Editor’s Note: This “Open Letter” started as a lengthy letter to the editor, but it was too long for that format and warranted more prominent placement. The author was so kind as to adapt the letter to this format.
I WISH TO RESPOND to an article that appeared in the May-June 2022 issue of this magazine titled “How Three Activists Stopped the Madness.” While the article is a creditable take on the more public and flamboyant side of the story, it leaves out the behind-the-scenes deliberations and actions that led to the APA’s momentous decision.
In December 1973, the American Psychiatric Association decided to remove “Homosexuality” per se as a mental illness diagnosis from the Diagnostic and Statistical Manual (Volume 2). That decision turned out to be widely important. Not only did many major national and international mental health groups soon support the change, but many laws in many countries changed as well. Many customs and policies and arrangements changed; much social understanding changed; and a great deal more art and sensible popular and scientific writing about homosexuality was published than had appeared before 1973.
Some reports of what led up to that decision, including the G&LR piece on that subject to which I referred, stress the picturesque moments—such as the 1972 panel featuring Barbara Gittings, Frank Kameny, and a masked John Fryer—which were powerful and useful, but often they don’t do justice to the many quieter, cooperative steps that were essential to the change. The headline to the piece, with its reference to “stopping the madness,” is a typically oversimplified summary. The three people on that panel helped the cause, to be sure, but a lot of other work, by a good many other people—as well as some good luck and timing—were essential to success.
As a now elderly psychiatrist who was an active part of the American Psychiatric Association’s diagnostic rethinking and change in 1972-73, and who went on to teach at Harvard for fifty years and eventually to become president of the APA, I want to bring to the attention of G&LR readers some of the issues slighted by the May-June article. Some questions that were not addressed are these: What is a psychiatric diagnosis? How and why does that matter? What was the standing of the American Psychiatric Association in the early 1970s? of the Board of Trustees of the APA? of the APA Assembly? of the DSM itself? How could a major change affecting a huge category of people happen in the large and then rather conservative APA? What were the discussions, the obstacles, the possibilities?
The APA was at the time by far the largest and most influential psychiatric organization in the world. It was far more influential, for instance, than was the relatively small World Psychiatric Association. This was partly because of science and partly because of the international standing of the U.S. in the postwar world. The DSM mattered, and it was internationally debated and approved. Could the APA be changed? The Vietnam War protests, the Civil Rights movement, and the Women’s Rights movement all helped to stimulate reconsideration and an openness to change, both inside and outside the APA.
On the LGBT front, Stonewall helped a lot, as did the separate research of Alfred Kinsey and Evelyn Hooker, both of whom studied non-institutionalized, non-incarcerated gay people. The status of homosexuality had evolved from sin to crime to mental illness over a period of several centuries. Now changing the concept from “mental illness” to mere “difference” was a difficult and major shift. However, there was a history of thought spanning at least two centuries that was very supportive of change, with precedents that included the philosophy of Diderot, the Code Napoleon, Jeremy Bentham’s utilitarianism, the science of Karl Heinrich Ulrichs, Karl Maria Kertbeny, and Magnus Hirschfeld, and the scholarship of John Addington Symonds and Edward Carpenter. In the 20th century, Sigmund Freud with his immense influence was partly supportive of normalizing homosexuality, though the next generation of Freudians was not. Some studies by historians, anthropologists, sociologists, ethologists, and animal studies scientists, while supporting LGBT acceptance, were not widely known, though their work was slowly beginning to accumulate by the mid-20th century.
In 1970, after the APA’s non-response to the invasion of Cambodia and the Kent State massacre, a small group of youngish members of the APA calling themselves the Committee for Concerned Psychiatrists (CFCP) met and actively set out to reform the rather conservative and guild-oriented APA of the time. Fuller Torrey and I and a few others took the lead in this endeavor. By petition, we repeatedly proposed changes to APA bylaws, which eventually were adopted, leading to competitive elections and a more diverse slate of nominees. For several years in the early 1970s, the CFCP nominated, and was successful in electing, several distinguished psychiatrists from major cities and psychiatric centers (e.g., New York, Chicago, L.A., Boston) who were open to the social aspects of psychiatry and patients, and not just “guild” and financial aspects of the practice. With lots of membership backing and enthusiasm, we got a remarkable number of such people onto the APA Board and as president and vice president of the organization (such as Al Freedman, John Spiegel, Judd Marmor, Jack Weinberg, Viola Bernard, Mildred Mitchell Bateman, and Alan Stone). That change was absolutely key to getting any change on homosexuality passed by the larger body of the APA. It would not have happened without them.
