par-
ticipants favoring and opposing removal debated the ques-
tion, ‘‘Should Homosexuality be in the APA Nomenclature?’
and shortly thereafter those proceedings were published in
the APA’s American Journal of Psychiatry (Stoller et al.,
1973). The Nomenclature Committee, APA’s scientific body
addressing this issue, also wrestled with the question of what
constitutes a mental disorder. Spitzer (1981), who chaired a
subcommittee looking into the issue, ‘‘reviewed the charac-
teristics 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
(Bayer, 1981; Drescher, 2003; Drescher & Merlino, 2007;
Hire, 2002; Rosario, 2003; Sbordone, 2003; Spitzer, 1981;
Stoller et al., 1973). Several other APA committees and delib-
erative bodies then reviewed their work and approved that
decision. Finally, in December 1973, APA’s Board of Trust-
ees (BOT) voted to remove homosexuality from the DSM.
Psychiatrists from the psychoanalytic community, object-
ing to the decision, petitioned APA to hold a referendum in
which the entire membership was asked to vote either in sup-
port of or against the BOT decision (Bieber, 1987; Socarides,
1995). The decision to remove was upheld by a 58% majority
of voting members.
31
The declassification of homosexuality
was accompanied by APA issuing a position statement
32
(Bayer, 1981;Drescher,2006a;Lynch,2003) which became
the first of many APA position statements supporting civil
rights protections for gay people:
Whereas homosexuality in and of itself implies no
impairment in judgment, stability, reliability, or voca-
tional capabilities, therefore, be it resolved that the
American Psychiatric Association deplores all public
29
For more contemporary biological studies of homosexuality in
animals, see Bagemihl (1999). For more contemporary anthropological
views regarding homosexuality and transgenderism see Herdt (1994).
30
Hooker compared 30 gay men with 30 heterosexual controls using
the TAT, the Make-a-Picture-Story test (MAPS test), and the Rorschach
inkblot test. Following Hooker, Siegelman (1972) compared 84 homo-
sexual women to 113 heterosexual control and found the former ‘to be
as well adjusted as the latter.’’ In a more extensive review of the liter-
ature, Riess (1980) concluded ‘there are no psychological test tech-
niques which successfully separate homosexual men and women from
heterosexual comparisons’’ (p. 308).
31
It should be noted that psychiatrists did not vote, as reported in the
popular press, on whether homosexuality should remain in the diagnostic
manual. What APA members voted on was to either ‘favor’ or ‘oppose’
the APA Board of Trustees decision and, by extension, the scientific pro-
cess they had set up to make the determination (Bayer, 1981,p.148).
32
The statement was largely based on language formulated by Richard
Pillard and Lawrence Hartmann and their pioneering work on this issue
within the Northern New England Psychiatric Society (Bayer, 1981).
434 Arch Sex Behav (2010) 39:427–460
123
and private discrimination against homosexuals in such
areas as employment, housing, public accommodations,
and licensing, and declares that no burden of proof of
such judgment, capacity, or reliability shall be placed on
homosexuals greater than that imposed on any other
persons. Further, the APA supports and urges the
enactment of civil rights legislation at local, state, and
federal levels that would insure homosexual citizens the
same protections now guaranteed to others. Further, the
APA supports and urges the repeal of all legislation
making criminal offenses of sexual acts performed by
consenting adults in private.
33
Thus ended the American classification of homosexuality
per se as an illness. Within two years, other major mental health
professional organizations, including the American Psycho-
logical Association, the National Association of Social Work-
ers, and the Association for Advancement of Behavior Therapy,
endorsed the APA decision.
This did not, however, mean that APA was endorsing a
normal variant model of homosexuality:
If homosexuality per se does not meet the criteria for a
psychiatric disorder, what is it? Descriptively, it is one
form of sexual behavior. Our profession need not now
agree on its origin, significance, and value for human
happiness whenwe acknowledge thatby itself it doesnot
meet the requirements for a psychiatric disorder. Simi-
larly, by no longer listing it as a psychiatric disorder we
are not saying that it is ‘‘normal’’ or as valuable as het-
erosexuality.What will be the effect of carrying out
such a proposal? No doubt, homosexual activist groups
will claim that psychiatry has at last recognized that
homosexuality is as ‘normal’’ as heterosexuality. They
will be wrong. In removing homosexuality per se from
the nomenclature we are only recognizing that by itself
homosexuality does not meet the criteria for being con-
sidered a psychiatric disorder. We will in no way be
aligning ourselves with any particular viewpoint regard-
ing the etiology or desirability of homosexual behavior
(American Psychiatric Association, 1973, pp. 2–3).
Nor did the diagnostic change immediately end psychia-
try’s pathologizing of some presentations of homosexuality.
For in ‘homosexuality’s place, the DSM-II contained a new
diagnosis: Sexual Orientation Disturbance (SOD).
