Twenty-five years ago APA leaders, in the glare of a national media spotlight, took the controversial step of deleting homosexuality from the Association's compendium of psychiatric disorders. That action launched APA on a quarter century of efforts to end discrimination against homosexuals and coincided with the increasing willingness of gay and lesbian psychiatrists to insist openly that APA must listen to them.
A panel of psychiatrists who played crucial roles in the fight to end the stigma attached to homosexuality both within and outside the mental health field came together at the APA annual meeting last month to provide insiders' perspectives on that initiative and more recent efforts to alter how psychiatry views gays and lesbians and their sexual orientation.
Melvin Sabshin, M.D., a member of the APA Board of Trustees in the early 1970s and chair of the Scientific Program Committee at that time, described how the alienation gay psychiatrists felt from their APA colleagues led in 1970 to the start of a concerted push for APA to include them in decision making and address their concerns and those of gay patients.
If there was an official kickoff for APA's newly energized gay psychiatrists, it was the 1970 annual meeting in San Francisco, Sabshin suggested, where Gay Liberation Front activists along with political protesters in support of other social and political causes disrupted the meeting. "It was guerilla theater" at that meeting and the one held in Washington, D.C., the next year, he said.
The onset in 1970 of a decline in psycho-analysis's dominance of the field also contributed to the change of mood in psychiatry about pathologizing homosexuality, he noted.
In 1972, for the first time, the annual meeting featured exhibits and discussions spotlighting positive aspects of the lives of gay individuals. Also during that year well-known psychiatrists such as Richard Green, M.D., Judd Marmor, M.D., and John Spiegel, M.D., began openly challenging psychiatrists' attitudes toward and treatment of homosexual patients, Sabshin observed. Marmor, a psychoanalyst who would soon be elected APA president, played a particularly significant role in trying to bridge the chasm that existed between his psychoanalytic colleagues and psychiatrists who were convinced that homosexuality was not an illness.
While many APA members welcomed the new openness and opportunities to reassess their thinking, the stubborn polarization and factionalism that dogged this issue did not suddenly retreat into a quiet corner.
Sabshin credited the chair of APA's Committee on Nomenclature in the early 1970s, Robert Spitzer, M.D., with playing a pivotal role in propelling the evolution of APA's position on homosexuality. That committee was charged with revising the initial version of DSM, and Spitzer-armed with research showing there were no valid data to link homosexuality and mental illness-advocated forcefully for the strategy of deleting homosexuality from the disorders list and replacing it with a new one called "sexual orientation disturbance."
In a key vote in December 1973, the Board of Trustees overwhelmingly endorsed Spitzer's recommendation. Opponents of the decision attempted to overturn it with a referendum of the APA membership in early 1974-just as Sabshin was beginning his 23-year tenure as APA medical director. The Board's decision to delete homosexuality from the diagnostic manual was supported by 58 percent of the membership.
At the same time the debates over sexual orientation and psychopathology were occurring, a small group of gay psychiatrists was holding informal meetings to explore forming an organization that would heighten their visibility and that of gay patients. This event, unthinkable two or three years earlier, explained Robert Cabaj, M.D., to the overflow audience, culminated in 1978 in the establishment of the organization that eventually became the Association of Gay and Lesbian Psychiatrists (AGLP), which now has more than 600 members.
Also in 1973 APA passed a position paper calling on psychiatrists to advocate for full civil rights for gays and lesbians and to work to end the discrimination they endure, noted Cabaj, who is medical director of the San Mateo County Mental Health System and coauthor of a textbook on homosexuality and mental health. He hailed that paper as "the cornerstone of everything that has happened since" in APA's relationship to homosexuality.
Through the rest of that decade, while issues affecting gay and lesbian psychiatrists and patients continued to achieve greater visibility in clinical and scientific forums, the voices of openly gay and lesbian psychiatrists were still rarely heard in APA policy discussions. That changed in 1982 when the APA Assembly granted a formal vote to gay and lesbian psychiatrists as a minority/underrepresented group, a status similar to that already achieved by other minority groups.
In the mid 1980s APA formed a task force on homosexuality issues, and by that time, Cabaj emphasized, it was able to focus not on the psychopathology battle but on homophobia, discrimination, and stereotyping. The task force was eventually elevated to a permanent component, the Committee on Gay, Lesbian, and Bisexual Issues. One of its earliest chairs was San Francisco psychiatrist James Krajeski, M.D., who this month became editor of Psychiatric News.
One of that committee's earliest endeavors was to remedy once again a defect that gay psychiatrists and many others perceived in the way in which the latest version of the DSM labeled some homosexuals. With the introduction of DSM-III in 1980 the diagnosis of sexual orientation disturbance had been changed to ego-dystonic homosexuality, which applied to people persistently distressed by their sexual orientation and desperate to change it. With another revision under way in 1986, committee members focused their efforts on successfully convincing the DSM task force to remove any such designation that linked sexual orientation with psychopathology.
The next several years will likely be a time of "consolidation of gains as psychiatrists who are more comfortable and open about homosexuality come up through the ranks," predicted Howard Rubin, M.D. A "gay-affirmative psychiatry" that has emerged over the last few years will become more commonplace "as long as we don't become complacent," he said.
While gay psychiatrists "now have a place at the table," APA and psychiatry in general will still have to address several troubling issues related to homosexuality, said Rubin, a research fellow at UCLA and member of the APA Committee on Gay, Lesbian, and Bisexual Issues. Prominent on this list is the large number of psychiatry residency programs where nothing is taught about homosexuality or where the program is "gay for a day," that is, where a few hours are devoted to this topic often via a guest speaker. In addition, psychiatrists will be called upon to take a leadership role in discussions of the relative influence of biological factors on the development of sexual orientation, he said.
With psychiatry having depathologized homosexuality, he said, the field's next task is to acknowledge that there are real mental health consequences of being gay, but to address them as individual responses to homophobia and social prejudice.
Carolyn Robinowitz, M.D., who recently became dean of Georgetown University's medical school and is a former senior deputy medical director of APA, has long been an advocate and ally on the many of the issues discussed by the other panelists.
"Let's hope," she emphasized, "that we have learned valuable lessons about the harm that comes from imposing a blanket of psychopathology over any group."
Robinowitz added, "While the DSM action was but one of many changes in the past 25 years, and while many people still view homosexuality in value-laden and not always rational ways, the decision had a major impact on other health professionals and the general public. I wish it had more.
"We still have a long way to go," she said, until gays and lesbians gain full acceptance.-K.H.