DSM-II_Homosexuality_Revision.pdf

APA Document Reference No. 730008

Homosexuality and Sexual Orientation Disturbance:

Proposed Change in DSM-II, 6th Printing, page 44

POSITION STATEMENT (RETIRED)

Approved by the Board of Trustees, December 1973

Approved by the Assembly, November 1973

Approved by the Reference Committee, November 1973

'Policy documents are approved by the APA Assembly and Board of Trustees... These are ... position

statements that define APA official policy on specific subjects..." -- APA Operations Manual.

302.0 Sexual orientation disturbance (Homosexuality)

This category 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, like other forms of sexual behavior which are not by themselves psychiatric

disorders, is not listed in this nomenclature of mental disorders. (In the first 5 printings of DSM-II, from 1968 to

1973, the code number for this category was for the ICD term homosexuality. The reasons for this change in

subsequent printings of DSM-1I are noted in a Position Paper by the Nomenclature and Statistics Committee of 1973

follows.)

BACKGROUND

(Rationale as formulated by Robert L. Spitzer, M.D., member, APA Task Force on Nomenclature and Statistics,

June 7, 1973)

A proposal About Homosexuality and the APA Nomenclature: Homosexuality as One Form of Sexual

Behavior and Sexual Orientation Disturbance as a Psychiatric Disorder

by Robert L. Spitzer, M.D

Controversy rages as to whether homosexuality should be regarded as a pathological deviation of normal sexual

development or as a normal variant of the human potential for sexual response. Recently, this controversy has

focused on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders DSM-II)

where homosexuality is listed as an official diagnosis in the section on Sexual deviations.

The proponents of the view that homosexuality is a normal variant of human sexuality argue for the elimination of

any reference to homosexuality in a manual of psychiatric disorders because it is scientifically incorrect, encourages

an adversary relationship between psychiatry and the homosexual community, and is misused by some people

outside of our profession who wish to deny civil rights to homosexuals. Those who argue that homosexuality is a

pathological disturbance in sexual development assert that to remove homosexuality from the nomenclature would

be to give official sanction to this form of deviant sexual development, would be a cowardly act of succumbing to

the pressure of a small but vocal band of activist homosexuals who defensively attempt to prove that they are not

sick, and would tend to discourage homosexuals from seeking much-needed treatment.

The American Psychiatric Association is a national medical specialty society, founded in

1844, whose 36,500 physician members specialize in the diagnosis and treatment of mental

and emotional illnesses including substance use disorders.

The American Psychiatric Association

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APA Document Reference No. 730008

When all of the arguments are carefully examined, a few simple statements can be made with which hardly anyone

can disagree.

1. Homosexuality refers to an interest in sexual relations or contact with members of the same sex. Some experts

in our field believe that predominant or exclusive homosexuality is pathological; other experts believe it a

normal variant.

2. A significant proportion of homosexuals are apparently satisfied with their sexual orientation, show no

significant signs of manifest psychopathology (other than their homosexuality, if this is considered by itself

psychopathology), and are able to function quite effectively. These individuals may never come for treatment,

or they may be seen by a psychiatrist because of external pressure (e.g., court referral, family insistence) or

because of other problems requiring psychiatric help (e.g., depression, alcoholism).

3. A significant proportion of homosexuals are quite bothered by, in conflict with, or wish to change their sexual

orientation. There is debate within our profession as to why this is so. Some argue that it is an inevitable result

of the underlying conflicts that cause homosexual behavior in the first place, while others argue that it is derived

from a host of social and cultural pressures that have been internalized. Nonetheless, some of these individuals

come voluntarily for treatment, either to be able to accept their sexual feelings towards members of the same

sex, or to increase their capacity for sexual arousal by members of the opposite sex.

4. Modern methods of treatment enable a significant proportion of homosexuals who wish to change their sexual

orientation to do so. At the same time, homosexuals who are bothered by or in conflict with their sexual

feelings but who are either uninterested in changing, or unable to change, their sexual orientation can be helped

to accept themselves as they are and to rid themselves of self-hatred.

Decisions about the labeling problem in DSM-11 require an understanding of the function of a manual of mental

disorders. Its purpose, as its name clearly implies, is to list and define mental (psychiatric) disorders. Its purpose is

not to list and describe all of the forms of human psychological functioning which are judged by the profession or

some members of the profession as less than optimal. Nor is its purpose to imply certainty about the nature of

conditions when there is not a consensus in the profession.

