Gene A Nakajima. Journal of Gay & Lesbian Psychotherapy. Volume 7, Issue 1-2, 2003.
Organizational Background
Because the Association of Gay and Lesbian Psychiatrists (AGLP) and the American Psychiatric Association (APA) have been instrumental in organizing lesbian-gay-bisexual (LGB) psychiatrists internationally, a brief description of these groups will follow. How United States (US) and Canadian psychiatrists struggled to establish formal structures will be described because these efforts are relevant to international attempts to organize LGB mental health professionals.
The APA is the world’s largest psychiatric group with 37,000 members (American Psychiatric Association, n. d.). In 1973, it was the first major health organization to eliminate homosexuality as a mental illness (Monroe, 1974). AGLP was officially founded in 1985 as an organization independent of the APA. AGLP promotes its own positions on issues relating to homosexuality and has its own board, staff, and dues structure. With strong ties to the APA, AGLP serves as the organized voice of LGB professionals and patients in psychiatry in North America, and the organization currently has over 500 members (Haller, 2001).
AGLP traces its roots back to the late 1960s when LGB psychiatrists met at APA conventions and jokingly referred to themselves collectively as the “Gay PA” (Bayer, 1987). Eventually, this informal group evolved into the Caucus of Gay, Lesbian, and Bisexual (GLB) Members of the APA in the mid 1970s (Hire, 2001; Krajeski, 1996). While there is overlap between the AGLP and the APA’s GLB Caucus, they are in fact separate groups. The GLB Caucus is regarded as a minority group within the APA, and as such has one vote in the APA Assembly (Drescher, 2002). In 1978, the Caucus petitioned the APA to create a Task Force on Gay, Lesbian, and Bisexual Issues; the task force was subsequently upgraded to a Committee of Gay, Lesbian and Bisexual (GLB) Issues in 1981. The charge of the APA committee on GLB Issues is to:
- Investigate problems and issues which affect the mental health of the gay, lesbian and bisexual populations, such as stigmatization and discrimination;
- Develop teaching programs to help correct the inadequate training of psychiatrists about homosexual issues;
- Establish liaison with other [APA] components regarding homosexual issues; and
- Promote the education of the APA membership and the general public about homosexuality (American Psychiatric Association, 2001, pp. D66-67).
In addition to its interest in GLB issues, the APA has an ongoing interest in international psychiatry and psychiatric issues. The Council of International
Affairs-now renamed the Commission on Global Psychiatry-is responsible for creating most official international positions for the APA. In the past, the APA had an independent Office of International Affairs, which employed two full time staff members.
International Efforts in the Early 1990s
AGLP celebrated its 20th anniversary in 1998. During its early history, the organization focused its efforts primarily on US concerns. In 1992, Richard Isay, MD chaired the APA’s GLB Issues Committee. At an APA meeting, he attended a discussion about the World Psychiatric Association (WPA) and its upcoming World Congress of Psychiatry. The WPA is an international psychiatric association of representatives from national psychiatric groups. Currently, it is comprised of 115 affiliate member societies from 99 countries. Every three years it sponsors a World Congress during which resolutions are debated. Isay asked the APA to submit a resolution concerning homosexuality at the upcoming World Congress. This resolution was based upon an earlier landmark statement by APA on Homosexuality and Civil Rights, passed at the time when homosexuality was removed as a disorder from the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II) in 1973 (APA, 1968; APA, 1974). In December 1992, the APA Board of Trustees passed the following resolution, which the APA delegate proposed and which the General Assembly of the WPA passed in June 1993 in Rio de Janeiro:
Whereas homosexuality per se implies no impairment in judgment, stability, reliability, or general social or vocational capabilities, the WPA calls on its member organizations and individual members to urge the repeal of legislation that penalizes homosexual acts by consenting adults in private. And further, the WPA calls on these organizations and individuals todo all that is possible to decrease the stigma related to homosexuality wherever and whenever it may occur. (American Psychiatric Association Committee on Gay, Lesbian, and Bisexual Issues, 1993)
In December 1992, the APA Office of International Affairs-under the leadership of Ellen Mercer, a strong advocate for LGB issues-conducted a human rights survey of 125 psychiatric associations around the world. Thirty-four responded. The survey included three questions about homosexuality. Associations in 8 countries responded that the general feeling of their psychiatrists was that homosexuality was a mental illness. Eleven of the respondents stated that psychiatrists in their countries viewed homosexuality as deviant, even if homosexuality were no longer listed as a mental illness. Five of the responding societies did not believe that homosexuality was a mental illness or a deviation. The rest indicated that there was not a consensus about the issue in their country. Only 2 associations indicated that there were efforts in the psychiatric community to protect homosexual legal rights (Hausman, 1993). This survey pointed to the importance of educating psychiatrists worldwide that homosexuality is neither deviant nor an illness, and it demonstrated the need to encourage psychiatric associations to become involved in the civil rights of lesbian, gay and bisexual people.
