50 years ago the APA removed code 302.0: Homosexuality from the DSM. Almost.
Publication Date: 07/03/2023
Duration: 19 minutes, 38 seconds
CHRIS AIKEN: 50 years ago the American Psychiatric Association removed the diagnostic code 302.0 Homosexuality from the DSM. Almost.
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.
CHRIS AIKEN: Last week, we left our unlikely hero Robert Spitzer in a Honolulu hotel room where he drafted the APA position statement on the removal of diagnostic code 302.0: Homosexuality. I was born a few months after that 1973 decision, and 25 years later I started my career as a psychiatric intern at the Weill Cornell Psychiatry program. One of the first patients I admitted was a young woman with mood symptoms and suicidality. She was a lesbian and had recently broken up with her girlfriend. My attending physician was a psychoanalyst, and believed that her homosexuality was part of her disorder.
I didn’t agree, and I thought I had the backing of the APA to challenge him. Six months before, in December 1998, the APA published a position statement against reparative or conversion therapy, quote “any therapy which is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that a patient should change hisor her sexual homosexual orientation.”
I was grateful that the attending allowed me this momentary rebellion. But when I came back to work the next day I found him smiling wryly at the nurses station, DSM-IV in hand. “Look,” he said, “it’s still here,” as he opened to diagnostic code 302.9, Sexual Disorder Not Otherwise Specified. From the text, “This category is included for coding a sexual disturbance that does not meet the criteria for any specific Sexual Disorder, examples include persistent and marked distress about sexual orientation.”
This young woman was distressed about losing her romantic partner, not about her sexual orientation, but I knew enough not to argue with a psychoanalyst about the unconscious roots of human motivation. The APA had left us in a stalemate, one they didn’t resolve until 2013. On the one hand, distress about sexual orientation was a disorder. On the other hand, therapies aimed to correct that orientation were prohibited. How did we get here?
The answer lies with Robert Spitzer who, unbeknownst to me, was going through his own reconciliation with this paradox at the same time in 1999, but we’ll get to that later. First, a preview of the CME quiz for this podcast.
KELLIE NEWSOME: 1. Which edition of the DSM fully removed criteria related to sexual orientation from all diagnosis?
A. DSM-III in 1980
B. DSM-IIIR in 1987
C. DSM-IV in 1994
D. DSM-5 in 2013
Now let’s go back to that hotel room at the Sheraton Waikiki where he drafted the first measure to remove homosexuality from the DSM.
CHRIS AIKEN: Spitzer’s interactions with gay activists had forced him to rethink how we define mental illness, and the definition he arrived at remains in the DSM today. He wrote it this way in the position paper, “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-II fulfill either of these two criteria. Therefore,” he argued, “homosexuality does not meet the requirements for a psychiatric disorder.”
Spitzer had whittled homosexuality out of the DSM not with empiric research but with a logical assertion, but that assertion left open a possibility: What about homosexuals who were distressed about their orientation? That was Spitzer’s compromise, and it allowed psychiatrists to function as they had for decades – continuing to bill insurers for conversion therapy – without pathologizing homosexuality itself. Spitzer did not remove 302.0 from the DSM. He simply changed its name, from Homosexuality to Sexual Orientation Disturbance.
KELLIE NEWSOME: Spitzer’s compromise nearly failed. Two psychiatrists we met in the last episode – Drs. Socarides and Bieber – were vehemently opposed to Spitzer’s revision. They convinced the APA to settle the matter over a vote – not a vote by the APA board – who had already voted to remove 302.0, but an unprecedented vote of the membership. Half of the 20,000 APA members responded, and the Yay’s supported the change – by a margin of 58% in favor to 42% opposed. A few years later, NBC polled its audience on the question – there the percentages were reversed with 57% believing homosexuality was a mental disorder.
Spitzer later speculated that the cause would surely have been lost if the vote was over removing homosexuality entirely. As it was, the change would only reign in coercive treatment of homosexuals, who in the most extreme cases had included ECT and psychosurgery. Even before it’s removal, DSM-II had at least one qualification aimed at limiting the over-use of the homosexual diagnosis. It did not allow the diagnosis if the homosexual behavior was driven by a complete inability to find a heterosexual partner, in other words, in prison.
There’s more to this story than we can fit here. The secret society of LGBQ psychiatrists – the GayPA – had nominated many of their own to positions of leadership in the APA that year, and some had won. The APA president elect, John Spiegel, was himself a closeted homosexual. But Spitzer penned the revision, and the APA rewarded his diplomatic abilities in 1974 with a position that would change the course of psychiatry: Chair of DSM-III.
CHRIS AIKEN: DSM-III continued the compromise, renaming it 302.00 Ego Dystonic Homosexuality. Here’s a summary of the text
“A desire to acquire or increase heterosexual arousal, so that heterosexual relationships can be initiated or maintained, and a sustained pattern of overt homosexual arousal that the individual explicitly states has been unwanted and a persistent source of distress.
This category is reserved for those homosexuals for whom changing sexual orientations is a persistent concern, and should be avoided in cases where the desire to change sexual orientations may be a brief, temporary manifestation of an individual's difficulty in adjusting to a new awareness of his or her homosexual impulses.”
For those who wonder if this meets the standard that a psychiatric disorder have consistent associated features, the DSM stepped with a list of them: Guilt, shame, depression, and loneliness.
But then the DSM takes a strange turn, suggesting that this so-called disorder is really a desperate response to a society that won’t accept them. “There is some evidence that in time many individuals with this disorder give up the yearning to become heterosexual and accept themselves as homosexuals. This process is apparently facilitated by the presence of a supportive homosexual subculture. Spontaneous development of a satisfactory heterosexual adjustment in individuals who previously had a sustained pattern of exclusively homosexual arousal is rare.”
