Homosexuality, Gender Identity Disorder, and Psychiatry

   In some areas, psychiatry has striven to be as scientific as possible, in studying the genetics of schizophrenia or the neurotransmitters involved in depression. In other areas, however, the discipline has proven very much a handmaiden of its cultural and political masters.

   Sexual behavior is one such area, and psychiatry’s tendency to drift with the prevailing winds is seen no more clearly than in the area of homosexuality. (But, see also Masochism; Sadism.) Although there has never been a moment since the Ancients when society smiled upon homosexuality, in the nineteenth century it became the object of medical censure in particular.

   Carl Friedrich Westphal and "contrary sexual feeling" (1870). Westphal (1833–1890), born in Berlin as the son of a high government official, graduated in medicine there in 1855. In the late 1850s, he worked as an assistant physician under Carl Wilhelm Ideler (see German "Romantic" Psychiatry) in the psychiatric division of the Charité; later, he served under Wilhelm Griesinger. In 1869, after Griesinger’s death, Westphal became head of the psychiatric and neurological services at the Charité, and in 1873 professor of psychiatry. In 1887, he fell ill with what seems to have been neurosyphilis and died 3 years later in the Binswanger family’s private nervous clinic in Kreuzlingen in Switzerland. (See Anxiety: Westphal’s agoraphobia-panic [1872]; also Obsessive-Compulsive Disorder: "obsessive ideas" [Zwangsvorstellungen] [1877].)

   In 1870, Westphal published an article in the Archives of Psychiatry and Nervous Diseases (Archiv für Psychiatrie und Nervenkrankheiten) on "Contrary Sexual Feeling: The Symptom of a Neuropathic (Psychopathic) Condition" ("Die conträre Sexualempfindung: Symptom eines neuropathischen [psychopathischen] Zustandes"). He began the article, "In the cases of illness that I communicate in following, the main finding emerged as a symptom which, as such, has been hitherto little or not at all described: an inborn perversion of sexual feeling with the patient aware of its pathological nature." The symptom was derangements of proper sexual identity: in one patient, the desire of a young lesbian admitted to the Charité for sexual intercourse with other women; in another, a cross-dressing male patient who felt himself to be a woman, denying the desire for sex with other men. Westphal found it significant that there was a history of depression in the woman’s family and that the man was subject to epilepsy, both being signs, he said, of a hereditary predisposition to pathology. With the term "contrary sexual feeling," Westphal said he did not intend necessarily to identify just the sex drive "but also the simple feeling [Empfindung] of being alienated from one’s own sex on the basis of one’s entire internal being" (p. 107). Westphal declared explicitly that he was not proposing homosexuality to be a disease. The male case, at least, constitutes an early description of what would later be called "gender identity disorder."

   Krafft-Ebing sees homosexuality as evidence of degeneration (from 1877). While he was still professor of psychiatry at Graz University, Richard von Krafft-Ebing occupied himself with "contrary sexual desire"; in an article in 1877 in the Archive of Psychiatry and Nervous Diseases (Archiv für Psychiatrie und Nervenkrankheiten), he argued that same-sex attraction between men resulted from a constitutionally based disorder of sexual identity, a mixture of female and male traits, and that it constituted evidence of degeneration in the central nervous system.

   In 1886, shortly after his arrival in Vienna as professor of psychiatry, he brought out the first edition of what was to become his massive encyclopedia of sexual perversion, Psychopathia sexualis. Here he discussed, "lack of sexual feeling towards the opposite sex with substituted sexual desire [Geschlechtsgefühl] and sexual drive [Geschlechtstrieb] to one’s own sex." The characteristic of this psychopathic disorder was a "lack of sexual feeling toward the opposite sex to the point of horror. . . . Also, the man-loving man assigns to the member of his sex the sexual role of the woman," ditto for the woman who loves other women (pp. 56–57). The disorder could be inborn or acquired, yet even the acquired cases possessed some kind of a predisposition. Among the evidence for homosexuality being a form of degeneration was (to take the first three points on Krafft-Ebing’s list of six) (1) that the behavior begins early in life, and with unusual intensity; (2) that the sex organs themselves are not deformed: the disorder stems from the "character and entire emotional feeling" of the individual; (3) that the affected individuals also manifest other suspicious anomalies (pp. 59–60). As Krafft-Ebing’s book evolved through subsequent editions, "contrary sexual feeling" acquired an ever more prominent place, appearing even in the title. The twelfth edition, published in 1902 just after his death, had more than 100 pages on the subject (up from 16 pages in the first edition).