In 1994, Mercer was working with an organization, the Geneva Initiative on Psychiatry, which disseminated education about human rights, including homosexuality. This organization collaborated with psychiatrists who had been isolated from international psychiatry before the fall of the Iron Curtain with the goal of reform in mental health in the former Soviet Union and East- ern/Central Europe. The Geneva Initiative produced a booklet concerning racism, sexism, and homophobia in psychiatry, which was published in several Eastern European languages, including Polish and Russian. Rochelle Klinger, MD, who succeeded Isay as chair of the APA Committee on GLB Issues, wrote an article for this booklet (Klinger, 1994).
Depathologization of Homosexuality in Japan
Through a US graduate student specializing in Japanese history, I became acquainted with OCCUR, The Japan Association for the Lesbian and Gay Movement, a leading gay rights group. In the summer of 1994, OCCUR members traveled to the US to solicit support for their landmark anti-discrimination lawsuit against the city of Tokyo. I met with Masaki Inaba who was working to encourage the Japanese Society of Psychiatry and Neurology (JSPN) to adopt an explicitly affirmative policy toward homosexuality.
They published a pamphlet that included a brief description of their efforts to change psychiatric attitudes towards homosexuality. The pamphlet explained that, in general, homosexuality was considered a disease by Japanese psychiatrists, and that Japanese textbooks described homosexuality as deviant. OCCUR had unsuccessfully tried to meet with the JSPN to discuss this issue. In addition, they demanded that the JSPN publish an “official opinion” on homosexuality. They requested that members of the international psychiatric community write letters to the JSPN to ask them to depathologize homosexuality, and to contact their own psychiatric associations and have them contact the JSPN directly as well (OCCUR, 1994).
I sent OCCUR the recently passed 1993 WPA resolution encouraging member societies to decrease stigma about homosexuality, as well as the results of the above-mentioned APA survey of psychiatric associations and homosexuality which included the following response from the JSPN:
In Japan homosexuality up to now has evoked little public or professional interest and has not been discussed among psychiatrists. Psychiatrists are aware that homosexuality has been deleted from the disorder categories of DSM and ICD, but their opinion about the nature of homosexuality at this time is not known.
I felt the best way to assist OCCUR was to request the APA to ask the JSPN to endorse officially the World Health Organization (WHO) position that “sexual orientation by itself is not to be regarded as a disorder” as published in the International Statistical Classification of Diseases and Health Related Problems, Tenth Revision, (ICD-10) (World Health Organization, 1992b, p. 367). I contacted Mercer at the APA’s International Affairs Office and drafted a letter for APA’s medical director, Melvin Sabshin, MD (Nakajima, 1995). I also contacted Klinger and Terry Stein, MD, who was then a member of the APA Council on National Affairs, to request that APA take official action. In his letter, Sabshin indicated that the APA had deleted homosexuality as a disorder in 1973, and that ego-dystonic homosexuality was deleted in 1987. He also cited the 1993 WPA resolution. He ended the letter, urging:
. . . the JSPN to join our [American Psychiatric] Association in making an official statement endorsing the ICD-10 position that homosexuality is not a disorder. In addition, I urge the [Japanese] Society to adopt the WPA Statement. I also urge the Society to work with OCCUR and other such groups to decrease the stigma of homosexuality in Japan. (personal communication, October 13, 1994, Letter to Board of Directors, JSPN)
Masahiro Asai, MD, the president of the JSPN replied. He said the JSPN had recently endorsed ICD-10’s position:
Concerning the official classification of diseases, the Japanese Government and the Ministry of Health and Welfare adopted ICD-10 as the official statistical classification of illness, injury and cause of death on and after the January 1st of this year 1995. ICD-10 had [been] translated into Japanese and officially published. ICD-10 “F66 Psychological and behavioral disorders associated with sexual development and orientation” has a note: “Sexual orientation by itself is not to be regarded as a disorder.” This sentence is translated into Japanese literally and included in the official Japanese classification.
We esteem ICD-10 as the official Japanese classification and are learning many things from ICD-10.