34
This
diagnosis regarded homosexuality as an illness if an individual
with same-sex attractions found them distressing and wanted to
change (Spitzer, 1981; Stoller et al., 1973). The new diagnosis
served the purpose of legitimizing the practice of sexual con-
version therapies (and presumably justified insurance reim-
bursement for those interventions as well), even if homosex-
uality per se was no longer considered an illness. The new
diagnosis of SOD also allowed for the unlikely possibility that a
person unhappy about a heterosexual orientation could seek
treatment to become gay.
35
In 1980, DSM-III dropped SOD and in its place substituted
Ego Dystonic Homosexuality (EDH) (Spitzer, 1981).How-
ever, it was obvious to psychiatrists more than a decade later
that the inclusion first of SOD, and later EDH, had been the
result of earlier political compromises and that neither diag-
nosis met the definition of a disorder in the new nosology
(Mass, 1990a, 1990b). Otherwise, all kinds of identity distur-
bances could be considered psychiatric disorders. ‘Should
people of color unhappy about their race be considered men-
tally ill?’ critics asked. What about short people unhappy
about theirheight?Why not ego-dystonicmasturbation(Mass,
1990a)?Asa result, ego-dystonichomosexualitywas removed
from the next revision, DSM-III-R, in 1987 (Krajeski, 1996).
In so doing,theAPAimplicitly accepteda normalvariant view
of homosexuality in a way that had not been possible 14 years
earlier.
Other diagnostic systems would eventually follow suit. In
1992, the World Health Organization (WHO, 1992) removed
‘homosexuality’’ from the Tenth Edition of the Internation-
al Classification of Diseases (ICD-10), replacing it with a di-
agnosis similar to Ego-Dystonic Homosexuality (Nakajima,
2003).
Gender Identity Disorder and the DSM
Today, expressions of gender variance or gender noncon-
formity are frequently subsumed by the popular term trans-
gender, a term that does not appear in the DSM or any other
diagnostic manual.
36
‘Transgender’ is a relatively new word. It was origi-
nally coined by Virginia Prince in the early 1970s to
refer to people who lived full-time in a gender that was
not the one that usually went with their genitals (Prince,
33
Retrieved November 9, 2008 from http://www.psych.org/Depart
ments/EDU/Library/APAOfficialDocumentsandRelated/PositionState
ments/197310.aspx.
34
Prior to 1980’s DSM-III, APA published a small number of copies of
the DSM. When those were exhausted, another small number was pub-
lished. After running out of copies of DSM-II printed before the 1973
decision, APA printed up new copies in which ‘homosexuality’ was
replaced by ‘sexual orientation disturbance’ (R. L. Spitzer, personal
communication).
35
‘As Frank Kameny, a ‘gay activist,’ remarked in 1973, he had no
objection to the category of Sexual Orientation Disturbance since any
homosexual who was distressed at being homosexual was clearly ‘crazy
and in need of treatment by a gay counselor to get rid of societally induc-
ed homophobia’’ (quoted in Spitzer, 1981,p.211).
36
Also see Leli and Drescher (2004).
Arch Sex Behav (2010) 39:427–460 435
123
personal communication).
37
In the 1990s, the word was
taken up by a variety of people who, in their own ways,
transgressed usual sex and gender expectations. It has
now come to have quite a broad meaning. For many
people, the term transgender includes a wide range of
sex, gender, and sexual expressions which may include
heterosexuals, lesbians, gays, bisexuals, queers and
transsexuals (Devor, 2002, p. 8).
Currah, Green, and Stryker (2008) further elaborate on the
term as
a sense of persistent identification with, and expres-
sion of, gender-coded behaviors not typically associ-
ated with one’s sex at birth, and which were reducible
neither to erotic gratification, nor psychopathological
paraphilia, nor physiological disorder or malady. The
self-applied term was meant to convey the sense that
one could live non-pathologically in a social gender not
typically associated with one’s biological sex, as well
as the sense that a single individual should be free to
combine elements of different gender styles and pre-
sentations, or different sex/gender combinations. At one
level, the emergence of the ‘transgender’ category
represented a hair-splitting new addition to the panoply
of available minority identity labels; at another level,
however, it represented a resistance to medicalization,
to pathologization, and to the many mechanisms whereby
the administrative state and its associated medico-le-
gal-psychiatric institutions sought to contain and deli-
mit the socially disruptive potentials of sex/gender non-
normativity. Having an intelligible social identity is the
means by which an individual body enters into a pro-
ductive relationship with social power. Thus ‘‘identity
politics,’ the struggle to articulate new categories of
socially viable personhood, remains central to the con-
sideration of individual rights in the United States, and
to the pursuit of a more just social order. The emergence
of ‘transgender’ falls squarely into the identity politics
tradition (p. 3).
Like homosexuality, medical scrutiny of transgenderism
also began in the 19th century. As noted above, a lack of dis-
tinction between homosexuality and transgender presen-
tations was common. Krafft-Ebing (1965) weighed in on the
side of transgenderism as psychopathology, documenting
both cases of gender dysphoria and of gender variant indi-
viduals born to one sex yet living as members of the other.
