from Clinical/Therapeutic Issues

To keep the historical record straight against the threat of psychological revisionism, NARTH will from time to time, publish articles which document pivotal events in the history of psychoanalytic and psychological thinking.

This 1978 article by NARTH past-president Charles Socarides describes the intellectual confusion and diagnostic inconsistency which led to the removal of homosexuality from the diagnostic manual. Those changes rendered chaotic, Dr. Charles Socarides notes, some very fundamental truths about unconscious dynamics.

Classical psychoanalysis conceptualized homosexuality as rooted in a fear-based emotional deficit. Yet when the A.P.A. removed the condition from its diagnostic manual, the Nomenclature Committee implied that (1) in homosexuality there are no clinical symptoms, (2) there is no course of development over time, and (3) there is no treatment. With that decision, decades of clinical theory and case study were immediately erased and considered irrelevant.

Dr. Socarides' paper is a classic from the clinical literature. In it, he critiques the A.P.A.'s new set of requirements for classifying a psychiatric disorder -- namely, subjective distress; impairment in social functioning; and intrinsic disadvantage. He explains why those criteria will never serve as accurate defining measures for a psychiatric disorder.

Psychoanalysts, he says, comprehend the meaning of a particular act of human behavior by delving into the motivational state which caused it. Not only is the concept of "disadvantage" not a psychoanalytic one, he notes, but disorders must not be dependent upon social criteria, without consideration of the unconscious motivation that drives them.

And even if "social disadvantage" were a legitimate criterion in defining psychiatric disorder, how could homosexuality NOT be a disadvantage? Heterosexuality, in direct contrast, has an innate biological and social usefulness. Therefore, using the "social disadvantage" criterion established by the APA itself, homosexuality would still be a disorder.

He also critiques the A.P.A.'s denial of "fundamental truths about...the interrelationship between anatomy and psychosexual identity."

Those words from Dr. Socarides have indeed proven to be predictive: today, there is a growing movement which conceptualizes gender as a personal choice--one which need not be correspondent with the person's biological sex. Gay activists have been mobilizing in order to rid the diagnostic manual of the category of Gender-Identity Disorder, and they are working to prevent clinicians from treating childhood gender-identity disorder as a problem--instead calling for an acceptance of a child's cross-gender behavior as expressive of "who that child really is."

Dr. Socarides provides a step-by-step account of the historical events leading to the normalization of homosexuality, the rationale presented by those who favored removal of homosexuality as a disorder, and the objections to this position held by other psychiatrists who were versed in the therapy of homosexuality.

(Reprinted by permission from the American Journal of Psychotherapy, Volume XXXII, Number 3, July 1978)

This paper presents an historical account and a critical analysis of the diagnostic problems surrounding our understanding of the sexual deviations and their position in our classification system.

Appropriate therapy can only be based on accurate diagnosis. Exceptions of this principle of psychiatric care cannot be made for social/political reasons without incurring formidable difficulties both for the diagnostician and the patient as well.

Introduction

"Being malcontent with diagnosis, if it leads merely to negativism or nihilism, does not constitute adequate reality testing...

"Psychiatric thought indeed carries enormous historical baggage; but if anyone simply seeks to divest himself of its unexamined bulk, the dangerous ignorance of such an act of bravado would doom him to repeating all the errors of the past."(1)

--P.W. Pruyer

If current views of the Task Force on Nomenclature and Statistics are approved, they will have far-reaching consequences to our understanding, research, and therapy of severe sexual disorders.

If such changes are due to social and/or political activism, neither the goal of individual liberties nor the best interests of society are served. These changes would remove from psychoanalysis and psychiatry entire areas of scientific progress, rendering chaotic fundamental truths about unconscious psychodynamics, as well as the interrelationship between anatomy and psychosexual identity.

The tragic consequences of the politicizing of the sexual area of diagnosis have already occurred, as homosexuality has been deleted as a psychiatric disorder from the latest printing (July 1974) of the DSM II, even from its bracketed position beside "sexual orientation disorder." This position misinforms psychiatry, the medical profession, individual homosexuals, their families and governmental agencies which are responsible for mental health policies and third party payments.

Leading authorities predict that the future may well be an era of mass preventive medical programs. Such efforts will hopefully include psychiatric preventive programs. A pillar of such efforts is the necessity for informed consent. Preventive medicine proponents cannot fulfill their obligations without an educated public as well as an educated medical and psychiatric profession.