I hope [for] future good relationship between the APA and the JSPN. (personal communication, January 23, 1995, Letter to Sabshin)
Depathologization of Homosexuality in China
In the fall of 1997, I read an article about Wan Yan Hai, who was a visiting scholar at the University of Southern California. He was working to delete homosexuality as a mental disorder in China (Yanhai, 2001). At our first meeting, he informed me that the Chinese Classification of Mental Disorder-Second Revision (CCMD 2-R) acknowledged that homosexuality had been depath- ologized in the international classification, but it clearly stated that Chinese psychiatry did not follow those changes (Wah-shan, 2000; Lee, 1996; Chinese Society of Psychiatry (CSP) of the Chinese Medical Association, 1995). I again contacted Mercer from the APA Office of International Affairs to request that a letter to the CSP task force revising the CCMD be sent. Robert Cabaj, MD, a former AGLP president, also spoke to Sabshin, about contacting the CCMD task force. Coincidentally, Mercer was working on a joint meeting between officers of the CSP and the APA at a regional meeting of the WPA in Beijing in October 1997. She asked the President of the APA at the time, Herbert Sacks, MD, to mention to the CSP the importance of deleting homosexuality as a mental illness. Although he gave a plenary talk at the conference, he brought up the subject of homosexuality in the context of other human rights abuses in private meetings (H. S. Sacks, personal communication, March 30, 2002; Nakajima, 2001; Sacks, 1997). To contact AGLP members for their help and advice, I also helped Yan Hai write an article about the situation for the Newsletter of AGLP (Yanhai, 1997).
In March 2001, the CSP announced that it would eliminate homosexuality as a mental disorder in CCMD-3 (Lee, 2001). However, they decided to add ego-dystonic homosexuality (Chinese Society of Psychiatry, 2001). Although it is unknown how much influence the APA had in this decision, the CCMD task force acknowledged the APA’s encouragement to change the classification (Chu, 2001). The Chinese Society for the Study of Sexual Minorities also mentioned that the CSP sent members to attend the APA annual meeting in 2000 to solicit advice. The vice president of CSP, Chen Yanfang, MD, in announcing the change, stated that it brought China closer to the WHO and the APA positions (Chinese Society for the Study of Sexual Minorities, 2001). The task force also conducted a field study examining 51 gay men and found that their data did not support the continued inclusion of homosexuality as a mental disorder because only 6 had emotional problems (Mental Disorder Redefined, 2001; Wu, 2003). In both Japan and China, pressure from US psychiatry was helpful in efforts to depathologize homosexuality.
World Psychiatric Association (WPA)
Building on the work of Isay and the 1993 WPA resolution, I organized the first symposium on lesbian and gay issues at a World Congress of Psychiatry with Guy Glass, MD of New York and Siegmund Dannecker, MD of Berlin. Ulrich Gooss, MD, a psychiatrist from Frankfurt, and a co-chair of the German Federation of Gays in the Health Service (Bundesarbeits Gemeinschaft Schwule im Gesundheitswesen (BASG)), had attended the World Congress in Rio de Janeiro in 1993, and reported that there had been no lesbian-gay presentations. Through announcements in the Newsletter of the AGLP and at the 1995 Miami APA annual meeting, seven speakers were chosen for a symposium entitled Perspectives on Gay Affirmative Psychiatry for the Tenth World Congress in Madrid in August 1996 (Glass et al., 1996).
Glass introduced the symposium with “An overview of Gay Affirmative Psychiatry.” I presented on “Developing Gay Asian Identities in Confucian Cultures” while Francisco Gonzalez, MD, a Cuban-American psychiatrist spoke on “Homophobic Stigma and Culture” (Nakajima, 1996). Olli Stalstrom described the rise of sexual conversion or “reparative” therapy in Finland. Howard Rubin, MD spoke about the depiction of homosexuality in US psychiatric textbooks, focusing on changes in various editions of Kaplan and Sadock’s textbook. Jurgen Graffe, MD presented a study in which he had interviewed directors of psychoanalytic institutes in West Germany about admission of gay applicants (Stakelbeck and Frank, 2003). Mercer gave an overview of the APA resolutions and policies adopted by a number of international organizations concerning homosexuality. Sabshin, then the APA medical director and a member of the executive committee of the WPA, was the most prominent discussant. Because of his presence, many APA and WPA officials came to the symposium, and it was covered in the APA newspaper, Psychiatric News (Hausman, 1996). One of the leading national daily newspapers of Spain, El Mundo, covered the symposium as well (Velasco, 1996). Most important, for many of the international psychiatrists, it represented their first symposium devoted to lesbian-gay issues at a psychiatric meeting.
In Madrid, BASG and AGLP co-sponsored a networking meeting for lesbian, gay and bisexual psychiatrists. The process of obtaining a room from the WPA (greatly facilitated by Mercer) required over a year of effort including several faxes and phone calls. A couple of months before the meeting, we were suddenly informed that the APA was required to request a room from the secretary of the WPA. After this letter was sent, we were granted a room at the last moment. Several signs about the meeting were posted throughout the convention center; however, they needed to be replenished because they were torn down repeatedly. At the beginning of the meeting, two people from the company contracted to organize the conference barged in and demanded to know how we had obtained the room. Unfortunately, the final details were done by phone and we did not have written confirmation. Mercer took charge, presented her business card to the two people, and we proceeded with the meeting.
