The Decision to Remove Homosexuality from the DSM: Twenty Years Later

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The Decision to Remove Homosexuality from the DSM: Twenty Years Later*

Twenty years have passed since the 1973 APA decision to remove "Ego-syntonic Homosexuality" from the DSM. The question arises, and is here examined, as to whether and to what extent therapists have indeed removed ego-syntonic homosexuality from their lexicon of disorders.

The diagnostic criteria of "Ego-dystonic Homosexuality" (a category eliminated from the revised edition for reasons discussed below) in the DSM-III are well defined. They include the patient's complaint about absence or weakness of heterosexual arousal, as well as a sustained pattern of homosexual arousal that the individual explicitly states is unwanted and a persistent source of disorder. The strictness of the criteria is evident, for example, from the first differential diagnosis required, which excludes homosexuality that is ego-syntonic. Therapists are warned that a patient's own attitude ("I guess life would be easier if I were heterosexual"), or distress resulting simply from a conflict between a homosexual and society, should not be classified as ego-dystonic homosexuality. Therapists' are also warned not to use this diagnostic category for homosexuals who develop a major depression and may then express self-hatred because of their sexual orientation. The factors that predispose to ego-dystonic homosexuality are, according to the DSM-m, those negative societal attitudes toward homosexuality that have been internalized.(1)

Ego-dystonic homosexuality was eliminated from DSM-III-R(2) because "In the United States almost all people who are homosexual first go through a phase in which their homosexuality is ego-dystonic. Furthermore, the diagnosis of ego-dystonic homosexuality has rarely been used clinically and there have been only a few articles in the scientific literature that use the concept. Finally, the treatment programs that attempt to help bisexual men become heterosexual have not used this diagnosis" (p. 426). Persistent and marked distress about one's sexual orientation should be classified, according to DSM-m-R, as "Sexual Disorder Not Otherwise Specified."

It appears then that psychotherapists appear to hold liberal attitudes toward homosexual orientation, at least on the ideological and proclaimed level. Martin,(3) for example, expressed a position entirely in accord with that of the APA,(1,2) contending that when the effects of homophobia are partialed out, few differences remain between homosexuals and heterosexuals.

A similar trend appears in the survey of Gartell et al.,(4) about the attitudes of 908 psychiatrists toward lesbians: Almost all (98%) supported legalizing homosexuality between consenting adults; 66 percent objected to the use of psychiatric labels for the diagnosis of homosexuality among women; 87 percent stated that their conception of mental health includes homosexual-adjusted women; and 66 percent denied that homosexuality among women is pathological or defective.

These attitudes are also in accord with the updated psychological literature regarding human sexuality, which suggests that homophobia--rather than homosexuality--is the problem that has to be treated.(5,6)

Another trend that leads us to believe that therapists would take stances that are not biased in the direction of treating ego-syntonic homosexuality as a disorder is the evident successful adjustment of homosexuals. Several investigators found that nonpatient homosexuals do not differ from nonpatient heterosexuals in their adjustment,(7-9) or even that homosexuals are better adjusted than heterosexuals.(10,11)

The openly liberal attitude of psychotherapists toward homosexuality is not surprising in light of their politically liberal attitudes and secular orientation in the United States(12) as well as in Israel.(13) However, one should keep in mind that the studies suggesting that psychotherapists maintain liberal attitudes refer to the declarative level. …