From the very outset, the field of sexual disturbances has tended to be clouded in confusion and mystery. Poets, historians, philosophers, sociologists, anthropologists, and psychiatrists themselves have all played a part in making this one of the murkiest areas of science. Freud himself deplored the word "perversion," as it carried a moralistic connotation, but he continued to use it as there were no other suitable words available until 1905 when he coined the term "inversion" to signify homosexuality.

Ferenczi followed with his term "paraphilia" to denote the same disturbance. "Sexual variation" connotes a variety of normal behaviors, thus obscuring the nature of these conditions as true disorders. The term "sexual deviation" is more acceptable to many, as it neither moralizes nor normalizes.

Some behavioral sciences insist that there are no sexual deviations, only alternative or different lifestyles, and that these conditions are merely a matter of social definition, some made permissible by society, and others socially condemned. This is in keeping with the behavioristic point of view that all one could see, test, and modify was conscious behavior; and if human beings were allowed to express their sexuality freely, culture would change to reflect and accept all individuals as healthy. The conclusion drawn, as in the case of homosexuality, is: homosexuals are healthy; society is "sick"; consequently in order to remedy society's ills, fundamental changes in psychiatric diagnosis must be undertaken.

The Psychoanalytic Approach

Karlen, one of our leading historians in the area of sexual customs and behavior, comments that some scientists, psychologists and psychiatrists "...ransack literature for bits of fact and theory that can be placed together in a pro-homosexual or bisexual concept of nature, man and society... they raise false or outdated scientific issues in their war with traditional values."(2) Many of our values could use change, but scientific findings cannot be altered to meet the demands of social change.

Does "Commonly Occurring" Mean a Condition is Normal?

Some statisticians, beginning with Kinsey, behavioral psychologists, and psychiatrists (in contrast to most psychoanalysts) supply incidence rates of certain phenomena as if behavior had no connection with motivation. Since neither conscious nor unconscious motivation is even acknowledged, these studies arrive at a disastrous conclusion that the resultant composite of sexual behavior is the norm of sexual behavior. The next step is to demand that the public, the law, medicine, psychiatry, religion, and other social institutions unquestioningly accept this proposition.

With a remarkable prescience, Lionel Trilling (3), social and literary critic, predicted as early as 1948 that in the future--

Those who most explicitly assert and wish to practice the democratic virtues [will have taken] ... as their assumption that all social facts - with the exception of exclusion and economic hardship - must be accepted not merely in the scientific sense, but also in the social sense; in the sense, that is, that no judgment must be passed on them, that any conclusion drawn from them which perceives values and consequences will turn out to be "undemocratic." (p. 242)

The value of Kinsey's exhaustive and informative survey was that it enumerated the manifold forms taken by a force so powerful it cannot be denied expression. The enormous public curiosity in Kinsey's figures blinded most people to some of the erroneous interpretations to which some of the figures gave rise, especially in the area of homosexuality.

Psychoanalysts such as Bergler, Kubie, Kardner and later myself criticized Kinsey's findings as regards interpretations he derived from them. These conclusions and interpretations have become a banner under which have rallied political and social activists, psychiatrists, special advocates and even some of those who have been entrusted with the task of formulating and modifying the classification system. Trilling's penetration of the issue revealed the future arguments that would be used by anti-psychoanalytic forces to discredit the dynamic approach to sexual disorders. He commented:

[The Kinsey Report] rejects the conclusions of psychoanalysis, which makes the sexual content an important clue to, even the crux, of, character. It finds the psychoanalytic view unacceptable for two reasons: (1) the psychiatric practitioner misconceives the relation between sexual aberrancy and psychic illness because only those sexually aberrant people who are ill seek out the practitioner: ... (2) the emotional illness which sends the sexually aberrant person to find psychiatric help is the result of no flaw in the psyche itself that is connected with the aberrancy, but is the result only of the fear of social disapproval of his sexual conduct." (3, p. 238)

Psychoanalysts comprehend the meaning of a particular act of human behavior by delving into the motivational state from which it issues. In their investigative and healing aims, psychoanalysts and psychodynamically oriented psychiatrists continually ask three major questions:

1. "What is the meaning of an event or piece of behavior or symptom?" (cause searching):

2. "Where did it come from?" (end-relating, means to ends); and

3. "What can be done to correct things?" (healing function)

By studying individuals with similar behavior, we arrive at objective conclusions as to the meaning and significance of a particular phenomenon under investigation. Thus is insight achieved.