Over 40 psychiatrists from 20 countries attended, including Canada, Finland, the Dominican Republic, Switzerland, Germany, Poland, Spain, the Czech Republic, Chile, Argentina, United Kingdom, South Africa, Brazil, Mexico, Italy, Norway, the Netherlands, Sweden, the US, and France (Glass, 1996). Participants introduced themselves and spoke briefly about their experiences as gay psychiatrists in their countries. For many, it was the first opportunity to talk with LGB colleagues in a professional meeting. Because a large number of people from Spain did not understand English well, AGLP members, Ken Campos, MD and Gonzalez translated. Prior to the meeting, we discovered an advertisement for a practice of psychologists and psychiatrists called Grupo Les-Hom, Servicios Psicologicos Para la Poblacion Gai y Lesbiana in a Madrid gay newspaper. We contacted them, and they too attended the meeting. They subsequently arranged two informal dinners at local lesbian-gay restaurants, which facilitated further networking.
Given the difficulty obtaining a meeting room and in an effort to provide a mechanism for psychiatrists to organize internationally, it was decided to explore the establishment of a formal section of LGB issues in the WPA. Mercer provided us with the information to start a section. Initially, we needed ten psychiatrists (no more than two from a single country) to start an ad hoc section, which would then require approval by the WPA’s executive committee and subsequently the General Assembly at the next World Congress (World Psychiatric Association, 2000). We easily obtained the ten psychiatrists at the 1997 APA meeting, and Dannecker sent the request.
Ahmed Okasha, MD of Cairo, the WPA Secretary of Sections, wrote back that the executive committee had denied our request in their April 1998 meeting in Beirut (personal communication, Letter to Dannecker, April 20, 1998). The committee had also received a request to start a section on Human Sexuality, and he suggested that this section could accommodate our needs. Dannecker wrote back asking the executive committee to reconsider. We discovered that the original request had been to establish a section on Sexual Disorders and that the executive committee had broadened its compass to Human Sexuality. We wrote:
. . . Gay and lesbian concerns are not related to sexual disorders and their treatments. To associate our group with sexual behavior in this way would be a fundamental mistake that would send quite the wrong message to professionals and their patients around the world.
Most psychiatrists who are interested in Lesbian, Gay, and Bisexual Issues would assume quite rightly that “human sexuality” mostly deals with sexual disorders and their treatments, and only peripherally involves lesbian, gay, and bisexual issues. One of the important functions of a Lesbian, Gay, and Bisexual Issues section is to make it easier for psychiatrists interested in those issues to meet and exchange ideas from their home countries. We do not think that this coming together will happen in a Human Sexuality Section, which will have many different areas of focus.
Gay and lesbian issues are akin to those of a cultural group. Sexuality is only one part of the conception of what it is tobe gay or lesbian. To focus on sexuality would be to propagate the stereotype that gays and lesbians can be completely defined by sexual behavior. The principal need for this section is to provide a forum in which minority issues can be addressed, such as discrimination, homophobia in psychiatric training, and gay affirmative therapies. We cannot underestimate the importance of examining homophobia as a serious cause of affective disorders including depression and suicide, youth suicide, substance abuse, and its role in personality disorders. (Personal communication, Letter from Dannecker to Okasha, May 1998)
Dannecker and I also informally met with Okasha at the Toronto APA meeting in May 1998. We felt that he would not be sympathetic to our request for starting a section, and we were not surprised when he wrote back that the executive committee met again in Johannesburg and declined our second request:
… We reviewed with great care and concern your proposal to create a section of Lesbian, Gay, and Bisexual Issues in Psychiatry. The Executive Committee found that the scientific objectives overlap with the new ad-hoc Section entitled “Psychiatry and Human Sexuality” and your participation in this existing section will enrich the scope of the section.
The other issues you mentioned in your proposal such as depression, substance abuse, and suicide can be dealt with in the respective sections
As to the problem of discrimination, the Ethics Committee of the WPA is preparing some specific guidelines, one being on ethnic discrimination, but this can be extended in this Committee or the next to include ethical guidelines for discrimination because of sexual inclinations.