   Yet, at the end of his life, Krafft-Ebing underwent something of a conversion: In 1901, a year before his death, he declared that homosexuality was "not an illness but rather an anomaly." He commented in an article, published in a gay-identified journal (The Yearbook for Sexual Transition States [ Jahrbuch für sexuelle Zwischenstufen]) that science had finally approached the viewpoint of homosexuals themselves, that their "singular sexual orientation," though minoritarian, nonetheless represents for them "an adequate, natural and thus legitimate" mode of sexuality. Krafft-Ebing did not, however, revise his previous opinions in the twelfth edition of Psychopathia sexualis, the preface of which he signed in December 1902, weeks or days before his death (perhaps he was too weak to change the text). The subsequent editions of Psychopathia sexualis were unchanged, and the fourteenth, published in 1912, was reprinted in the 1990s. Krafft-Ebing’s interpretation of homosexuality, as articulated in Psychopathia sexualis, remained dominant in psychiatry for decades to come.

   Gay psychiatrists and medical writers who opposed the degeneration view of homosexuality (from ca. 1900):

   Marc-André Raffalovich (1864–1934). Although Raffalovich was not actually a physician, he had studied medicine and spent much of his life as a medical journalist. Of Russian origin but circulating between Paris and London, he was openly gay and in numerous publications vehemently denied that homosexuality was a sign of degeneration. He is best known for Uranism and Unisexuality: A Study of Different Manifestations of the Sexual Instinct (Uranisme et unisexualité: Étude sur différentes manifestations de l’instinct sexuel), published in 1896, a book that presented homosexuality on the spectrum of normal sexual behavior. Raffalovich wrote, "The normal sexual invert is not necessarily sick or criminal; he is no more at the mercy of his sexual instinct than any other civilized man who has principles, duties and conventions to observe. There are criminal sexual inverts. . . . But one may not refuse to recognize the existence of the sexual invert who is not mentally unbalanced, not degenerate" (p. 25). According to sexuality historian Vernon A. Rosario, it was Raffalovich who introduced the modern concept of homosexuality as same-sex desire to France. (Uranism was a contemporary coinage for homosexuality.) (Note: There was a lively discussion over homosexuality within the French medical community in these years, with such prominent figures as forensic-medicine specialist Ambroise-Auguste Tardieu [1818-1879] dead set against it.)

   Paul Näcke (1851–1913) Näcke was a German psychiatrist who came as close to acknowledging his own bisexuality as one could without actually coming out of the closet. Näcke, born of a German father and French mother, graduated in medicine from Würzburg University in 1873, then from 1880 occupied various staff positions in a series of asylums, ending as medical director of Colditz asylum (well-known because of its conversion to an Allied prisoner-of-war camp during the Second World War from which several high-profile escapes occurred). He had lived in France for a number of years and was fluently bilingual. From 1901, Näcke began writing a series of articles in such venues as the main French and German journals for criminal anthropology that betrayed an astonishingly close familiarity with the gay scene focused about public urinals in Paris, Berlin, and other cities. (Although Näcke was well disposed to Raffalovich’s book, he found it improbable that the Russian author could know much about the actual life in Paris.) Näcke denied that homosexuality represented a degenerative phenomenon. He argued that men and women were basically born bisexual, and that their subsequent development was really almost a matter of chance. Said to be "happily married," he nonetheless declaimed upon such themes as gay tongue-kissing and shoe fetishism. As he wrote in 1910 in the journal Sexual Problems (Sexual Probleme), "At the present time, one finds Urnings at most abnormal, but certainly not sick or degenerate, and it is evident that the mere existence of contrary desire does not conceivably represent a stigma of degeneration" (p. 591). Moreover, Näcke insisted that it was mainly the educated classes who found homosexuality repellent and that "among the common people the subject is usually received with great indifference" (Archiv für Kriminal-Anthropologie, 1910, p. 79). In an article published posthumously, in the Archive of Psychiatry and Nervous Diseases (Archiv für Psychiatrie und Nervenkrankheiten) in 1914, Näcke allowed that he had had "a pretty considerable personal experience" with homosexuality (p. 323).

