Jack Drescher. Journal of Gay & Lesbian Mental Health. Volume 16, Issue 2. 2012.
The 1973 American Psychiatric Association (APA) decision to remove homosexuality from the Diagnostic and Statistical Manual (DSM) could be regarded as the culmination of almost 100 years of psychiatric theorizing about and attitudes toward the subject of homosexuality (Bayer, 1981; Drescher & Merlino, 2007). In the 19th century, as part of a general shift from religious to scientific models of understanding human behavior, psychiatrists began classifying homosexuality as a mental disorder (Krafft-Ebing, 1886/1965). As the Western world’s conceptual paradigm shifted from religion to science, many “sins” were reclassified as “illnesses.” Demonic possession became insanity, drunkenness became alcoholism, and sodomy became homosexuality (Bayer, 1981; Szasz, 1965, 1974).
The word “homosexual” first appeared in 1869 in a political manifesto written by Hungarian journalist Karl-Maria Kertbeny (Karoly Maria Benkert) in a critique of Bavarian laws that criminalized sexual relations between men (Bullough, 1979). However, the German psychiatrist Richard von Krafft-Ebing popularized the term in his classic sexology text Psychopathia Sexualis, first published in 1886. As a physician writing about the diverse sexual activities and gender presentations of various people, he and those for whom he was writing naturally presumed that all the presentations he catalogued were “sexual disorders.”
Freud took issue with this conceptualization of homosexuality as a disease. In Three Essays on the Theory of Sexuality (1905/1953), he disagreed with Krafft-Ebing’s theory of homosexuality as a form of “degeneracy,” a 19th century neurological theory that attributed mental disorders to decadent lifestyles. Freud noted that homosexuality was found in primitive cultures (which therefore could not be decadent) as well as in ancient Greece and Rome at the height of their civilizations. Further, he noted that “it is similarly found in people whose efficiency is unimpaired, and who are indeed distinguished by specially high intellectual development and ethical culture” (Freud, p. 138).
Freud offered an alternative theory of homosexuality: as a normal step in human development. However, he labeled those whose homosexuality persisted into adulthood as having what he called a “developmental arrest.” In Freud’s view, although not quite an illness, adult homosexuality was not quite normal. His was a theory of immaturity (Drescher, 1998, 2002). Calling someone “childish” is not as offensive as calling someone “sick.” However, neither term is particularly complimentary.
Although Freud believed homosexuality was not a “neurotic” illness, after his death in 1939 the psychoanalysts who followed him would disagree. A landmark paper by Sandor Rado in 1940 was particularly influential. Rado, a Hungarian émigré to the United States, would go on to found the Columbia Psychoanalytic Institute (Roazen & Swerdloff, 1995). His view, which would be adopted by psychoanalysts in the United States and abroad, was that heterosexuality was the normal end goal of human development and that homosexuality represented an avoidant anxiety of the other sex. In this nosology, homosexuality is an anxiety disorder and in some cases even a psychotic disorder. Those who followed in Rado’s footsteps saw “homosexuals” as having less developed levels of psychological functioning than others and described them as “narcissistic” or “perverse” (Bieber et al., 1962; Socarides, 1968; Kernberg, 1975; McDougall, 1980).
As one of these theorists, Joyce McDougall (2001), notes in her later work, her often-cited theory of female homosexuality “was based on a small number of analysands and I drew conclusions that, as a young and inexperienced analyst, I believed could apply to female homosexuality in general” (p. 6). This approach was true of much psychoanalytic theorizing about homosexuality, which was mostly based on prison populations and patients coming in for mental health issues rather than the general population.
In contrast to the case studies used to develop psychoanalytic theory, field studies are the means by which sex researchers learn about the population. Sex researchers leave their offices, speak to subjects in the wider world, and usually talk to individuals who are not psychiatric patients. A view of homosexuality that regarded it as a normal variation of human sexuality emerged from this perspective.
Theories describing homosexuality as a normal variation of human sexual expression have been present since the mid-19th century (Ulrichs, 1864/1994; Ellis, 1905/1978; Hirschfeld, 1914/2000). However, in the mid-20th century, Alfred Kinsey and his associates from Bloomington, Indiana (Kinsey et al., 1948, 1953) contributed to the increasing popularity of this perspective. The first Kinsey Report dealt with male sexuality and the second with female sexuality. The 1948 volume, although published as an academic tome, nevertheless sold millions of copies to the general public. Kinsey found that homosexuality was not rare, that it occurs rather frequently, and, depending on how the data are sorted, 10-35% of the people he interviewed said they had engaged in some kind of homosexual activity in adulthood. This finding was at odds with the then-prevalent psychoanalytic theory that adult homosexuality was a rare condition. Kinsey’s conclusion could be summarized as, “If it’s that common, how can it be a disease?”