Enclosed you will find a copy of the letter sent by Professor Norman Sartorius, President of the WPA, to Dr. Hubschmid, President of the Swiss Psychiatric Association. (Personal communication, Letter to Dannecker, September 21, 1998)
Because of the rejection of our request for a section, we have decided to work with the Human Sexuality Section until we can start one of our own. Ruben Hernandez-Serrano, MD from Caracas, the former President of the International Association of Sexology, who had proposed the new Human Sexuality Section, became its head. He knew Carlos Greaves, MD, a Venezuelan American psychiatrist from Palo Alto, CA, and an active AGLP member. We invited Hernandez-Serrano to come to an AGLP meeting for international participants, which Greaves also attended, at the 1999 APA meeting in Washington, DC. Greaves and I subsequently attended the meeting of the Human Sexuality Section at the WPA Congress in Hamburg and are currently members. To show our willingness to collaborate with Hernandez-Serrano, I participated in a symposium that the Human Sexuality section organized in Hamburg, and spoke on the prevalence and treatment of sexual dysfunction in a study of 200 Asian and Pacific Islanders with HIV/AIDS in the US.
International conferences typically require a long period to review proposals for presentations, but the abstract submission deadline for the August 1999 Eleventh World Congress in Hamburg was unusually early-16 months before the conference. Because of several deadline extensions, we were able to organize 43 presenters of 69 abstracts into 16 symposiums. This large number of submissions appeared to disturb conference organizers. They rejected several of the symposia and asked that many be combined. By March 1999, only three symposia had been accepted, and several had neither been accepted nor rejected. Because of the large number of rejections, Dannecker and I met informally with the vice-chair of the scientific committee of the Hamburg conference, Wolfgang Gaebel, MD at the 1999 APA annual meeting. We gave him information about AGLP presentations, and he told us he had noticed how gay and lesbian topics had been integrated into the APA annual meeting. Eventually, six symposia were accepted with 26 speakers (World Congress of Psychiatry, 1999).
In Hamburg, LGB activities were expanded. Dannecker, with the help of BASG, organized a reception at the Magnus Hirschfeld Zentrum, Hamburg’s lesbian and gay community center. Over 75 people attended the reception funded by the Solvay pharmaceutical company. We organized two informal dinners, and rented rooms at a gay-lesbian hotel in Hamburg, where Cabaj led an informal discussion group on coming out as a gay psychiatrist, and Julie Leavitt, MD led one for lesbian participants.
The conference provided free booths for non-profit organizations like AGLP. Several hundred psychiatrists saw the booth, many visited, took copies of the Newsletter of the AGLP and membership brochures, browsed through books and samples of the Journal of Gay & Lesbian Psychotherapy. Some discussed issues about homosexuality in their countries. We also provided copies of the APA’s Fact Sheet: Gay, Lesbian, and Bisexual Issues, which summarized official APA positions (American Psychiatric Association, 2000a).
Cabaj held a signing for his Textbook of Homosexuality and Mental Health (Cabaj and Stein, 1996). A LGB organizational meeting sponsored by the Human Sexuality Section was arranged. The affiliation with a WPA section greatly facilitated this room request. During the meeting, a discussion was held on whether to start an international LGB psychiatry organization, but there was insufficient interest. However, attendees expressed interest in an Internet discussion list serve, which we hope to start soon.
Based on the work I had done with China and Japan, I felt that the issue of depathologizing homosexuality was an important one to press. I believed an official WPA position would be useful in countries like China whose psychiatric society, at the time of the conference, still considered homosexuality a mental disorder. I wanted to introduce a non-controversial resolution, which endorsed the ICD-10 stand depathologizing homosexuality. I assumed that it would be easy to pass since the WHO had already approved depathologization. The resolution stated:
Whereas in 1992, on the basis of large body of scientific research, the WHO deleted homosexuality as a disorder in the ICD-10, stating “sexual orientation by itself is not be regarded as a disorder,” the WPA calls on its member organizations and individual members to urge the elimination of homosexuality as a disorder in all medical and psychiatric textbooks and other nosologic systems. And further, the WPA calls on these organizations and individuals to do all that is possible to oppose any mental health evaluation or treatment which is based upon the assumption that homosexuality per se is a mental disorder.
This resolution was discussed at a conference call of the APA Council of International Affairs. It passed easily thanks to the help of Lawrence Hartmann, MD, a member of the Council and the first openly gay president of the APA. This resolution was the only one that the APA submitted for consideration at the WPA Hamburg meeting. Usually, the APA president is the US delegate for the WPA; however, this resolution was scheduled last for discussion in the General Assembly. Because it was brought up after midnight, the APA president at the time, Allan Tasman, MD, asked the immediate past president, Harold Eist, MD, to stay for the debate. Unfortunately the WPA failed to make a decision about the resolution after more than 30 minutes of discussion (Nakajima, 1999). Instead, the WPA Executive Committee is supposed to discuss this resolution and reintroduce it at the next General Assembly in Yokohama in August 2002. Ruedi Gloor, MD reports that since Hamburg, the WPA president has received positive input from representatives of some psychiatric associations, including the president of the Swiss Psychiatric Association, Tedy Hubschmid, MD (personal communication, March 15, 2000, Letter from Hubschmid to Okasha).