Hirschfeld (1923) is credited with being the first person to
distinguish the desires of homosexuality (to have partners of
the same-sex)fromthose of transsexualism (to live as the other
sex).
38
By the 1920s, physicians in Europe had begun exper-
imenting with sex reassignment surgery (SRS).
39
However,
the surgical construction of gender (Garber, 1993) truly seized
the popular imagination when George Jorgensen went to
Denmark as a natal man and returned to the U.S. in 1952 as
trans woman Christine Jorgensen (Jorgensen, 1967). Amidst
great public and professional controversy, the physicians who
participated in Jorgensen’s SRS published a report of their
treatment of her in the Journal of the American Medical Asso-
ciation (Hamburger, Stu
¨
rup, & Dahl-Iversen, 1953).
The publicity surrounding Jorgensen’s transition, begin-
ning with a 1952 New York Daily News headline: ‘Ex-GI
Becomes Blonde Beauty,’ eventually led to greater popular,
medical, and psychiatric awareness of a scientific concept
that would eventually come to be known as gender identity, as
well as recognition of an increasing number of people wish-
ing to ‘cross over.’ For those who eventually would come to
identify as transsexual, increased public discussions of sex
reassignment and gender identity would provide them with a
way to put a name to their feelings and desires.
40
As a result, a
presentation of gender(Stoller,1985) onceconsideredexceed-
ingly rare would gradually become more commonplace.
41
Yet, at the time of Jorgensen’s 1950s transformation and
for the next three decades, many psychiatrists, and particu-
larly psychoanalytic practitioners, remained critical of sex re-
assignment as a treatment for gender dysphoric individuals.
42
Most psychiatric theorizing of that time conflated sexual ori-
entation and gender identity, and many analysts were unaware
37
Prince’s original term was ‘transgenderal’ and she coined it as an
alternative to ‘transsexual’ to describe people who lived in the non-
natal gender but did not have transsexual surgery. Prince’s life story and
a collection of some of her academic publications can be found in Prince,
Ekins, and King (2005). Prince passed away on May 2, 2009 at the age of
96.
38
It should be noted that there are transgender individuals who desire to
live as a member of the other sex and who neither desire nor seek medical
or surgical treatment to accomplish that goal.
39
In 1930, Lily Elbe (born Einar Mogens Wegener), who had been
living as a woman for more than a decade, underwent sex reassignment
in surgery in Germany under the supervision of Hirschfeld. Ebershoff
(2000) has written a novel about Elbe, soon to be released as a film. Also
see Hertoft and Sørensen (1978). Hoyer’s (1933) Man Into Woman is
also a classic early account.
40
Blanchard (2003) attributes increased social acceptance of sex
reassignment to five factors: (1) high-profile, attractive trans pioneers;
(2) positive clinical evidence; (3) the backing of prestigious experts and
institutions; (4) sympathetic media; and (5) a favorable social climate.
41
In line with these cultural changes, in recent years a few states have
enacted laws that establish ‘‘gender identity’’ as a protected legislative
characteristic, although it remains to be defined as a ‘suspect category,’
a term for groups likely to be subject to discrimination (other suspect
classifications include race, ethnicity, age, sex, and, less frequently,
sexual orientation). This is a remarkably rapid cultural shift as the mod-
ern coinage of ‘gender identity’ only emerged in the mainstream scien-
tific community half a century ago (Stoller, 1964).
42
See Socarides (1969), Hertoft and Sørensen (1978), and McHugh
(1992) for psychiatric views opposing sex reassignment and Chiland
(2000, 2003) for a contemporary, psychoanalytic criticism of SRS.
436 Arch Sex Behav (2010) 39:427–460
123
of,indifferent to,or at timeshostile towardsresearchfromnon-
analytic sources that did not support their own theories (Bayer,
1981; Lewes, 1988). Many physicians and psychiatrists criti-
cized using surgery and hormonesto irreversibly—and in their
view incorrectly—treat people suffering from what they per-
ceived to be either a severe neurotic or psychotic, delusion-
al condition in need of psychotherapy and ‘reality testing.
Mainstream medical thinking at the time was captured in a
1960s survey of 400 physicians that included psychiatrists,
urologists, gynecologists, and general medical practitioners
asked to give theirprofessional opinionsabout a case history of
a trans individual seeking SRS.
