50 years ago the APA removed code 302.0: Homosexuality from the DSM. Almost.
CHRIS AIKEN: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report.
KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. 50 years ago the American Psychiatric Association removed homosexuality from the DSM. At least, that is what we’re told. The real story is more complex, a bit like the proverbial joke. You can put a dozen, even 3 dozen psychiatrists in a dark room with a brand new light bulb, but the light bulb has to want to change.
But first, a preview of the CME quiz for this episode
1. A 1957 study by psychologist Evelyn Hooker found that homosexual and heterosexual men were similar on what outcome?
A. Rates of psychiatric disorders
B. Stages of psychological development
C. Functional status
D. Projective testing
CHRIS AIKEN: Let’s journey back to where it all began at the Sheraton Waikiki where the APA annual meeting was held in Honolulu, May 7 1973. Back then, membership had its benefits. The conference was free for APA members and their families, crowned by a grand ballroom dance for the participants. But it was a more restrictive group. Heterosexuality was part of the admissions criteria for psychoanalytic training, and even the general psychiatrist could risk losing their job or medical license by revealing a different sexual orientation.
Education was more experiential back then. The makers of a blood alcohol monitoring device hosted a booth that would “make drinking and blood alcohol level a personal experience for the psychiatrist. Limit one per customer.” Otto Kernberg cohosted a symposia that promised to show both personalities of a patient with multiple personality disorder through the new videotape technology. Robert Post tested cocaine in depressed patients, concluding this dopaminergic could not be classified as an antidepressant because of the affective flooding and dysphoria mixed in with its mood-elevating effects.
Talks on cultural diversity were prominent, but the tone was different than what we see at today’s APA, with titles like “Aggression Among American Indian Tribes,” and “Blue Collar Patients at a Psychoanalytic Clinic.” And at 9:00 AM on Wednesday, the Robert Spitzer chaired a 3 hour symposia: “Should homosexuality be in the APA nomenclature?”
The pressure behind the talk would have been palpable to anyone in the packed room. Gay protestors had stormed the APA’s meetings in 1970 and 1971. The APA diffused the tension by inviting the protesters in as guest speakers. They organized a panel for the 1972 conference called “Gay is Good,” and worked through back channels to pull a gay psychiatrist half-way out of the closet and speak directly to his colleagues.
KELLIE NEWSOME: That psychiatrist was John Fryer, who was introduced as Dr. Anonymous as he stepped onto the stage in Richard Nixon mask. To further emphasize the necessity of disguise, he wore an oversized suite and spoke through a voice-distorting microphone. For the next 10 minutes, Fryer described a secret world of psychiatrists who collectively called themselves the GayPA, connecting through mutual recognition at gay bars surrounding the APA conventions.
“All of us have something to lose,” he said. “We may not be under consideration for a professorship; the analyst down the street may stop referring us his overflow; our supervisor may ask us to take a leave of absence.”
But “We are taking an even bigger risk, however, in not living fully our humanity,” he said. “This is the greatest loss, our honest humanity.”
The audience stood up in applause, but Dr. Fryer kept his mask on, and for good reason. In the front row was an administrator at Friends Hospital who – although clapping in public – would later fire Fryer when he learned he was gay, explaining, “If you were gay and not flamboyant, we would keep you. If you were flamboyant and not gay, we would keep you. But since you are both gay and flamboyant, we cannot keep you.” The administrator never knew that Fryer was the masked physician he had applauded.
CHRIS AIKEN: That was the atmosphere when Spitzer took the stage in Honolulu in 1973. Robert Spitzer trained as a psychoanalyst, but became disillusioned by the lack of progress in his patients. He turned instead to diagnosis and rating scales. In his heart, Spitzer believed that homosexuality was a disorder, but he was a contrarian, even with himself, so organized this panel of voices pro-, con-, and in the middle.
On the pro-diagnosis side was Charles Socarides, a psychoanalyst who had carved out a niche through his purported ability to mend the broken stages of oedipal development that tilted otherwise healthy toddlers toward the homosexual lifestyle. Life is complex, and in 1986 Socarides’ son Richard would come out of the closet to his father. After a burst of anger, Dr. Socarides wrote his son a letter of conditional acceptance, “If being gay is what makes you happy, then it's okay with me. That's all I can ask.” With that peace behind them, the father would go on to co-found the NARTH Institute to promote research on conversion therapy for people with same-sex attraction in 1992. In the same year, his son joined the Clinton administration as a liaison to the LGBQ community.
KELLIE NEWSOME: In the middle was Irving Bieber, who argued that same-sex attraction was not a disease, but it was not normal, and could be reversed through psychotherapy. Two other psychiatrists, Robert Stoller and Richard Green, joined Bieber in this middle ground, arguing that homosexuality was an abnormal behavior, but not a mental illness. There were too many causes of homosexual behavior, and no consistent associated signs and symptoms to warrant its inclusion in the DSM. Stoller and Green may have argued for the remove of 302.0 Homosexuality, but they went on to create another controversial condition that sits uncomfortably in the DSM today: Gender Identity Disorder.