After Hamburg, AGLP organized a symposium and prepared a booth for a smaller conference in Paris in June 2000 celebrating the Jubilee (50th anniversary of the founding) of the WPA (Nakajima et al., 2000). At this meeting, I met informally with Eist who told me that he had strongly advocated for the resolution in Hamburg. However, the delegate from the United Kingdom during the debate asked how could it be certain that homosexuality is not a mental illness. Other delegates then expressed reservations about the resolution, and it was tabled. Eist, who is currently chair of the APA Commission on Global Affairs, has been asked by the WPA to be a consultant on this issue. Hopefully, this resolution will be brought up and passed without significant change at the Yokohama meeting. Soliciting national psychiatric associations to support the resolution will be important.
Starting an AGLP International Committee
In anticipation of the Madrid WPA Congress, Kenn Ashley, MD and I planned a meeting of international psychiatrists attending the 1996 New York APA annual meeting. The APA annual meetings are the world’s largest psychiatric conferences, and increasing numbers of international psychiatrists attend; 5,186 (33%) of the 15,949 who registered for the 2001 conference in New Orleans lived outside the US and Canada (Annual Meeting, 2001). Although international psychiatrists have attended LGB functions at the APA meeting, particularly workshops and symposia which were part of the official APA program, they rarely participated in most AGLP events. Major functions like the opening reception with more than 300 people made many feel “lost.” Most North American psychiatrists attending AGLP functions generally spent time with colleagues from current or past workplaces or with acquaintances from past AGLP functions. International psychiatrists often did not know many people at AGLP functions and did not feel included because they had not attended APA meetings regularly. Few psychiatrists outside North America joined AGLP, because of its primary focus on the APA annual meeting. Most international psychiatrists found out about AGLP events through posters or the information booth at the convention center. They discovered AGLP events late in the conference, missing many functions like the Saturday pre-convention symposium, the Sunday evening opening reception, or the closing dinner and awards ceremony on Wednesday, which required early reservations. By establishing a meeting time for international psychiatrists and interested North American AGLP members, we wanted to help them feel more welcome in AGLP. We placed notices about the meeting in the Daily Bulletin, an informational newspaper available at the annual APA meeting. We also placed signs in the International Hospitality Center, again with the assistance of Mercer. The meeting was listed in the Newsletter of the AGLP and the AGLP booklet listing LGB events at the conference.
At the first meeting, which took place in the AGLP hospitality suite, 12 international psychiatrists attended. Mercer answered questions about how to become an international member of the APA, which, among other benefits, reduces the annual meeting registration fee. An international psychiatrist who wanted to join the APA in the past needed three reference letters from APA members, which were usually difficult to obtain. By writing letters of reference, AGLP members have helped several international psychiatrists become APA members. At the meeting, we answered questions about AGLP, and international psychiatrists discussed the situation for LGB psychiatrists in their own countries.
For several years, AGLP had held a reception for LGB psychiatrists of color including Asian Pacific Islanders, African Americans, Latino/as, and other minority psychiatrists. In New York, we added international psychiatrists to this reception. We have continued to organize meetings and receptions for international psychiatrists, and these efforts have tremendously increased their participation at all AGLP events. For example, at the 2001 New Orleans APA meeting, over 40 international psychiatrists attended the international-minority AGLP reception, which was followed by a dinner. A reduced international rate for AGLP was introduced because most international psychiatrists did not attend APA meetings frequently. International members now account for seven percent of AGLP (Haller, 2001). Ashley and I currently chair a newly formed AGLP International Committee.
At the 1996 New York APA meeting, German and Dutch psychiatrists, who met at an AGLP symposium, planned and presented a workshop for the following year in San Diego called Gay and Lesbian Psychiatrists: A European Perspective (Dannecker et al., 1997). Proposing workshops is challenging for international participants because the deadline for submission is in September of the year before the May conference. In contrast to the US, where American Medical Association (1991) ethics guidelines do not allow physicians to accept paid trips from pharmaceutical companies, other countries do not restrict companies from providing support for psychiatrists to attend meetings. Because of financial constraints, many international psychiatrists will attend conferences only if they are sponsored, and they frequently do not find out about sponsorship until significantly after abstract submission deadlines. At the Toronto APA meeting, I organized another workshop by international psychiatrists, which included psychiatrists from Norway and Switzerland, titled International Perspectives on Gay Psychiatry (Nakajima et al. 1998). Dutch gay psychiatrists have presented two workshops at annual meetings, one called Gay Psychiatrists: An Amsterdam Perspective (Hettinga et al., 1998) and the other Narcissism Below Sea Level: A Dutch View of Future Gay Developments (Hettinga et al., 2001).