The issue of prevalence was also taken up by Kinsey’s collaborators. Ford and Beach (1951) published a report showing that homosexuality occurs across different cultures, that different cultures have different attitudes about it (both accepting and rejecting), and that homosexuality appears in nature in various animal species. The latter fact contradicted the then-common belief that homosexuality only occurs in animals who are caged, in zoos, or in other “unnatural” conditions.
A groundbreaking study by Evelyn Hooker, a California psychologist, was published in 1957. Her research involved 30 gay men and 30 heterosexual men, none of whom were patients. She administered three projective tests (the Rorschach, Thematic Apperception Test [TAT], and Make-A-Picture-Story [MAPS] Test) to each of the 60 men and then asked the leading experts on each test to interpret them. However, she did not tell these experts who was gay and who was not. None of the three raters found evidence for greater psychopathology in the gay group than in the heterosexual group. These results, again, were at odds with the psychoanalytic perspective of the time. Psychoanalysts considered homosexuality to be not just a sexual disorder, but a global disorder of function. Using current terminology, psychoanalysts claimed that homosexuality was only found in the narcissistic, borderline or psychotic range of development. Hooker’s study, which was reproducible, unlike psychoanalytic reports, disproved that.
Hooker’s work did not get much psychiatric or psychoanalytic attention. Further, the psychoanalytic community’s responses to Kinsey’s findings were quite hostile (Lewes, 1988). It would take gay activism following the 1969 Stonewall riots (Duberman, 1994) in New York City to force a confrontation between the two theories.
Following Stonewall, there was an energized national movement of gay and lesbian activists who knew that one of the biggest obstacles to achieving equality for gay people was the psychiatric diagnosis of homosexuality. The activists “zapped,” that is, disrupted, the 1970 APA meeting in San Francisco (Bayer, 1981; Gittings, 2008; Kameny, 2009; Silverstein, 2011). These activities succeeded in getting the attention of APA, and the activists were offered the opportunity to speak on a panel at the 1971 meeting. There they presented their perspectives as nonpatient “homosexuals” talking about themselves and the impact of the psychiatric diagnosis on their lives.
At the 1972 meeting, activists organized another panel but wanted a gay psychiatrist to appear with them. But where could one find an openly gay psychiatrist in 1972? At the time, homosexuality was illegal in most states. A physician could lose his license for engaging in “immoral behavior” that was against the law. He would certainly lose his job and would never get patient referrals. The solution was for Dr. John Fryer to appear in a mask as Dr. H. Anonymous (Scasta, 2002). He did so on a panel with Barbara Gittings and Frank Kameny.
Fryer wore a rubber Richard Nixon Halloween mask, a fright wig, and an oversized tuxedo. Speaking through a voice-disguising microphone, he had several comments, including:
I am a homosexual. I am a psychiatrist … We … psychiatrists who are homosexual, we must know our place and what we must do to be successful. If our goal is academic appointment, a level of earning capacity equal to our fellows, or admission to a psychoanalytic institute, we must make certain that no one in a position of power is aware of our sexual orientation or gender identity. Much like the black man with the light skin who chooses to live as a white man, we cannot be seen with our real friends—our real homosexual family—lest our secret be known and our dooms sealed. (Scasta, 2002, pp. 80-81)
During this same period, scientific committees within the APA were also reviewing the question of whether or not homosexuality should be classified as a disorder. The opposing sides presented their views, and the issue was discussed in various APA components and committees. Finally, it was the judgment of APA’s scientific committees that the sexology literature carried greater scientific weight than the psychoanalytic literature. As a result, the Board of Trustees of the APA voted to remove homosexuality from the DSM-II.
In response, a dissatisfied psychoanalytic community, armed with 200 gathered signatures, petitioned APA to force a membership referendum about the Board’s decision. The result of the vote was that 58% of the 10,000 voting APA members supported the decision. Somewhat ironically, the losing side in the referendum would often maintain “one cannot decide science by a vote” (Gadpaille, 1989). However, those who said this often failed to mention that they were the ones who asked for a vote in the first place. As to the issue of whether scientists should vote on scientific matters, in 2006, astronomers—and there is no harder science than astronomy—voted on whether or not Pluto should be considered a planet (Vedantam, 2006). Even in the hardest of sciences, some decisions about interpretation of the data are made by group consensus.