The middle ground these voices arrived at might disappoint the modern eye, but for them it was a compassionate stance. By making homosexuality a diagnosis, it removed it from the world of sin and crime that sent Oscar Wilde to a soul-killing sentence of hard labor in 1895. And some of the middle-voices wanted to take it a step further, changing homosexuality from a diagnosis to a behavioral quirk, one that could be addressed in psychotherapy. And they had a point.
Keeping homosexuality as a disorder came with lots of baggage – homosexuality was seen not just a sexual behavior but an entire personality defect. They were seen as immature, untrustworthy, paranoid, defensive, and sociopathic; and unfortunate stereotypes lingered long past the removal of 302.0.
CHRIS AIKEN: A more determined rejection of the diagnostic label came from the vice president of the APA, Judd Marmor, who saw it as a human rights issue. “It seemed to me that what I was hearing was the stereotyping and stigmatizing of an entire group of individuals, a pattern that I had already learned to distrust as a reflection of social prejudice in other areas, for example, towards Catholics, Jews, blacks, and other minority groups.” Marmor also pulled from science, though not psychiatric science. Zoological research showed us that homosexuality a normal part of animal behavior, and zoologist turned sex-researcher Alfred Kinsey had shown that homosexuality occurred on spectrum and was much more common than previously thought. Closer to home was a 1957 study by psychologist Evelyn Hooker.
Dr. Hooker performed the Rorschach and other projective tests on 60 men who were similar in age, IQ, and education, but who differed in their sexual orientation. Half were homosexual, and half heterosexual. She then asked two ink-blot experts to rate the mental health of the subjects based on their projective responses. The experts, were blinded to the subject’s orientation, found no difference in the two groups.
That’s more than I can say for myself. I took the Rorschach test once, and I didn’t come out looking so healthy, but Dr. Hooker was drawing from a sample of well-adjusted men. The psychiatrists who treated homosexuals, however, sampled from the opposite end. People with mental disorders are more likely to seek psychiatric help – whether homosexual or not – and this, Dr. Marmor argued, was behind his colleagues errant belief that homosexuals were troubled souls. If they did, the source of that trouble was in society, not in the patient. “It’s similar to the problem of anti-Semitism,” Marmor explained. “All kinds of terrible things are said about people who are Jewish. But the problem is not in being Jewish, the problem is in the social prejudice of the civilization of the anti-Semite.”
The debate ended in a stalemate, but that night the balance tilted. One of the gay activists, Ronald Gold, invited Robert Spitzer to a tiki bar. A gay tiki bar, where members of the secretive GayPA were gathering. Spitzer and Gold had become unlikely friends a few years before, when Spitzer went to a lecture on using behavior therapy to reshape same-sex attraction. The lecture never happened. It was disrupted by a gay activists who yelled at the presenters to “leave us alone.” But Spitzer stuck around to chat with the protesters, and that’s where he befriended Gold. “It was really the first time that I had any personal contact with people that were openly homosexual. It was quite a different experience for me because they became human people. I started to think what could be done with this? I guess my own feelings were of compassion, wanting to be helpful.”
KELLIE NEWSOME: At the tiki bar, Spitzer saw closeted homosexuals – members of his own profession, some of them esteemed psychiatrists. Then he saw something that changed him. A man entered the bar dressed in a military uniform. He was an Army psychiatrist stationed in Honolulu who had spent his entire life in the closet. The man walked up to Gold and Spitzer and broke down crying, thanking Gold for his presentation.
Spitzer, who had recently decided that all mental illnesses had to cause either significant distress or impairments of functioning, saw that homosexuality was causing neither of these. The men and women at the bar were functioning at a very high level, and the officer’s distress was not caused by his sexual orientation. It was caused by the stigma he experienced, and the psychiatric label was contributing to that stigma.
Spitzer and Gold left the bar and went back to the hotel, where they wrote the first draft an APA statement that would remove homosexuality from DSM-II. Almost.
Next week, we’ll look at what Dr. Spitzer undid, and what he left undone in his historic revision.
Now, for the study of the day The Efficacy of Lumateperone in Patients With Bipolar Depression With Mixed Features, and industry sponsored paper in the Journal of Clinical Psychiatry.
CHRIS AIKEN: Roger McIntyre and colleagues reanalyzed the data from a large phase III trial of lumateperone (Caplyta) in bipolar depression. They plucked out the 376 bipolar I and II patients who had mixed features at the start of the study to see how well the drug worked in that group and whether it triggered any worsening of mania in those who already had racing thoughts, high energy, or impulsivity on top of their depression. Bottom line: Lumateperone worked just as well in mixed bipolar depressions as pure ones, and there was no difference in manic switching which was very rare in both groups.
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