AGLP sponsors pre-conference symposia on the Saturday before the APA annual meeting. At the 1997 San Diego meeting, Nico Hettinga, MD gave a presentation titled “International Fears and National Affairs: Same-Sex Marriage in the Netherlands.” This paper was subsequently published in the Newsletter of the AGLP, the first article written by an international psychiatrist (Hettinga, 1998). International psychiatrists have helped AGLP members learn about mental health issues in other countries. Interestingly, most international psychiatrists who have presented at APA meetings except for the Dutch have not presented at their own psychiatric societies.
AGLP members have been active internationally outside the WPA. Terry Stein, MD presented a paper about eliminating ego-dystonic homosexuality from DSM-III-R at a conference sponsored by the International Gay and Lesbian Association and the University of Utrecht, in the Netherlands in 1987 called “Homosexuality beyond Disease.” Isay, after the publication of his book Being Homosexual: Gay Men and Their Development (1989), travelled to several European countries to lecture. His book has had several European printings and has been translated into several European languages (Stakelbeck and Frank, 2003). Kewchang Lee, MD presented a paper on Gay Asian Americans at the Seventh Scientific Meeting of the Pacific Rim College of Psychiatrists in Fukuoka, Japan (Lee, 1995). The Australian Gay, Lesbian, and Bisexual Interest Group in Psychiatry organizes a yearly conference which coincides with the Sydney Gay and Lesbian Mardi Gras (see Appendix for contact information). Cabaj presented at the third annual conference in 1997 and the fifth in 1999, while Ashley, Glass, and I presented at the fourth annual conference (Glass, 1998). Michael King, MD, President of the Section of Psychiatry from the Royal Society of Medicine organized a conference on Gay and Lesbian Mental Health in London in October 1997, at which Rubin and Isay presented papers (Gosling, 1998). King has subsequently started a Gay and Lesbian Mental Health Interest Group in the Royal College of Psychiatrists. To start an ongoing collaboration between the two groups, AGLP members Cabaj and Ronald Hellman, MD participated in a workshop with King at the Royal College of Psychiatrists’ annual meeting in Cardiff, Wales in June, 2002.
APA resolutions about homosexuality, largely crafted by its Gay, Lesbian, and Bisexual Issues Committee have been used internationally. For example, Reidar Kjaer, MD and colleagues used the APA resolutions against sexual conversion or “reparative” therapy to write a similar one which was adopted by the Norwegian Psychiatric Association (Kjaer, 2003; Kjaer and Selle, 2001; APA Committee on Gay, Lesbian, and Bisexual Issues, 1999; American Psychiatric Association, 2000b). Jack Drescher, MD, current chair of the APA Committee on Gay, Lesbian, and Bisexual Issues was contacted by Stalstrom because a Finnish member of Parliament was making arguments on the efficacy of conversion-“reparative” therapy, during debates on a proposed domestic partnership law. Drescher provided the Finnish government with the APA resolutions rejecting conversion-“reparative” therapy as well as the recent APA resolution endorsing same-sex unions (Hausman, 2001; Olarte, 2001; American Psychiatric Association Trustees, 2001).
Ralph Roughton, MD, the former Chair of the Committee on Issues of Homosexuality of the American Psychoanalytic Association and an AGLP member, was appointed to the House of Delegates of the International Psychoanalytic Association. He has been leading efforts to ensure non-discrimination for LGB applicants to psychoanalytic institutes worldwide (Roughton, 2003).
Future Goals
AGLP’s executive board and executive director have been extremely supportive of recent efforts to expand internationally. More psychiatrists outside North America are continuing to join AGLP and participate in its activities. Since the APA meetings attract so many international participants, integrating their needs into AGLP remains an important, ongoing task.
Much of what was accomplished in the past few years was made possible through strong advocacy from the APA. The International Affairs Office has been eliminated, and many of its functions have been subsumed under International Research Programs in the DSM Programs of the Division of Research (Tasman, 2000). In the future, the APA may not be as capable of proactive advocacy on LGB issues in international psychiatry because there may be less institutional support to do the work.
Although the WPA has not been open to formal recognition of LGB psychiatrists, continuing to work within the WPA structure is important. Many LGB psychiatrists attend their conferences and organize meetings and symposia. There are no other worldwide psychiatric meetings which leaders of national psychiatric associations regularly attend.