To form conclusions as to the specific meaning of an event simply because of its frequency of occurrence is to the psychoanalyst scientific folly. Only in the consultation room, using the techniques of introspective reporting and free association, protected by the laws of medicine and professional ethics, will an individual, pressed by his suffering and pain, reveal the hidden (even from himself) meaning and reasons behind his acts.

Using these techniques, it can thus be ascertained that the sexual deviations are roundabout methods of achieving orgiastic release in the face of overwhelming fears. It becomes apparent that the differences in sexual behavior are the different stimulation patterns aimed at releasing the orgiastic reflex. Thus the study of deviant sexual practices itself could be reduced to a simple proposition: the study of the method by which this reflex is released.

Sexual activities that are a result of unconscious fears and the inhibiting action of those fears may be considered reparative patterns (4). In direct contrast to the reparative patterns, situational and variational types of homosexuality are consciously motivated, not fear-induced, and the person is able to function with a partner of the opposite sex. In reparative forms, the sexual pattern is inflexible and stereotyped. If forced to participate in male-female sexual relations, the act is experienced, with little or no pleasure. Deviant sexual patterns are roundabout methods of achieving arousal and orgiastic release, as the usual channels for behavior are blocked by massive fears.

Psychoanalysis is a motivational psychology. By utilizing concepts of situational, variational and reparative (unconsciously motivated and fear-induced) motivations to categorize varieties of sexual behavior, we arrive at the answer to the question as to when certain sexual activities can be considered to be sexual deviations.

This basic principle was supplied by Freud in 1916 when he stated: Let us once more reach an agreement upon what is to be understood by the "sense" of a psychical process. We mean nothing other by it than the intention it serves and its position in a psychical continuity (5).

Thus, whether or not certain sexual practices can be termed sexual deviations can be determined by a study of the conscious and/or unconscious motivations from which they issue.

In addition to exclusivity, unconscious determinants, stereotypy of object choice, and incapacity to perform in any other way, it is evident upon studying a carefully taken case history that the developmental history of most individuals (whether male or female) suffering from well-structured sexual deviations usually shows severe disturbances in the preoedipal phase of development with concomitant object-relations conflict involving anxiety and guilt associated with self-object differentiation.

This type of conflict leaves unmistakable signs on the developing personality and its future maturation. There is usually a deep disturbance in approaching a person of the opposite sex, pronounced gender-identity confusion (either hidden or overt), and the predominance of archaic primitive mental mechanisms. Clinically, there are signs and symptoms of a continued undue fixation to the mother. Thus an in-depth life history is a central task to be undertaken before the diagnosis of true sexual deviation can be made.

Parenthetically it should be pointed out that many individuals with sexual deviations may be in many other ways highly developed both ethically and intellectually.

The sexual deviation itself neutralizes warring intrapsychic forces so that very often, these individuals are able to attain a high degree of personal development. Thus, with the exception of a sexual deviation, they may appear upon superficial examination to be without psychopathology except when subjected to penetrating investigation of their defensive system.

The theoretical chasm separating the above views from those of the current Nomenclature Committee is striking. When asked "What distinguishes pathological sexual behavior from a normal deviation?", its chairman asserts: "If the homosexuality is in conflict with the individual's own value system, then it is best to regard it as a mental disorder, since it then is likely to lead [my emphasis] to distress at the inability to function heterosexually."6

Historical Review

An enlightened, scientifically advanced classification of sexual deviations, correcting previous errors in the DSM 1 appeared in the first DSM II published in 1968 under the chairmanship of Dr. Ernest M. Gruenberg. It went through six printings until October 1973 and listed sexual deviations under the general headings of Personality Disorders and Certain Other Non-Psychotic Mental Disorders. It noted:

This category is for individuals whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances such as in necrophilia, pedophilia, sexual sadism, and fetishism. Even though many find their practices distasteful, they remain unable to substitute normal sexual behavior for them. This diagnosis is not appropriate for individuals who perform deviant sexual acts because normal sexual objects are not available to them (7).