More importantly, at the time, APA members were not actually voting on whether or not homosexuality was an illness. Most of them considered it to be a disorder because almost every psychiatrist of that generation was trained in a pathologizing model. What psychiatrists voted to support was APA’s scientific process of reviewing the issue and to accept the expert consensus of their professional community.
The Cultural Aftermath of the APA Decision
In the wake of the APA decision, social acceptance of openly gay men and women gradually reached unprecedented levels. In part this was because religious, government, military, and educational institutes were deprived of a medical or scientific rationalization for discrimination. Prior to the APA decision, one could prevent “homosexuals” from doing any number of things, including immigrating to the United States, because doctors classified them as having a mental disorder. Once homosexuality was no longer a mental disorder, it no longer provided a rationale for exclusion. Nevertheless, it is notable that the Immigration and Naturalization Service did not officially remove homosexuality as a barrier to immigration until 1990.
It took a long time for the changes effected by the APA decision to work their way into the wider culture. As a result, a new cultural perspective gradually emerged:
| 1. | If homosexuality is not an illness, and |
| 2. | If one does not literally accept biblical prohibitions against homosexuality, and |
| 3. | If contemporary, secular democracy separates church and state, and |
| 4. | If openly gay people are able and prepared to function as productive citizens, then what is wrong with being gay? |
If there is nothing wrong with being gay, then what moral and legal principles should the larger society endorse if gay people were to freely and openly live their lives? Although in 1973 APA was not prepared to take up the issue of gay marriage, it was inevitable that the issue would arise. If gay people were no longer considered mentally ill and, like everyone else, had to organize their personal lives, how could society morally and legally allow them to freely do so?
Sociopolitical Issues
Any discussion of marriage equality or gay marriage requires some mention of the culture wars. The term’s modern usage is often credited to a book by James Davison Hunter (1991), Culture Wars: The Struggle to Define America. Hunter maintained that society had divided on social issues, in a polarizing way, so as to constitute two warring groups, defined primarily not by nominal religion, ethnicity, social class, or even political affiliation but rather by ideological worldviews. The term entered into broader awareness at the 1992 Republican Convention when then-presidential candidate and TV commentator Patrick Buchanan claimed, “There’s a religious war going on in our country for the soul of America. There’s a culture war that is as critical to the kind of nation we will one day be as was the Cold War itself.”
In a rough outline of the divisions in the culture war, one finds the following labels or categories:
| • | Conservatives versus liberals |
| • | Religious versus secular groups |
| • | Traditional versus progressive values |
| • | Believers in small or no government versus believers in a wider role for government |
| • | Believers in unrestrained markets versus believers in regulated markets |
| • | Republicans versus Democrats |
| • | Those who believe government should regulate sexual behaviors versus those with libertarian attitudes toward sex |
| • | Those who oppose gay rights versus those who support them |
| • | Those who are pro-life versus those who are pro-choice |
The abortion issue is an important example of how culture wars are fought, in part, as a public relations battle. Both sides present themselves as being “pro something” because it is almost always preferable to have a “positive” message that says what you are for rather than a “negative” message that communicates what you are against. This is why opponents of marriage equality rarely say they are “against gay marriage,” a negative message, but instead adopt a more positive message of being in favor of “traditional marriage.”
Contemporary marriage equality debates also raise questions about the definition and purposes of marriage. These may include:
| • | Transitioning to adulthood |
| • | Procreating and child rearing |
| • | Solemnizing relationships |
| • | Stabilizing society and maintaining traditions |
| • | Creating financial arrangements |
| • | Upholding civil rights |
Within the marriage debate, opposing arguments fall on either side of the existing political and social fault lines: conservatives versus liberals, Republicans versus Democrats, those who believe in an evolving Constitution versus those who believe in strict constructionism. The debates pit courts against legislatures and the older generation against the younger one. Surveys continue to show that younger people, including younger evangelical Christians, are more likely to support gay marriage and gay rights than their elders. The marriage debate pits religious against sectarian views as well as believers in so-called traditional marriage against those who support new family structures. Needless to say, marriages in the Bible do not resemble what people today call “traditional” marriages.
Though the marriage debate has, for the most part, fallen along existing divisions, it has also created cracks in existing sociopolitical alliances. For example, some members of the African-American community resent the adoption by the gay community of the language of their civil rights movement. There are also differences of opinion between social conservative and libertarian Republicans. Among Democrats, so-called Reagan or working-class Democrats do not see the marriage issue the same way as progressive Democrats do. Finally, in the gay community itself, there are differences of opinion about whether marriage equality is a good thing. Some argue for assimilation into the mainstream, while others believe unattached sexual liberation is the true definition of a gay identity.