   Havelock Ellis (1859–1939). Ellis, the English physician–sexologist whose monumental anthropological investigation of sex appeared in his seven-volume series, Studies in the Psychology of Sex, between 1897 and 1928. It began in German, in 1896 with a volume on "The Contrary Sexual Sense," which appeared in English in 1897. Ellis summed up his work in a final volume, called Psychology of Sex, in 1933. He referred to homosexuality in quite accepting tones: "Inversion [is] a congenital anomaly . . . which if it is pathological, is only so in [the] sense that pathology is the science not of diseases but of anomalies, so that an inverted person may be as healthy as a color-blind person. Congenital sexual inversion is thus akin to a biological variation" (pp. 228–229).

   Note: There were numerous gay psychiatrists who remained mute on the subject of homosexuality, such as Edward Mapother (1881–1940), superintendent of the Maudsley Hospital from 1923 until 1939.

   Psychoanalysis sets itself against homosexuality. Sigmund Freud himself was quite tolerant of homosexuality and did not advocate the use of psychoanalysis to convert gays into straights. Freud believed that people were basically born bisexual, and that events in development determined which orientation they would seek out. As for a psychoanalytic explanation of the nature of homosexual desire itself, as Freud wrote in the fourth edition, published in 1920, of his 1905 book, Three Contributions to the Theory of Sex, "To be sure, psychoanalysis has not to the present produced any complete explanation of the origins of inversion, yet nonetheless we have discovered the psychic mechanism of its genesis. . . . We have discovered in all cases examined to the present, that those who later become inverts experience in the first years of childhood a phase of very intensive, but very brief, fixation upon a woman (usually the mother), and that after overcoming it they identify with the woman and make themselves into a sex object, meaning that, on the basis of narcissism, they hunt out youthful men as much like themselves as possible, whom they so love as their mothers had loved them" (Drei Abhandlungen zur Sexualtheorie, p. 44). (See NARCISSISM.)

   Yet, later generations of psychoanalysts, particularly in the United States after the Second World War, did not share Freud’s tolerance. In his discussion of " Sexual Deviations" in Silvano Arieti’s big textbook, American Handbook of Psychiatry (1959), New York psychoanalyst Paul Friedman (1899–), an emigré from Switzerland and Paris, managed to make the whole subject of homosexuality—which he discussed together with coprophilia and pedophilia—sound as nasty as possible: "The anus here serves as a substitute for the maternal vagina. . . . There may be considerable latent hostility toward the father, with unconscious ideas of castrating him through homosexual intercourse" (p. 595). Friedman considered psychotherapy to convert these unfortunates into heterosexuals quite appropriate, to be sure psychotherapy of an unusually directive kind: The therapist must mandate the gay patient to be abstinent. But, quoting Freud, Friedman said there was some good news: "In a certain number of cases we succeed in developing the blighted germs of heterosexual tendencies which are present in every homosexual" (p. 607).