Under the heading of Sexual Deviation were included homosexuality, fetishism, pedophilia, transvestitism, exhibitionism, voyeurism, sadism, masochism, and other sexual deviations. It should be noted that this classification utilizes the concept of motivation, as allowance is made for institutional and variational forms of homosexuality and other sexual practices. The obligatory nature of the sexual practice is noted in the statement, "...they remain unable to substitute normal sexual behavior..."

Under Dr. Gruenberg's guidance, an important advance was made over the previous classification in that the sexual deviations were removed from the general heading of Sociopathic Personality Disturbance--a term which connotes anti-social behavior and a deficiency in conscience formation. Furthermore, since the diagnosis of Sociopathic Personality Disturbance was reserved for "individuals... ill primarily in terms of society and of conformity with the prevailing cultural milieu..." (7), it successfully removed the sexual deviations from societal definitions.

In 1972, during his induction of the national meeting in Dallas, a vice-president of the American Psychiatric Association took the occasion to criticize severely any psychiatrist who practiced psychotherapy that attempted to change homosexuality to heterosexuality. According to a report in the June 7 issue of Psychiatric News, he labeled such colleagues cruel, inhuman, and a "disgrace to the profession." (8)

In early 1973, a group superheaded by several leaders of the A.P.A., other psychiatrists, and members of the Gay Activists Alliance, the Mattachine Society, and the Daughters of Bilitis undertook to influence the Nomenclature Committee of the A.P.A. at a closed meeting at Columbia University Psychiatric Institute by requesting deletion of homosexuality from the Diagnostic and Statistical Manual(9).

By spring 1973 the A.P.A. Committee on Nomenclature and Statistics was seriously considering the removal of homosexuality from the DSM II without consultation with the psychiatrists and psychoanalysts who had long labored in this area of clinical research, and held opposing views.

A Symposium held in Hawaii on May 9, 1973 was entitled "Should Homosexuality Be in the A.P.A. Nomenclature?" As a member of this panel, I presented the conclusions of the eleven-member Task Force on Homosexuality appointed in 1970 by the New York County District Branch of the A.P.A., of which I was chairman. (10)

In April 1972, after two years of intensive work, the members of the Task Force had unanimously agreed upon the following conclusions as regards male homosexuality:

(1) Homosexuality arises experientially from a faulty family constellation.

(2) It represents a disordered sexual development not within the range of normal sexual behavior.

(3) There is a continuity and severity of pathological parent-child relationships in the background of all homosexuals studied to an extent not found in the comparison groups.

(4) The majority of the mothers of homosexuals interfered with the development of their sons' peer group relationships, heterosexual development, assertiveness, and decision-making. The fathers of homosexuals were demasculinizing.

The New York County District Branch Task Force on Homosexuality concurred without question that societal rejection damages those who are rejected. However, if all criminal discrimination were to stop today and the punitive laws against homosexuals were repealed immediately - as indeed our Task Force recommended - the homosexual's inner anxieties would still not be eliminated.

This latter report was later disavowed by its parent body, whose local leadership deemed he issue too "controversial." (10)

At this meeting I further stated that current proposals to place homosexuality in a group of other sexual disorders such as premature ejaculation, retarded ejaculation and so forth, under the heading of "sexual dysfunction," would damage scientific knowledge. The sexual dysfunctions themselves are disturbances in the standard male-female coital pattern (a separate diagnostic entity both symptomatically and developmentally). Thus the immutable distinction between the sexual deviations and the sexual dysfunctions could not be semantically blurred without incurring formidable scientific chaos.

In addition, the view held by the Nomenclature Committee that in homosexuality there are no clinical symptoms, no course of development, and no effective treatment was in direct opposition to the Task Force's position on this issue, as well as to numerous other psychiatric and psychoanalytic contributions offered.

By October 1973, the proposed change to eliminate homosexuality from the DSM II went to the Council on Research and Development, then to the Assembly, and then to the A.P.A. Reference Committee. It was later announced that, "minor changes" were made in these committees, e.g., "Heterosexual Orientation Disturbance" was to be included along with homosexuality as a "sexual orientation disturbance" to identify those people who are "disturbed" at the knowledge that they are heterosexual! (11) It was decided a few weeks later that this was perhaps ill-advised, and heterosexuality as a disorder was deleted.