43
Green (1969)summarized
the findings as follows:
Eight percent [8%] of the respondents considered the
transsexual ‘severely neurotic’ and fifteen percent[15%]
considered the person ‘psychotic.’ The majority of the
responding physicians were opposed to the transsex-
ual’s request for sex reassignment even when the pa-
tient was judged nonpsychotic by a psychiatrist, had
undergone two years of psychotherapy, had convinced
the treating psychiatrist of the indications for surgery,
and would probably commit suicide if denied sex reas-
signment. Physicians were opposed to the procedure
because of legal, professional, and moral and/or reli-
gious reasons. In contrast to the conservatism with which
granting of sex-reassignment procedures was viewed,
there was a paradoxical liberalism in the approach to
these patients should they already have been successful
in obtaining their surgery elsewhere. Among the
respondents, three quarters [75%] were willing to allow
the postoperative patient to change legal papers such as
a birth certificate and to marry in the new gender, and
one-half [50%] would allow the person t adopt a child as
a parent in the new gender. (pp. 241–242)
It was in this cultural context that the first two editions of
the DSM were published. With a significant emphasis on psy-
choanalytic theories of normal and pathological mental func-
tioning, the GID diagnoses or anything equivalent did not
appear in either one (APA, 1952, 1968). By 1980, however, a
newly revamped DSM-III would abandon the psychodynamic
theories informing the first two volumes and instead adopt a
neo-Kraepelian, descriptive, symptom-based framework draw-
inguponcontemporaryresearchfindings(Spiegel,2005;Zuc-
ker & Spitzer, 2005). In that shift, a growing body of research on
child and adult gender identity found its way into the manual.
Zucker and Spitzer (2005) summarize the vicissitudes of the
current gender diagnoses from DSM-III through DSM-IV-TR:
In the third edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-III; APA, 1980), there
appeared for the first time two psychiatric diagnoses per-
taining to gender dysphoria in children, adolescents, and
adults: gender identity disorder of childhood (GIDC) and
transsexualism (the latter was to be used for adolescents
and adults). In the DSM-III-R (APA, 1987), a third diag-
nosis was added: gender identity disorder of adolescence
and adulthood, nontranssexual type. In DSM-IV (APA,
1994, 2000a), this last diagnosis was eliminated (‘‘suns-
etted’’), and the diagnoses of GIDC and transsexualism
were collapsed into one overarching diagnosis, gender id-
entity disorder (GID), with different criteria sets for child-
ren versus adolescents and adults. (p. 32)
The decision to place transsexualism in the DSM was based
on the research and clinical contributions of John Money, Harry
Benjamin, Robert Stoller, and Richard Green. All took issue
with the prevailing psychiatric view of their time that dismissed
the existence of transgender subjectivities as a unique psycho-
logical phenomenon in its own right. The pioneering activities
of these men—creating gender clinics and providing medical
and surgical treatment to trans individuals—ultimately led to
the new diagnosis in the DSM. They also changed professional
and eventually public attitudes toward sex reassignment. Their
contributions are briefly summarized below.
John Money, a psychologist and sexologist, first began pub-
lishing his theories regarding gender identity development in the
1950s (Money et al., 1955a, 1955b, 1957). Based on studies of
children born with intersex conditions, Money theorized that
one’s sense of being male or female—what eventually came to
be known as one’s gender identity—was acquired and that ac-
quisition was primarily determined by external, environmental
factors. Citing cases of gender assignment in intersex children
born with ambiguous genitalia, Money believed parental atti-
tudes have a strong effect on whether a child accepts the gender
category to which it had been surgically and medically assigned.
For Money, the role of the psychosocial environment was crit-
ical: ‘In those instances [where the child does not accept the
category to which it has been assigned,]it is common to find a
history in which uncertainty as to the sex of the baby at birth was
transmitted to the parents and never adequately resolved [within
the parents’ mind]’(Money & Ehrhardt, 1996,p.153).
Money coined the term gender role (Money 1985a, 1994),
which he defined as those things that a person says or does to
43
‘The case history in the questionnaire read as follows: Since early
childhood, this 30-year-old biological male has been very effeminate in
his mannerisms, interests, and daydreams. His sexual desires have al-
ways been directed toward other males. He would like to be able to dress
exclusively in woman’s clothes. This person feels inwardly and insists to
the world that he is a female trapped in a male body. He is convinced that
he can only be happy if he is operated on to make his body look like that
of a woman. Specifically, he requests the removal of both testes, his
penis, and the creation of an artificial vagina (all of which can, in fact, be
done surgically). He also requests that his breasts be made to appear like
a woman’s, either surgically or by the use of hormones (this, too, is
medically possible)’’ (Green, 1969, p. 236).
Arch Sex Behav (2010) 39:427–460 437
123
disclose himself or herself as having the status of boy or man,
girl or woman, respectively (e.g., general mannerisms, deport-
ment and demeanor, etc.) and regardless of the person’s ana-
tomical sex. Gender identity refers to one’s persistent inner
sense of belonging to either the male or female gender category.
Money (1994) credits the latter term’s coinage to Robert Stol-
ler.
44
Gender identity can be an independent variable in relation
to sexual orientation. For example, some people can be born
with a male body, have a female gender identity, and, in some
cases, be attracted to men (androphilic) while others may be
attracted to women (gynephilic). Money came to see gender
identity as the private experience of gender role and gender role
as the public manifestation of gender identity: ‘As originally
defined, gender role consists of both introspective and the ex-
traspective manifestations of the concept. In general usage, the
introspective manifestations soon became separately known as
gender identity. The acronym, G-I/R, being singular, restores
the unity of the concept’ (Money, 1985b,p.279;seealsoMoney
&Ehrhardt,1996).