   Psychoanalyst Edmund Bergler (1899–1962), who had emigrated from Vienna to New York in 1938, wrote an article in 1944 in the Psychoanalytic Review on "Eight Prerequisites for the Psychoanalytic Treatment of Homosexuality," announcing "The prognosis of analytical treatment of homosexuals is a favorable one" (p. 268). In 1956, Bergler brought out Homosexuality: Disease or Way of Life? a book that left little doubt which he thought it was. "The perversion has become more widespread through artificial creation of new recruits as a result of the dissemination of misleading statistics," he wrote, referring to the 1948 study Sexual Behavior in the Human Male by Alfred C. Kinsey (1894–1956) and co-workers. Bergler reemphasized the conclusion he had reached in 1944: "It has recently been discovered that homosexuality is a curable illness" (p. 7). Why would they need curing? "Without exception, deep inner guilt arising from the perversion is present in homosexuals. This is shifted guilt, and it belongs to the masochistic substructure" (p. 24). On other psychoanalysts who set themselves against homosexuality, the reader may consult Ronald Bayer’s Homosexuality and American Psychiatry (1987).

   Homosexuality counts as a "sexual deviation" in DSM-I (1952) and DSM-II (1968). Without further discussion, these early editions of the American Psychiatric Association Manual simply declared homosexuality to be deviant. Gender identity disorders were not even mentioned.

   Homosexuality becomes a nondisease for psychiatry (1973). The reassessment of homosexuality within the American Psychiatric Association began after sustained attacks from within by such psychiatrists as Thomas Szasz (see Antipsychiatry: Szasz) and Judd Marmor (1910–2004). (Both had been trained as psychoanalysts.) There were also increasing attacks from without: at the annual meeting in 1970 of the American Psychiatric Association (APA) in San Francisco, a group of gay activists interrupted the proceedings of a panel on "issues in sexuality," cursing at New York psychoanalyst Irving Bieber (1908–1991), who had argued for conversion therapy. Again, in May 1973, the APA at its annual meeting organized a symposium on "Should Homosexuality Be in the APA Nomenclature?" The presentations, which included that of gay activist Ronald Gold ("Stop It, You’re Making Me Sick!") and gay psychiatrist Richard Green (who argued that "heterosexuality should be in the APA nomenclature"), were printed in the American Journal of Psychiatry in November 1973. At the instigation of Robert Spitzer, in December 1973 the board of trustees of the APA decided that homosexuality would no longer be considered a psychiatric illness; this decision was ratified in a vote by the membership the following year.

   Ego-dystonic homosexuality appears in DSM-III (1980). The issue of homosexuality remained so controversial within APA, however, that the advisory committee on "psychosexual disorders" of the Task Force on Nomenclature that designed DSM-III was virtually torn apart by it. Finally, the committee agreed to stigmatize "ego dystonic homosexuality" as a psychiatric illness, stipulating that it be applied only to homosexuals unhappy with their condition yet unable properly to respond to heterosexual desire. For the first time in the DSM series, DSM-III featured "gender identity disorders," such as "transsexualism," as psychiatric illnesses. A "gender identity disorder of childhood" was also created.

   Homosexuality vanishes entirely from DSM-III-R (1987). This edition of the Manual made no mention of it. This edition also shifted gender identity disorder to the pediatric section of the manual ("disorders usually first evident in infancy, childhood, or adolescence").

   "Sex and gender identity disorder" becomes an independent category in DSM-IV (1994). Clearly having great problems with the classification of sexual issues, the drafters of DSM-IV removed sexual identity disorders entirely from any kind of "perversion" section and instead made sexual sadism and masochism subordinate to "identity disorders." This state of affairs would clearly satisfy none of the players whose sexual preferences were still being labeled pathological. One may anticipate that future DSM editions will also de-pathologize such practices as sexual sadomasochism, now referred to in the community as "roleplaying," as well as transgendering, which is the subject of protective regulations on university campuses everywhere.

   The American Psychiatric Association officially disapproves of "reparative," or "conversion" therapy, of homosexuals (1998). The board of trustees of the APA issued a position statement opposing any kind of "reparative" therapy based on the assumption that homosexuality per se is a mental disorder or that the patient should change his or her sexual orientation.