On December 14, 1973 the Board of Trustees of the American Psychiatric Association, meeting in Washington, D.C., eliminated homosexuality from the official Diagnostic and Statistical Manual without presenting substantive evidence for such a drastic revision of basic concepts of healthy vs. unhealthy sexual development. It should be noted that the World Health Organization's Diagnostic and Statistical Manual has not as yet followed suit.

One of the two reasons for the removal was an official position paper (12) prepared by Dr. Robert Spitzer (Chairman, Nomenclature Task Force on Homosexuality, A.P.A.) for the Board prior to its decision. According to an article in Psychiatric News, "It was essentially upon the rationale of Dr. Spitzer's presentation that the Board made its decision."(13) This paper in essence repeated Kinsey's earlier assertion that homosexuality did not meet the requirements of a psychiatric disorder since it "does not either regularly cause subjective distress or [is] regularly associated with some generalized impairment in social effectiveness or functioning."

The second was the conclusion of Drs. Marcel T. Saghir and Eli Robins in their volume entitled Male and Female Homosexuality. (14) These findings were derived from one structured lengthy interview with homosexuals (recruited through homophile organizations) and "unmarried heterosexual controls" (solicited by mail and paid for the interview), and coincided with the position paper above.

The term "sexual orientation disturbance (homosexuality)" was now to be substituted for homosexuality. It is defined as follows:

This is for individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation. This diagnostic category is distinguished from homosexuality, which by itself does not constitute a psychiatric disorder. Homosexuality per se is one form of sexual behavior, and with other forms of sexual behavior, which are not by themselves psychiatric disorders, are not listed in this nomenclature.(15)

In essence and by direct implication, this action officially declared that homosexuality of the obligatory type was a normal form of sexual life. Henceforth, the only "disturbed" homosexual is one who is disturbed that he is homosexual. He is to be considered neurotic only if unhappy. A referendum was demanded on this issue by 243 psychiatrists, members, and fellows of the A.P.A.

It was a credit to psychiatrists in general that in the referendum (marred by hidden lobbying by homosexual activists) held months later, more than 3700 psychiatrists (40% of the bare majority who voted) in the United States believed that there were no legitimate scientific reasons for the A.P.A.'s change in fundamental psychiatric theory. Only a handful, however, have continued to work for the reversal of this decision.

Aftermath

The removal of homosexuality from the DSM II was all the more remarkable when one considers that it involved the out-of-hand and peremptory disregard and dismissal not only of hundreds of psychiatric and psychoanalytic research papers and reports, but also of a number of other serious studies by groups of psychologists, psychiatrists, and educators over the past seventy years (the Group for the Advancement of Psychiatry Report, 1955; the New York Academy of Medicine Report, 1964; the Task Force Report of the New York County District Branch A.P.A. 1970-72). It was a disheartening attack upon psychiatric research and a blow to many homosexuals who looked to psychiatry for more help, not less.

The seventh printing of the DSM II, second edition, July 1974, reflected the changes voted upon. (15) A perusal of this printing revealed that the sexual deviations themselves were defined similarly to previous printings. Instead of homosexuality, however, the term "sexual orientation disturbance" was substituted. The terminological dilemma facing the Nomenclature Committee was evident in a footnote to the page on which it first appeared.

This term (sexual orientation disturbance) and its definition are inconsistent with the change in thinking that led to the substitution of Sexual Orientation Disturbance for Homosexuality in the list below. However, since no specific recommendations were made for changing this category or its definition, this category remains unchanged for the time being.

It should be noted that the term "sexual orientation disturbance" disserves not only the concept of disorder, but in addition the basic concept of orientation as used in psychiatry. It is a corruption of basic psychiatric terminology so essential in conducting the psychiatric examination.

Is Distress a Prerequisite for Disorder?

That the politicizing of homosexuality could have far-reaching effects on other theoretical and clinical concepts dealing with sexual conditions and the psychoanalytic view of them was quickly borne out. Revisions in the third edition of the DSM were proposed that would have further damaging effects on our understanding, research, and therapy of the remaining sexual deviations. The proposal made before the Assembly of the A.P.A. on May 3, 1975 made it a requirement that any sexual condition, in order to be termed a disorder, must "coexist with distress." (15) For example, a fetishist must experience distress to be considered as having a disorder.