Money believed a person’s gender identity was fixed by three
years of age, and considered efforts to change a person’s gender
identity difficult, if not impossible, in anyone older. Pessimism
about changing an adult’s gender identity left only one thera-
peutic alternative to improve the affected individual’s well-
being: sex reassignment. In the mid-1960s, in the wake of
Money’s theoretical work and his clinical and research findings,
Johns Hopkins opened the first university-affiliated, multidis-
ciplinary gender clinic offering sex reassignment to transsexuals
seeking treatment (Green & Money, 1969). More than 40 aca-
demic centers in the U.S. would later open gender clinics as well
(Denny, 1992, 2002).
45
Harry Benjamin, a physician, is credited with both popu-
larizingthe termtranssexual in itscurrentusage and forraising
awareness about trans individuals within the medical profes-
sion (Benjamin, 1966; Green, 2009a; Ihlenfeld, 2004; Person,
2008;Pfa
¨
fflin, 1997).
46
Benjamin was a pioneering maverick
who offered transgender individuals hormonal treatment at a
time when mainstream psychiatry and medicine regarded gen-
der incongruent individuals as confused homosexuals, neu-
rotics, transvestites, schizophrenic or some combination thereof
(e.g., Socarides, 1969). Benjamin, who had an essentialist
view of transsexualism, had little regard for his era’s psy-
chiatrists or psychoanalysts (Ihlenfeld, 2004). He ‘believed
that the transsexual suffers from a biological disorder, that his
brain was probably ‘feminized’ in utero. He eschews any psy-
chological explanation’ (Person, 2008, p. 272). Consistent
with his essentialist view, he believed psychotherapeutic
attempts to change gender identity were ‘futile’ (Benjamin,
1966, p. 28). As an outgrowth of his interests in the devel-
oping fields of endocrinology, gerontology, and sexology in
the 1920s and 1930s, Benjamin was among the first physi-
cians to experiment with hormonal and surgical treatments
for aging—he eventually pioneered the treatment of gender
dysphoric individuals using sex hormones (Ihlenfeld, 2004).
According to a colleague, ‘By 1972, Benjamin had diag-
nosed, treated, and befriended at least a thousand of the ten
thousand Americans known to be transsexual. In the process,
he had come to be regarded not only as the discoverer but also
as the patron saint of transsexuals’ (Person, 2008, p. 260).
Notably, he accomplished this in a private practice setting
without either university or academic support. In acknowl-
edgment of Benjamin’s early advocacy for the medical treat-
ment of transsexualism, in 1979 the newly formed Harry Ben-
jamin International Gender Dysphoria Association (HBIG-
DA),
47
which would go on to develop standards of care (SOC)
for treating trans individuals, was named in his honor.
48
Robert Stoller was a preeminent member of both the
American psychiatric and psychoanalytic establishments of his
time (Green, 2009a). Like Money, Stoller’s (1968) theorizing
about gender evolved from working with both intersex and
transsexual patients. Stoller (1964) is credited with introducing
the concept of gender identity into both the psychoanalytic lit-
erature and into the consciousness of many psychiatrists as
44
‘I trace my initial acquaintance with this new term to communica-
tion at the time with Evelyn Hooker, the psychologist now famed for
her pioneering studies in Los Angeles that led to the official depathol-
ogization of homosexuality. According to a personal communication
(1984) with the late Robert Stoller, there was a psychoanalytic gender
identity study group at the University of California at Los Angeles
(UCLA) Medical Center during this same period, the middle 1960s’
(Money, 1994, p. 166). Regular attendees of that study group included
Ralph Greenson, Judd Marmor, Robert Stoller, and Richard Green (R.
Green, personal communication, July 6, 2009).
45
Money, as well as his ‘‘nurture’’ theory of gender identity develop-
ment, was attacked in Colapinto’s (2000) As Nature Made Him. He was
accused, among other things, of falsifying published data about a pair of
twin boys, one of whom lost his penis at age 8 months in a botched
circumcision and was later reassigned to be a girl. Money claimed the
child, referred to as ‘John/Joan’ in the case report, successfully accept-
ed gender reassignment. In Colapinto’s book, John/Joan was revealed
to be David Reimer who publicly came forward to tell his story of having
rejected female assignment.
46
Hirschfeld (1923) is credited with coining the term transvestism in
1910 and transsexualism in 1923, although he did not define the latter in
its current usage (Pfa
¨
fflin, 1997). Cauldwell (1949) is often credited with
the first usage of the contemporary meaning of transsexualism (Hertoft
& Sørensen, 1978; Pfa
¨
fflin, 1997).
47
Founding members include Jack Berger, Richard Green, Donald
Laub, Walter Meyer, Jude Patton, Charles Reynolds, Jr., Paul Walker,
Alice Webb, and Leo Wollman. Retrieved from A. H. Devor’s web
based history, ‘Reed Erickson and The Erickson Educational Foun-
dation,’’ at http://web.uvic.ca/*erick123/#HB, July 7, 2009.