The APA Board had and has the power to set rules and policies for the organization, but structurally it sat on two large pillars, both of which were important in influencing the Board on major policy. One pillar was the Council and Committee System, leading up to the Reference Committee, which was made up of the council chairs and headed by the APA president-elect. Councils working on a range of issues—Women, Children, Education, Research, Government, International Affairs—and their committees tended to be staffed by national experts chosen by successive APA presidents. The other pillar was the APA Assembly of District Branches, comprised of about 140 people largely based on local and state psychiatric societies, organized into regional Area Councils. The Assembly tended to over-represent rural and private practice psychiatrists and to be firmly conservative on social and financial issues.
The APA Board usually tried to reconcile differences and create cooperation between its two pillars on large policy issues. On the December 1973 decision to end homosexuality as a diagnosis, both pillars were essential, and the publicity generated by Robert Spitzer, MD, who chaired the Committee on Nomenclature of the Council on Research (which tended, and still tends, to overshadow the Assembly pillar), was indispensable. How was the Assembly brought to be comfortable with the December 1973 change?
In 1972, well ahead of the Committee on Nomenclature—which did most of its widespread consultation with other APA councils and committees in 1973—an APA District Branch (Northern New England) and its Social Issues Committee took the lead in creating and articulating psychiatric positions on social issues such as women, children, Blacks, racism, drugs, Hispanics, the elderly, and poverty. That committee, which I chaired at the time, discussed psychiatric diagnoses and possible abuses of such diagnoses, and in late 1972 we wrote up a two-page argument for opposing discrimination against homosexuals and ending homosexuality as a psychiatric diagnosis. The document outlined much of the evidence, arguments, and material that would be more widely discussed by the APA Committee on Nomenclature, and several APA Councils, in the following year. This paper, with a bit of minor editing, was passed by the nneps (made up of Massachusetts and New Hampshire at that time), and then by Area I of the Assembly (New England plus Eastern Canada), and finally, to the pleasure of its writers, by the APA Assembly. Without the usually conservative APA Assembly taking up and furthering the cause, the APA would almost certainly not have voted to accept the resolutions put forth in our paper.
Thus in December 1973, the APA Board, which now included a good many social-psychiatrically aware psychiatrists, was faced with a closely watched, noisy, and risky-seeming decision, with largely overlapping positions from its two pillars, the Council and Committee structure and the Assembly. The APA Board adopted some of the Assembly language and voted 13 to 0, with 3 abstentions, to pass the removal of homosexuality per se as a psychiatric diagnosis. That was decisive. Other major mental health organizations in the U.S. and abroad—psychologists, social workers, psychoanalysts—soon followed the APA, and a remarkable number of laws, regulations, and social policies were reformed.
Two well-known blips followed the December 1973 decision. First, as a sop to some conservatives and some vocally prominent psychoanalysts, a provisional diagnosis was created for those homosexuals who thought or felt deeply damaged by their homosexuality, labeled as “Ego-Dystonic Homosexuality.” That was clearly a stopgap for a minority of dissenters, and it was predictably deleted after a few years. Second, some conservatives in the APA, led by some psychoanalysts who claimed to be able to “cure” homosexuals, instigated a referendum of all APA members in an effort to overturn the Board’s December 1973 decision. That effort failed decisively, but it did muddy the waters a bit, enough so that many—perhaps half or more—of the journalists writing about the event since then have stated incorrectly that the APA “cured millions” of mental illness in a referendum. In fact, the Board’s decision was the result of a conscientious study of the science, which was carefully and widely discussed. While the media have sometimes overdramatized the events of 1972-73, the APA’s decision would prove to have widespread consequences.
Lawrence Hartmann, MD, a past president of the American Psychiatric Association, is a child psychiatrist and activist who played a critical role in the APA’s declassification of homosexuality as a mental illness.