The disorder was quietly removed in 1987’s revision of the DSM, but it lived on in that NOS section of DSM-IV until DSM-5 cut it altogether in 2013. This year marks the APA’s 50th anniversary not of a removal – but of a revision to the homosexual diagnosis. It’s only been 10 years they cut it out, and they are still wrestling with a similar quagmire, Gender Dysphoria. Many in the APA wanted to remove this entirely from the 5th Edition, but they ran into a problem of a different sort. Jack Drescher, who served on this DSM work-group, explained it to us in a 2018 interview with the Carlat Report:
KELLIE NEWSOME: "The challenge we faced... was to reduce stigma while maintaining access to care for patients who have a diagnosis of gender dysphoria. Removing the diagnosis completely would limit access to care for these patients, which includes access to endocrinology consultation and gender reassignment surgery."
The DSM managed this through a familiar compromise. As they did with homosexuality in 1973, they changed the criteria for this so-called disorder so that it could only be diagnosed if the person was distressed about remaining in their gender of birth. That is what was behind the name change – from Gender Identity Disorder in DSM-IV – which implies the problem is in their identification with another gender – to Gender Dysphoria in DSM-5 – implying the problem can be fixed by changing their gender.
CHRIS AIKEN: Dr. Spitzer lived another 4 decades after his historic turn in Honolulu. Ever the contrarian, he grew uncomfortable with his motion even as society grew more comfortable with it. He realized his distress criteria did not cut nature at its joints. Pedophile is still in the DSM, but pedophiles regularly lobby the APA claiming their orientation causes them no distress. Spitzer often argued for the removal of sexual fetishes from the DSM, but held fast to the idea that pedophilia is a mental illness.
Last week, we shared how Dr. Spitzer started this journey, through a confrontation with gay activist protestors at a behavioral therapy convention. Fast forward 25 years, and he was confronted again by a different sort of protester. In 1999 the APA meeting in Washington DC was briefly interrupted that year by a protest from Christians who had undergone conversion therapy to break free of their homosexual tendencies. They shouted down the APA meeting to protest the recent position statement against conversion therapy, and Dr. Spitzer found himself once again caught up in trying to understand the other side. As he explained in an interview with Jack Drescher, he started to wonder “What if some people successfully could change their orientation?”
KELLIE NEWSOME: To settle the matter, Spitzer tried to organize a sequel to his 1973 symposium. He called up Charles Socarides, his one-time adversary and a leading advocate of conversion therapy. For the other side, he gathered psychiatrists who specialized in LGBQ health like Marshall Forstein. But this was not 1973, when a matter of this significant could be settled with a clever argument. You’ll notice, outside of a small study with the rorschach test, there was very little empiric data presented in 1973. Without grounding evidence, the debate fell apart, with presenters dropping out before it began. This gave Spitzer an idea: He would conduct the seminal study to test the effectiveness of conversion therapy.
What resulted was one of the most controversial studies in psychiatric history, published in 2003 as Can some gay men and lesbians change their sexual orientation? 200 participants reporting a change from homosexual to heterosexual orientation.
CHRIS AIKEN: Imagine if a pharmaceutical company had asked doctors to recruit patients who felt satisfaction with their drug, interviewed them by phone about their experience, and then published it as a ground-breaking study. That is exactly the methodology Spitzer used in this retrospective study of a self-selected group. If you haven’t read it, you’re not missing much. You’ve probably seen the same thing on television, where people go on the air to describe their recovery through conversion therapy, only to recant it several years later.
Spitzer had no way of knowing if the self-selected respondents were telling him – or themselves – the truth, and no way of measuring how much harm the therapy did to those who didn’t change their ways. Then he met a journalist, Gabriel Arana, who described the horror of his own conversion therapy, and how it had led to thoughts of suicide. Spitzer spent the night agonizing over what he had done, and sent a letter of retraction and apology to the journal that published it. He died 3 years later in 2015 with only one regret in his career: The conversion paper.
We know of no randomized controlled trials of conversion therapy, and we’re unlikely to. Sometimes the harms of an intervention are clear enough to render controlled trials in humans unethical. That’s when science stops short at epidemiologic studies, which is where we land with conversion therapy. About one in ten LGBTQ individuals have gone through conversion therapy – aimed at either their gender identity or sexual orientation. The practice is associated double the risk of suicide – after controlling for other environmental factors such as parental attitudes toward their child’s orientation. It is associated with higher rates of depression, substance use disorders, lower educational attainment, and psychological distress. It is illegal in 20 US states and almost 30 countries.
Special thanks to psychoanalyst Jack Drescher for his research which informed much of this podcast.
KELLIE NEWSOME: And now for the study of the day: High fried food consumption impacts anxiety and depression due to lipid metabolism disturbance and neuroinflammation by Anli Wang and colleagues from the Proceedings of the National Academy of Sciences.
This two-part study began with a epidemiologic look at the rate of depression and anxiety in 140,000 people, correlating it to their consumption of fried foods. People who regularly consumed fried foods – particularly French fries – were 7-12% more likely to suffer depression and anxiety. With data like that, we’re unlikely to see controlled trials of French fries in humans, but the investigators followed it with a a controlled trial in fish, where a by-product of fried foods, acrylamide, caused depressive behaviors in the fish. At a mechanistic level, acrylamide causes inflammation in the brain by promoting lipid peroxidation and oxidation stress. Fried foods are strongly discouraged in the Mediterranean style diet that improved depression in 4 controlled trials.
Follow Dr. Aiken on his linkedin or twitter feeds @chrisaikenmd for daily research updates like these. Earn CME credits for this episode through the link in the show notes, or subscribe to the journal online and get $30 off with the promo code PODCAST to get. The Carlat Report has operated free of industry support since 2003.