48
In 2006, it was proposed that HBIGDA’s name be changed to the
World Professional Association for Transgender Health (WPATH).
That name change became official in 2009 after a membership ballot
(H. F. L. Meyer-Bahlburg, personal communication, March 2009).
438 Arch Sex Behav (2010) 39:427–460
123
well.
49
However, in contrast to Benjamin’s essentialist views,
Stoller (1967) believed that in some cases, childhood family
dynamics were responsible for ‘causing’ adult transsexual-
ism.
50
Stoller (1985), undoubtedly influenced by the separation-
individuation theories of Mahler, Pine, and Bergman (1975),
opined that GID in boys was a ‘developmental arrest in
which an excessively close and gratifying mother–infant sym-
biosis, undisturbed by father’s presence, prevents a boy from
adequately separating himself from his mother’s female body
and feminine behavior’’ (p. 25).
As a medical student at Johns Hopkins, Richard Green
studied cross-gender behavior in children under the supervision
of his mentor John Money. Green did his psychiatric training as
a UCLA resident with Robert Stoller, and later developed a
close relationship with Harry Benjamin (Green, 1987, 2009a).
GreenandMoney(1969) co-edited a groundbreaking, multidis-
ciplinary treatment textbook, Transsexualism and Sex Reas-
signment, and published two early and important scholarly
works in the field of GIDC research (Green & Money, 1960,
1961). His later volume, The ‘Sissy Boy Syndrome’ and the
Development of Homosexuality (Green, 1987) was a prospec-
tive study that tracked into adulthood the development of 66
gender-atypical boys who stated a wish to be a girl. Seventy-five
percent of the children Green studied grew up to be gay men.
Stoller and Green were among the most prominent of psy-
chiatrists who supported the APA decision to remove homo-
sexuality from the DSM-II (Stoller et al., 1973). They also
served on the DSM-III Subcommittee on Psychosexual Disor-
ders that recommended including transsexualism (now called
GID in adolescents and adults) in the DSM-III.
During the 1960s, North American psychiatry had begun
to take a look at the phenomenon of transsexualism in
adults (see, for example, Green & Money, 1969; Stoller,
1968). It became apparent that psychiatrists and other
mental-health professionals had become increasingly
aware of the phenomenon, that is, of adult patients report-
ing substantial distress about their gender identity and
seeking treatment for it, typically hormonal and surgical
sex-reassignment. Indeed, there were enough observed
cases that it was possible in the 1960s to establish the first
university- and hospital-based gender identity clinics for
adults. Many clinicians and researchers were writing
about transsexualism, and by 1980, there was a large
enough database to support its uniqueness as a clinical
entity and a great deal of empirical research that exam-
ined its phenomenology, natural history, psychologic
and biologic correlates, and so forth. Thus, by the time
DSM-III was in its planning phase in the mid-1970s,
there were sufficient clinical data available to describe
the phenomenon, to propose diagnostic criteria, and so
on (Zucker & Spitzer, 2005,p.37).
According to Zucker and Spitzer, the case for including GID
of Childhood in the DSM-III was made for similar reasons:
At thesametime, there also was an emergingclinicaland
research literature on children who expressed the desire
to be of the opposite sex, leading to a similar situation,
that is, there was a clear description of the phenomeno-
logy, development of diagnostic criteria, and so on (e.g.,
Green, 1974;Stoller,1968, 1975). Although research on
both GIDC and transsexualism likely lagged behind
other psychiatric phenomena with much higher preva-
lence rates, expert consensus clearly concluded that
there was sufficient indication of clinical usefulness and
acceptability for these two disorders to be considered for
the DSM-III. In this respect, the reliance on expert
consensus regarding parameters that justified inclusion
was probably not much different from the many other
DSM diagnoses, such as borderline personality disorder
or narcissistic personality disorder, that had not been
subjected to more systematic field trials (Zucker &
Spitzer, 2005
,p.37).
The World Health Organization (1992) followed the
DSM-III’s lead in 1992’s ICD-10 and included the diagnoses
of transsexualism and gender identity disorder of childhood.
It should be noted that while the two GID diagnoses are
grouped together in DSM, treatment approaches for GIDC seem
at marked variance from the treatment philosophy of GID in
adolescents and adults. In the latter case, successful treatment of
gender dysphoria through sexual reassignment seems relatively
uncontroversial.
51
However, there is much controversy about
the treatment of GIDC. Until recently, in cases of GIDC in very
young children, treating gender dysphoria to prevent transition
in later life was felt to be a legitimate goal. Only when such
efforts fail would transition be sanctioned (Wallien & Cohen-
Kettenis, 2008; Zucker, 2008a, 2008b).