A wave or protest both from individual psychoanalysts and psychoanalytic societies in this country greeted this proposal. It was obvious that this requirement ran counter to everything we know dynamically about mechanisms involved in these serious disturbances. For example, the enactment of any perversion helps keep the individual in equilibrium and neutralizes anxiety. It has been unconsciously specifically fashioned for this purpose. Therefore, the presence or absence of anxiety cannot be an adequate criterion to use when determining whether the condition is a disorder or not. Some of the most severely disturbed pedophiliacs have had no anxiety because of their constant enactment of the pedophilic act.

Furthermore, this proposal disregarded the following:

(1) The presence of a specific need, desire, compulsion, or other symptom formation may so circumscribe pathology, that a patient may appear to be functioning well in every other aspect of his life;

(2) Fully developed neurotic symptoms can mask illness as well as express it;

(3) The mechanism of perversion results in producing an ego-syntonic symptom, namely, one which allays and neutralizes anxiety.

Does Homosexuality Constitute a Disadvantage?

In 1976, the Nomenclature Committee introduced the concept of "disadvantage" into the rationale for declaring a condition a "disorder." But the view that the homosexual of the obligatory type is at no "social disadvantage" is a denial of the realities which surround us when one considers that a society governs the behavior of its members from birth to death through its laws, mores, and other institutions.

A human being is born with responses which constitute his mammalian heritage (a product of evolution). He is then introduced into a web of social institutions, a product of cumulative tradition, which constitute his cultural heritage. The two, mammalian and cultural heritage, lead man to his sexual pattern - heterosexuality.

Heterosexuality has a biological and social usefulness. It creates the family unit and allows men and women to live together under conditions where there is likely to be the least amount of fear, rage and hate. It furthermore regulates this relationship through a series of laws, penalties and rewards.

The Nomenclature Committee's present understanding and conceptualization of the sexual deviations was printed in the Newsletter of the American Psychoanalytic Association. (17) Thus the "general principles" which are guidelines for declaring the sexual deviation "disorders" are:

(1) subjective distress;

(2) impairment in social functioning;

(3) intrinsic disadvantage.

These principals, when examined closely as to their use and meaning, represent beliefs and concepts which are largely in direct opposition to dynamic concepts, psychoanalytic theory, and our growing clinical understanding of these conditions. If generally accepted, they could have far-reaching negative effects. Finally, it was conceded that it was "a foolish provisional approach" to insist that a sexual disorder could only be termed a disorder if it "coexisted with distress."

Furthermore, it was asserted that "all of the traditional sexual deviations are included in DSM III." A perusal of the latest publication (18) discloses that the phrase "sexual deviation" is nowhere to be found in the new nomenclature proposal.

Are Sadism and Voyeurism Truly "Arousal Disorders"?

The conditions referred to such as exhibitionism, voyeurism, sexual sadism, etc. are listed under the heading of "sexual arousal disorders," a phrase commonly used and understood to refer to those disturbances of performance in the standard male-female coital pattern. In fact, all sexual disorders are "sexual arousal disorders" in that there is a disturbance attendant to the achievement of orgasm. However, the sexual deviations owe their special configuration to earlier preoedipal disturbances not usually found in simple sexual arousal disturbances commonly represented by premature ejaculation, retarded ejaculation, etc. The former are usually due to object-relations conflicts, in contrast to the latter, which are usually the result of structural conflicts.

Even more disconcerting however is the reason given for listing exhibitionism, voyeurism, fetishism, etc. as disorders, namely, that they place the "individual at an intrinsic disadvantage since no society can generally tolerate such behavior." Not only is the concept of "disadvantage" not a psychoanalytic one, but it is evident that disorders are to be dependent upon social definition, giving little or not credence to the unconscious psychopathological determinants in the production of these serious sexual conditions.

Lastly, it is ironic that one of the main reasons put forth by those in favor of removing homosexuality from the DSM 2 was that it should not be considered a disorder because of negative societal attitudes towards it and therefore should be removed from our nomenclature!

In June 1977 a new draft of the DSM III was published in Psychiatric News (19). It includes several corrections to previous errors commented upon here, such as separating the "psychosexual dysfunctions" from the sexual deviations, now alluded to as the "paraphilias." Furthermore sexual disorders are correctly grouped under the general heading of Psychosexual Disorders.

