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Ask the Mental Health Expert Archives 2001-2004

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Homosexuality and DSM-IV

Q. Do you have any information on how homosexuality was eliminated from the DSM-IV vs DSM-III? Is there an established revision procedure whereby disorders are either included or excluded in new editions? If so, is there a way to determine whether that procedure was followed in the revision work that excluded homosexuality in the current fourth edition?

A. The issue of whether homosexuality is a disease has been one of the more controversial matters that has faced the framers of the various DSMs over the last few decades. The very first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) classified homosexuality as a sexual deviation, as did DSM-II in 1968. However, in December of 1973, the DSM-II was modified by the Board of Trustees of the American Psychiatric Association (APA), who voted to eliminate the general category of homosexuality, and replace it with sexual orientation disturbance.

As Dr. Jon Meyer notes (see Comprehensive Textbook of Psychiatry, 4th ed., eds. Kaplan & Sadock), "...this change reflected the point of view that homosexuality was to be considered a mental disorder only if it was subjectively disturbing to the individual. The decision of the APA Board...took place in the context of new sociological data, biological inferences, and de-emphasis of psychoanalytic observations. It also took place in an atmosphere of confrontation. Beginning in 1970, various gay activist groups demonstrated....at APA meetings. At issue was the conceptualization of homosexuality as an illness..."

The DSM-III committee and subcommittee charged with drafting the new manual (1976-78) settled on the diagnosis of ego-dystonic homosexuality, which, according to Meyer, "...represented a compromise between those individuals whose clinical experience, interpretation of the data, and, perhaps, biases, led them to the conviction that homosexuality was a normal variant of sexual expression..." By the time DSM-III-R (revised version of DSM-III) came out in 1987, the tide had shifted again. The category of ego-dystonic homosexuality was eliminated. As DSM-III-R itself stated, "...the diagnosis...has rarely been used clinically, and there have been only a few articles in the scientific literature that use the concept..."

However, one could use the category of sexual disorder not otherwise specified to include cases that previously would have been called ego-dystonic homosexuality. Our present DSM-IV does not include homosexuality per se as a disorder, but still permits the diagnosis of "Sexual Disorder Not Otherwise Specified" for someone with "...persistent and marked distress about sexual orientation".

For details on how the DSM-IV committees made their decisions, I suggest you get hold of a copy of the actual manual, and read the detailed description on p. xx in the introduction. I think it's fair to say that DSM-IV was more reliant on empirical data, and less on political considerations, than were some earlier DSMs. You may also want to see the article by Bayer & Spitzer in which edited correspondence by the DSM-III framers is presented on the issue of homosexuality (J Hist Behav Sci 18:32, 1982).

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May 2001

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