It is beyond the scope of this paper to review all the issues in
the debates regarding appropriate treatment of gender variant
children. It should be noted, however, that changing cultural
attitudes about what exactlyconstitutes ‘appropriate’ expres-
sions of gender are leading some clinicians to encourage par-
ents in helping their children transition at earlier ages (Ken-
nedy, 2008;Rosin,2008; Spiegel, 2008a, 2008b). Further-
more, as in the case of homosexuality in the 1970s, LGBT
49
A search of the largest psychoanalytic data base, PEP-WEB (http://
www.pep-web.org/), shows that the term ‘gender identity’ only ap-
pears in the psychoanalytic literature for the first time in the 1964 Stoller
paper.
50
Stoller’s hypothesis of a ‘blissful symbiosis’ between mother and
son as a ‘‘cause’’ of GID is disputed by Coates (1990, 1992; Coates &
Wolfe, 1995), who argues for some combination of inborn, biological
temperament and alternative family dynamics as factors predisposing to
GID of childhood.
51
However, see Chiland (2003), Hertoft and Sørensen (1978), and
McHugh (1992) for critical views of SRS.
Arch Sex Behav (2010) 39:427–460 439
123
advocacy groups have had some recent successes in changing
professional opinions about GID diagnoses. For example, in
November 2008, ‘After repeated contacts’ from the Swedish
Association for Sexuality Education (RFSU) and the Swed
ish Federation for Lesbian, Gay, Bisexual and Transgen
der Rights (RFSL), the Swedish National Board of Health and
Welfare (Transvestitism no longer, 2008), a governmental
agency made Sweden the first country to remove the GIDC
diagnosis from the Swedish version of the ICD-10, citing its
potential, along with five other diagnoses, of being offensive
and contributing to prejudice.
52
The Swedish diagnostic man-
ual, however, will retain the Transsexualism diagnosis in or-
der to continued providing sex reassignment.
Homosexuality and GID: Parallels
Many trans activists, with the support of LGB and straight
allies, are calling for removal of the GID diagnoses. In many
respects, these calls resemble historic arguments that led to
the 1973 removal of homosexuality from the DSM-II.
The Parallel of Turning Sin into Illness
Traditionally, religion has played a strong role in codifying
socially acceptable expressions of gender and sexuality. Gender
beliefs about the proper roles of men and women are firmly
rooted in Judeo-Christian and other traditions that regard gender
role transgressions as grounds for censure and castigation—
even punishment by death. Given the historical conflation of
gender expression and sexual orientation, biblical prohibitions
against homosexuality are, at times, framed in language that
describes men as transgressing their ‘natural’ (that is, God-
given) gender roles:
Thou shalt not lie with mankind, as with womankind: it is
abomination. (Leviticus 18:22)
If a man also lie with mankind, as he lieth with a woman,
both of them have committed an abomination: they shall
surely be put to death; their blood shall be upon them.
(Leviticus 20:13)
And likewise also the men, leaving the natural use of the
woman, burned in their lust one toward another; men with
men working that which is unseemly, and receiving in
themselves that recompence of their error which was
meet. (Romans 1:27)
Know ye not that the unrighteous shall not inherit the
kingdom of God? Be not deceived: neither fornicators,
nor idolaters, nor adulterers, nor effeminate, nor abusers
of themselves with mankind, nor thieves, nor covetous,
nor drunkards, nor revilers, nor extortioners, shall inherit
the kingdom of God. (I Corinthians 6:9).
53
In addition to condemning sexual transgressions, some
biblical passages touch upon what would today be referred to
as transvestism and transsexualism. For example, Deuter-
onomy 22:5 explicitly forbids cross-dressing: ‘‘The apparel
of a man shall not be upon a woman and a man shall not wear
woman’s garments for anyone who does these is an abomi-
nation to the Lord.’’ In orthodox Jewish traditions, Leviticus
22:24, ‘And one that is bruised, or crushed, or broken, or cut
in the testicles, shall ye not offer unto the Lord; and in your
land shall ye not make the like,’ is interpreted as a prohibition
against castrating both animals and human beings and is ta-
ken to forbid sex reassignment surgery.
54
For centuries, religious views and the legal consequences
of those prohibitions held sway.
55
However, accompanying
the rise of Western secularism, in the mid-19th century,
scientific and medical explanatory models of nature sought
to supplant religious and supernatural explanations. Yet, ‘as
ecclesiastical authority began to wane with the rise of the
modern state, the religious abhorrence of homosexual prac-
tices was carried over into secular law’ (Bayer, 1981, p. 17).
In the process of casting a critical, scientific eye on a range of
what were then deemed to be socially unacceptable behaviors,
many ‘sins’ would eventually come to be classified as ‘ill-
nesses’’: demonic possession redefined as insanity, drunkenness
as alcoholism, and sodomy as an illness called homosexuality.
Bayer (1981) contends that this was a model ‘inspired by the
vision of a thoroughly deterministic science of human action.
It rejected the ‘pre-modern’ stress on will and the concomi
tant moral categories of right and wrong. Instead it sought the
causes of deviance in forces beyond the control of the individ-
ual’’ (p. 18).