However, transvestitism is removed from the sexual deviations and incorrectly placed under the heading of Gender Identity or Role Disorders. What is overlooked here is that all the sexual deviations involve some degree of gender-identity disturbance. While zoophilia, pedophilia, voyeurism, etc. are listed under the heading of paraphilia, the term "sexual orientation disorder" is nowhere to be found. In its place is a newly coined word, "dyshomophilia."

It appears that while the other "philias" are pathological, "homophilia" (not listed) is only a disorder where it is preceded by a prefix (dys) which in medical terminology is commonly used to signify a disturbance in a normal function. Thus "dyshomophilia" connotes "faulty homosexual love" or a disturbance arising from dissatisfaction with homosexuality. "Plus ca change, plus c'est la meme chose."

Finally, the view that "sexual politics" may not in the long run prevail over science was evident in the result of a poll of 10,000 psychiatrists by Medical Aspects of Human Sexuality in late 1977. Of 2500 replies received, approximately 68 percent answered the question, "Is homosexuality usually a pathological adaptation (as opposed to a normal variation)?" in the affirmative. This strongly suggested to the interpreter, Dr. Harold I. Lief of the University of Pennsylvania, that the previous "A.P.A. vote was influenced by political and social considerations [emphasis added] in that the vote was perceived as a step toward stopping the denial of rights to homosexuals."(20)

Summary

Prior to 1973, the Diagnostic and Statistical Manual had made valuable contributions our comprehension of the sexual deviations so that clinical research was beginning to fathom their ineluctable secrets. The "normalizing" of homosexuality and the consequent revision of the DSM reflecting this position cannot help but slow scientific progress, produce despair in those with a sexual deviation, and diminish efforts at prophylaxis based on sound principles of causation and treatment.

This author provides a step-by-step account of events leading to the "normalization" of one of the major sexual disorders, the rationale presented by those who favor removal of homosexuality as a disorder, and the objections to this position held by other psychiatrists versed in the therapy of these conditions.

Endnotes

1. Pruyer, P.W., Diagnosis and the Difference It Makes. Bull., Menninger Clinic, 40-411, 1976.

2. Karlen, A., Sexuality and Homosexuality, Norton, New York, 1971.

3. Trilling, I., The Kinsey Report, Partisan Review, April, 1948. (Also in The Liberal Imagination. Scribners, New York, 1976, p. 242.

4. Rado, S. An Adaptational View of Sexual Behavior. In: Psychosexual Development in Health and Disease, Hoch, P.H. and Zubin, J., Eds., Grune and Stratton, New York, 1949.

5. Freud, S. Introductory Lectures on Psychoanalysis (1916). Standard Edition, 15:40, London, Hogarth Press, 1963.

6. Spitzer, R.L., Medical Aspects of Human Sexuality, 10:142, 1976.

7. Diagnostic and Statistical Manual of Mental Disorders, DSM II, American Psychiatric Association, 1968, p. 44.

8. Psychiatric News, June 7, 1972.

9. Psychiatrists Review Stand on Homosexuals. New York Times, March 13, 1973.

10. Socarides, C.W., et al. Homosexuality in the Male: A Report of a Psychiatric Study Group, Int. J. Psychiatry 11:451, 1973. (Report of the Task Force on Homosexuality, N.Y. County District Branch A.P.A.).

11. Minutes, A.P.A. Council, Nov. 3, 19973.

12. Spitzer, R.L., The Homosexual Decisions - A Background Paper. Psychiatric News, Jan. 16, 1974, pp. 11-12.

13. Psychiatric News, Jan. 16, 1974, p. 11.

14. Robins, E. and Naghir, M.T. Male and Female Homosexuality. Williams and Wilkins Co. Baltimore, 1973.

15. Diagnostic and Statistical Manual of Mental Disorders, July, 1974.

16. Psychiatric News, June 4, 1974.

17. Newsletter of the American Psychoanalytic Association, December, 1976, vol. 10, no. 4.

18. Spitzer, R.L. and Sheehy, M. DSM 3: A Classification System in Development. Psychiatr. Ann. 6:446, 1976.

19. Psychiatric News, March 18, 1977.

20. Lief, H.I., Sexual Survey #4. Current Thinking on Homosexuality. Medical Aspects of Human Sexuality, 1:110, 1977.

Updated: 8 February 2008

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