Although the resolution submitted by the APA in Hamburg was not voted on, a discussion of this issue among the delegates and their national psychiatric associations on how to vote in Yokohama is now in progress. At the time of this writing, we have begun preparation for the Twelfth World Psychiatric Congress in Yokohama in August 2002, and we are working with OCCUR, the Japanese activist group. Three lesbian-gay symposiums and workshops have been accepted. The Thirteenth World Psychiatric Congress will be in Cairo, September 10-15, 2005, and the Fourteenth will be in Prague in 2008. Two smaller meetings, International Congresses of the WPA, are tentatively scheduled for June 18-21, 2003 in Vienna, and November 10-13, 2004 in Florence and a regional conference in Caracas in for October 2-4, 2003 (WPA, 2002). A lesbian-gay-bisexual presence will be important at all those, as well as in regional WPA conferences. Hopefully, the current resolution will be passed and the WPA executive committee will reconsider starting aLGB section. Having such a section will be important until more interest is generated in starting an independent international LGB psychiatric organization.
In the event the WPA votes to endorse ICD-10’s position depathologizing homosexuality, working with the WPA on eliminating problematic diagnoses in the ICD-10 inconsistent with DSM could be a future goal. Although the WHO deleted homosexuality as a mental disorder in ICD-10, it included the diagnosis of “Egodystonic [sic] sexual orientation.” In the previous edition, ICD-9, homosexuality was listed under Sexual Deviations and Disorders, with the statement “Exclusive or predominant sexual attraction for person of the same sex with or without physical relationship. Code homosexuality here whether or not it is considered a mental disorder” (World Health Organization, 1977, p. 196). According to the ICD-10, April, 1988 Draft, the WHO, although eliminating homosexuality, considered adding three diagnoses: ego-dystonic sexual orientation associated with heterosexuality (Code F66.1); ego-dystonic sexual orientation associated with homosexuality (Code F66.2), and ego- dystonic sexual orientation associated with bisexuality (Code F66.3) (Junge, 1989; World Health Organization, 1988). Eventually, the WHO modified these three diagnoses into one, Egodystonic Sexual Orientation (Code F66.1), in the main ICD-10 volume that was published. The ICD-10 defines Ego- dystonic sexual orientation as “The gender identity or sexual preference (heterosexual, homosexual, bisexual, or prepubertal) is not in doubt, but the individual wishes it were different because of associated psychological and behavioural disorders, and may seek treatment in order to change it.”
The ICD-10 has two other problematic diagnoses. One is Sexual Maturation Disorder (Code F66.0):
The patient suffers from uncertainty about his or her gender identity or sexual orientation, which causes anxiety or depression. Most commonly this occurs in adolescents who are not certain whether they are homosexual, heterosexual, or bisexual in orientation, or in individuals who, after a period of apparently stable sexual orientation (often within a longstanding relationship), find that their sexual orientation is changing.
The other problematic diagnosis is Sexual Relationship Disorder (Code F66.2): “The gender identity or sexual orientation (heterosexual, homosexual, or bisexual) is responsible for difficulties in forming or maintaining a relationship with a sexual partner (World Health Organization, 1992b, pp. 367-8).” A supplementary ICD-10 volume, published on Mental and Behavioral Disorders with Clinical descriptions and diagnostic guidelines, suggests that the F66 diagnoses can be further subdivided more precisely by recording the sexual orientation with a fifth character code (Heterosexual (F66.x0), Homosexual (F66.x1), Bisexual (F66.x2), or Other, including prepubertal (F66.x8)) (World Health Organization, 1992a, p. 221; Drimmelen-Krabbe et al., 1994). Therefore, someone hypothetically with “Egodystonic sexual orientation, Homosexual” would be coded as F66.11. Of great concern is that unethical practitioners advocating for sexual conversion or “reparative” therapy may misuse these three diagnoses.
In the future, when committees form to consider ICD-11, elimination of Egodystonic Sexual Orientation, Sexual Maturation Disorder, and Sexual Relationship Disorder could be a goal for LGB psychiatrists worldwide. Having an international network of LGB psychiatrists could be instrumental in working with the WHO, WPA, and delegates to the ICD-11 committees. As a start, national psychiatric associations calling for the deletion of these diagnoses could pass their own resolutions. AGLP will need to work with the International Research Programs of the DSM Programs in the APA Office of Research to have the APA use its influence in the WHO to resolve favorably this major discrepancy between ICD and DSM.
Although a worldwide movement for LGB psychiatry has started, very few countries have formal or informal groups. Only the United Kingdom and US have formal groups within their national psychiatric associations. Some countries are starting to organize; for example, in Australia lectures and informal dinners have taken place at the Royal Australian and New Zealand College of Psychiatrists conventions. Canada (through AGLP), the US, and Australia have independent LGB psychiatry organizations. Hopefully in the future, more countries will formalize LGB psychiatry committees within their national psychiatry groups, which will ultimately strengthen international LGB psychiatry. With greater organization, goals, like education about LGB issues in psychiatry and the elimination of pathologizing diagnoses can be achieved.