For a mental or psychiatric condition to be considered a psychiatric disorder, it must either regularly cause

subjective distress, or regularly be associated with some generalized impairment in social effectiveness or

functioning. With the exception of homosexuality (and perhaps some of the other sexual deviations when in mild

form, such as voyeurism), all of the other mental disorders in DSM-11 fulfill either of these two criteria. (While one

may argue that the personality disorders are an exception, on reflection it is clear that it is inappropriate to make a

diagnosis of a personality disorder merely because of the presence of certain typical personality traits which cause

no subjective distress or impairment in social functioning. Clearly homosexuality, per se, does not meet the

requirements for a psychiatric disorder since, as noted above, many homosexuals are quite satisfied with their sexual

orientation and demonstrate no generalized impairment in social effectiveness or functioning.

The only way that homosexuality could therefore be considered a psychiatric disorder would be the criteria of failure

to function heterosexually, which is considered optimal in our society and by many members of our profession.

However, if failure to function optimally in some important area of life as judged by either society or the profession

is sufficient to indicate the presence of a psychiatric disorder, then we will have to add to our nomenclature the

following conditions: celibacy (failure to function optimally sexually), revolutionary behavior (irrational defiance of

social norms), religious fanaticism (dogmatic and rigid adherence to religious doctrine), racism (irrational hatred of

certain groups), vegetarianism (unnatural avoidance of carnivorous behavior), and male chauvinism (irrational belief

in the inferiority of women).

If homosexuality per se does not meet the criteria for a psychiatric disorder, what is it? Descriptively, it is one form

of sexual behavior. Our profession need not now agree on its origin, significance, and value for human happiness

when we acknowledge that by itself it does not meet the requirements for a psychiatric disorder. Similarly, by no

longer listing it as a psychiatric disorder we are not saying that it is "normal" or as valuable as heterosexuality.

Homosexuality: Proposed Change in DSM-11, 6 th Printing (2 of 3)

The American Psychiatric Association • 1000 Wilson Boulevard, Suite 1825 • Arlington, VA 22209

Telephone: (888) 357-7924 • Fax: (703) 907-7300 • Email: apa@psych.org

APA Document Reference No. 730008

Having suggested that homosexuality per se is not a psychiatric disorder, what about those homosexuals who are

troubled by or dissatisfied with their homosexual feelings or behavior? These individuals have a psychiatric

condition by the criterion of subjective distress, whether or not they seek professional help. It is proposed that this

condition be given a new diagnostic category defined as follows: "Sexual orientation disturbance." "This is for

individuals whose sexual interests are directed primarily toward people of the same sex and who are either bothered

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 a form of sexual

behavior and, with other forms of sexual behavior which are not by themselves psychiatric disorders, are not listed

in this nomenclature."

It is further proposed that this category replace, in subsequent printings of DSM-II, the currently undefined category

Homosexuality, and that for purposes of continuity and since Sexual orientation disturbance is a subset of the

category of Homosexuality, it uses the same code number, 302.0. As is customary for other diagnostic ICD terms

not to be used in this country, the term homosexuality will appear following the American term, Sexual orientation

disturbance, in brackets [Homosexuality].

What will be the effect of carrying out such a proposal? No doubt, homosexual activist groups will claim that

psychiatry has at last recognized that homosexuality is as "normal" as heterosexuality. They will be wrong. In

removing homosexuality per se from the nomenclature we are only recognizing that by itself homosexuality does

not meet the criteria for being considered a psychiatric disorder. We will in no way be aligning ourselves with any

particular viewpoint regarding the etiology or desirability of homosexual behavior.

By creating a new category, Sexual orientation disturbance, we will be applying a label only those homosexuals who

are in some way bothered by their sexual orientation, some of whom may come to us for help. We will no longer

insist on a label of sickness for individuals who insist that they are well and who demonstrate no generalized

impairment in social effectiveness. We will thus help to answer the charge of some members of own profession,

who claim that mental illness is a myth and that by labeling individuals we are merely acting as agents of social

control. Furthermore, we will be removing one of the justifications for the denial of civil rights to individuals whose

only crime is that their sexual orientation is to members of the same sex. In the past, homosexuals have been denied

civil rights in many areas of life on the ground that because they suffer from a "mental illness" the burden of proof is

on them to demonstrate their competence, reliability or mental stability. (By linking the removal of homosexuality

from the diagnostic nomenclature with an affirmation of the civil rights of homosexuals, no implication is intended

justifying the irrational denial of civil rights to individuals who do suffer from true psychiatric disorders.)