Yet, by the mid-20th century, critics of psychiatry and the
medical profession would argue that psychiatric disorders
merely reflected existing social attitudes and prejudices and
that they were often nothing more than forms of social control.
52
The other five diagnoses are F64.1, Dual-role transvestism; F65.0,
Fetishism; F65.1, Fetishistic transvestism; F65.6, Sadomasochism, and
F65.6, Multiple disorders of sexual preference. See ‘‘Transvestism ‘no
longer a disease’ in Sweden,’ published November 17, 2008; retrieved
from http://www.thelocal.se/15728/20081117/, February 15, 2009.
53
Other biblical passages interpreted as prohibitions against homo-
sexuality can be found in Genesis 19, Leviticus 18:7, Judges 19, I Kings
22:46, II Kings 23:7, and I Timothy 1:9–10.
54
Thanks to Naomi Mark for the Biblical references as well as the
information regarding their current interpretations within the orthodox
Jewish community.
55
Boswell (1980, 1994) challenges the historical view of a linear
tradition of condemnation, arguing that in different historical eras the
western church tolerated same-sex relationships. Boswell (1980) and
Gomes (1996) point out the selective use of biblical prohibitions by reli-
gious authority figures. Gomes (1996) and Helminiak (1994) offer alter-
native religious interpretations of traditional religious dogma condemn-
ing homosexuality.
440 Arch Sex Behav (2010) 39:427–460
123
The most telling example of medicine’s history of diagnostic
excess—and one easilyheld up forridicule—isdrapetomania,
a 19th century ‘disorder of slaves who have a tendency to run
away from their owner due to an inborn propensity for wan-
derlust’ (Schwartz,1998, p. 357). Szasz (1960),a psychiatrist,
psychoanalyst, and spokesperson for a nascent anti-psychiatry
movement, declared mental illnesses to be myths, no more
than metaphors for physical illness. He characterized psychi-
atric nomenclature as an effort by mental health practitioners
to exercise control in the guise of ‘providing treatment’’ for
individuals by first defining them as ‘patients’ and then
labeling their thoughts, feelings, and behaviors as ‘symp-
toms of imaginary ‘diseases.’ For Szasz (1965, 1974a), psy-
chiatry’s diagnosis of homosexuality was a prototypical ex-
ample of social control as was the medical model of drug
addiction and the concomitant criminalization of drug users.
Although few psychiatrists today would accept Szasz’s
line of reasoning, particularly his theory of schizophrenia
(Szasz, 1974b), his arguments regarding the social context
of diagnosing mental disorders are not completely without
merit. For example, the first edition of the DSM (APA, 1952)
explicitly and non-self consciously articulated a role for
social values in making a diagnosis of the overarching cate-
gory of sociopathic personality disturbances which included
homosexuality: Individuals to be placed in this category are
ill primarily in terms of society and conformity with the
prevailing cultural milieu, and not only in terms of personal
discomfort and relations with other individuals’ (p. 38, my
emphasis).
While physicians and psychiatrists are often accused of
seeking power and control, there are also altruistic reasons for
turning ‘sinners’ into ‘patients’’: the medical model’s promise
of hope for treatment and cure. An ill person was not necessarily
responsible for his or her ‘symptoms,’ and, in the best of cir-
cumstances, would benefit from therapeutic compassion rather
than religious judgment and condemnation.
The stigma of psychiatric illness and the paternalism of
medical practitioners notwithstanding, many ‘homosexuals’
accepted, if not embraced, the medical model as an alternative
to religious and legal condemnation. While some saw in the
illness model hopes for a ‘cure,’ Bayer (1981) sees a more
practical concern:
Since the threat of criminal prosecution was the im-
mediate danger, it is not surprising that homosexuals
did not attack the standard psychiatric view of sexual
deviation. With professional support hard to come by, it
would have been surprising if those attempting to foster
legal reform had diverted energy to the attack of those
who argued that homosexuality was an inappropriate
target of the criminal law (pp. 67–68).
By the 1950s and 1960s, ambivalence toward the medical
model would play out in the publications of the American
homophile movement
56
as its members and allies openly
debated the relative social merits and costs of pathologizing
homosexuality. For example, Cory
57
(1965) spoke not only
for retaining the medical model but also defended the mental
health professionals coming under attack from an increas-
ingly militant homophile movement:
Once the name was Edmund Bergler [1956]; today it is
Albert Ellis I am more and more convinced that the
homophile movement in the United States will do
great harm to its struggle if it gets into a head-on clash
with men of science whose work it finds threatening:
and that there is nothing inconsistent between accep-
tance of the work of psychotherapists who report suc-
cess, nay cure, and the struggle for the right to par-
ticipate in the joys of life for those who cannot, will not
or do not undergo such change (pp. 8–9).
By the mid-1960s, Cory’s approach—advocating for gay
people to have access to treatment of their homosexuality and
for the gay community to collaborate with psychiatrists who
pathologized