The State(s) of Marriage Equality
What are the legal benefits of marriage? According to the U.S. General Accounting Office, marriage offers more than 1,138 federal benefits and responsibilities, not including hundreds more offered by every state (www.marriageequality.org). None of the federal benefits are currently available to same-sex couples due to the Defense of Marriage Act (DOMA). Today, if one is married in Massachusetts and one’s partner contributed money to Social Security (SS) and that partner dies, the surviving partner is not eligible for SS spousal benefits. Other denied benefits include bereavement leave and insurance and tax breaks. For example, the surviving spouse in a heterosexually married couple does not pay federal inheritance taxes on their joint estate. Married same-sex survivors are subject to federal inheritance taxes as the marriage is not legally recognized. Then there is the issue of citizenship: if one is in a heterosexual marriage and one’s spouse is a foreign national, the spouse is eligible to apply for U.S. citizenship. However a married same-sex couple does not have that option. Even today, gay spouses face the threat of deportation, although these deportations are not being pursued as vigorously as they had been in the past.
Marriage equality is now available in many countries in Europe, North America, and South America. In November 2010, the European Parliament declared that any civil documents, including birth certificates, marriage certificates, etc., issued in one European Union (EU) country must be recognized in all of them. This would mean that someone married in Belgium or Spain, which allows marriage, can go to Italy or Poland, which do not, and the latter states will have to recognize the marriages performed in the former. It remains to be seen how that declaration unfolds.
In the United States, there is marriage equality in Massachusetts, which set the U.S. precedent in 2004, as well as in Connecticut, Iowa, Vermont, New Hampshire, New York, and Washington, D.C. Some states, such as Rhode Island, Maryland, and New Mexico, although they do not allow permit same-sex marriage, will recognize those marriages performed in other states or countries.
There have been some reversals, however. For example, marriage equality passed by the legislature in Maine in 2009 was overturned by a referendum of 53% to 47%. In California, there has been a long and protracted legal battle over Proposition 8 and marriage equality that is discussed by Dr. Kertzner (2012, this volume).
“Civil union” is a term invented in 2000 by the Vermont legislature when ordered by the Vermont Supreme Court to find some type of equivalency to marriage. The legislators did not wish to use the term “marriage.” However, civil unions are not as transportable as marriage because most laws in most states affecting committed couples refer only to marriage and do not necessarily recognize civil unions as equivalent. In the United States, civil unions are available in New Jersey, Illinois, Hawaii, and Delaware. In fact, Delaware just passed a civil union bill in 2011 that will go into effect in 2012. In the EU, many countries including Austria, the Czech Republic, Denmark, France, and the United Kingdom have civil unions, as does Switzerland. In Latin America, countries are beginning to endorse civil unions as well. Despite setbacks in Maine and California, the direction continues to be toward increased recognition of marriage rights.
In the United States, domestic partnerships are another kind of legal union. Again, laws in other states do not necessarily treat these legal relationships as equivalent to marriage. Domestic partnerships exist in a number of states, including California, Nevada, Oregon, and Washington. Many local municipalities, such as New York City, also have domestic partnerships.
In addition to the 1996 Federal DOMA, a majority of U.S. states have legislatively enacted mini-DOMAs or have held referendums creating constitutional amendments that prohibit recognition of same-sex marriages. Some states have enacted both mini-DOMAs and constitutional amendments. In certain states, these amendments are interpreted as prohibiting domestic partnership benefits. Although supporters of these amendments say that they do not oppose same-sex partnerships, as soon as a constitutional amendment passes, as happened in Michigan, supporters then moved to rescind domestic partner benefits for same-sex couples that had been granted by the Governor’s executive order.
There are currently several legal challenges to the federal DOMA. Some lower courts have already ruled that sections of DOMA are unconstitutional. In 2011, the Obama administration’s Justice Department said it would not defend DOMA and as a result the defense of the law has been taken up by the Republican-dominated House of Representatives.
Finally, the Full Faith & Credit Clause of the U.S. Constitution requires that official acts and proceedings of each state have to be recognized by other states. This means, for example, that a heterosexual couple married in New Jersey does not have to remarry when they move to Iowa. One’s heterosexual marriage contract is recognized in other states and in other countries. Today, with some states and countries now allowing and others prohibiting same-sex marriage, someone will have to decide which rules apply. The decision as to whether same-sex marriages performed in a US State or abroad should be recognized in US states banning them, will rest, of course, with the Supreme Court. Whatever that outcome, none of these changes in executing and discussing social policies that affect gay people would have occurred without the APA decision.