This revision in the nomenclature provides the possibility of finding a homosexual to be free of psychiatric disorder,

and provides a means to diagnose a mental disorder whose central feature is conflict about homosexual behavior.

Therefore, this change should in no way interfere with or embarrass those dedicated psychiatrists and

psychoanalysts who have devoted themselves to understanding and treating those homosexuals who have been

unhappy with their lot. They, and others in our field, will continue to try to help homosexuals who suffer from what

we can now refer to as Sexual orientation disturbance, helping the patient accept or live with his current sexual

orientation, or if he desires, helping him to change it.

Homosexuality: Proposed Change in DSM-H, 6' Printing (3 of 3)

The American Psychiatric Association • 1000 Wilson Boulevard, Suite 1825 • Arlington, VA 22209

Telephone: (888) 357-7924 • Fax: (703) 907-7300 • Email: apa@psych.org

SPECIAL NOTE—SEVENTH PRINTING

Since the last printing of this Manual, the trustees of the

American Psychiatric Association, in December 1973, voted to

eliminate Homosexuality per se as a mental disorder and to

substitute therefor a new category titled Sexual Orientation

Disturbance. The change appears on page 44 of this, the

seventh printing. In May, 1974 the trustees' decision was

upheld by a substantial majority in a referendum of the

voting members of the Association.

DEFINITIONS OF TERMS

MENTAL DISORDERS

efficiency, or stubbornness. This behavior commonly reflects hostility

which the individual feels he dare not express openly. Often the

behavior is one expression of the patient's resentment at failing to

find gratification in a relationship with an individual or institution

upon which he is over-dependent.

302.1 Fetishism

302.2 Pedophilia

302.3 Transvestitism

302.4 Exhibitionism

301.82* Inadequate personality*

This behavior pattern is characterized by ineffectual responses to

emotional, social, intellectual and physical demands. While the

patient seems neither physically nor mentally deficient, he does

manifest inadaptability, ineptness, poor judgment, social instability,

and lack of physical and emotional stamina.

302.5* Voyeurism*

302.6* Sadism*

302.7* Masochism*

302.8 Other sexual deviation

[302.9 Unspecified sexual deviation]

301.89* Other personality disorders of specified: types (Im-

mature

personality,

Passive-dependent

personality,

303 Alcoholism

This category is for patients whose alcohol intake is great enough to

damage their physical health, or their personal or social functioning, or

when it has become a prerequisite to normal functioning. If the alcohol-

ism is due to another mental disorder, both diagnoses should be made.

The following types of alcoholism are recognized:

303.0 Episodic excessive drinking

If alcoholism is present and the individual becomes intoxicated as

frequently as four times a year, the condition should be classified

here. Intoxication is defined as a state in which the individual's co-

ordination or speech is definitely impaired or his behavior is clearly

altered.

303.1 Habitual excessive drinking

This diagnosis is given to persons who are alcoholic and who either

become intoxicated more than 12 times a year or are recognizably

under the influence of alcohol more than once a week, even though

not intoxicated.

303.2 Alcohol addiction

This condition should be diagnosed when there is direct or strong

presumptive evidence that the patient is dependent on alcohol. If

available, the best direct evidence of such dependence is the appear-

ance of withdrawal symptoms. The inability of the patient to go one

etc.)*

301.9 [Unspecified personality disorder]

302 Sexual deviations a

This category is for individuals whose sexual interests are directed

primarily toward objects other than people of the opposite sex, to-

ward sexual acts not usually associated with coitus, or toward coitus

performed under bizarre circumstances 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 per-

form deviant sexual acts because normal sexual objects are not

available to them.

302.0 Sexual orientation disturbance [Homosexuality]

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 diag-

nostic 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 be-

havior which are not by themselves psychiatric disorders, are not

listed in this nomenclature.

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