R. Spitzer and the depathologization of homosexuality: some considerations on the 50th anniversary

Fifty years ago, in what is arguably the most socially momentous decision in the modern history of psychiatry, the American Psychiatric Association (APA) removed homosexuality as a category of mental disorder from its official Diagnostic and Statistical Manual of Mental Disorders (DSM), then in its second edition (DSM‐II). Although removal is often dated to the APA Board of Trustees’ vote in December 1973, that vote was actually challenged, and removal was finalized in a referendum in April 1974. Rather than awaiting the DSM‐III, the change was made immediately in the next printing of the DSM‐II.

The elimination of homosexuality as a category of psychiatric disorder depended on many people, including courageous gay activists as well as sympathetic psychiatrists and APA officers. However, the primary architect and moving force behind removal was R. Spitzer (1932‐2015), who played a unique role both intellectually and politically ¹ , ² . Moreover, Spitzer's arguments justifying removal continue implicitly to shape the DSM today, a legacy worth making explicit.

Spitzer, a member of the APA's Nomenclature and Statistics Committee that produced the DSM‐II in 1968, took a leadership role in confronting the homosexuality issue even though he had no fixed opinion at the start. In late 1972, he attended a conference session on aversive behavioral treatment of homosexuality, during which gay activists protested against the categorization of homosexuality as a mental disorder. He invited them to present their case to the Nomenclature and Statistics Committee, and promised to organize a debate on the issue at the next annual APA meeting.

In February 1973, a group of gay activists presented their arguments to the Committee. The main speaker was C. Silverstein, a clinical psychologist who, rather than simply attacking psychiatry for the harm that the diagnostic category was doing to gays by justifying persecutory laws, tried to address the issue in professionally relevant terms. He pointed to lack of evidence for increased psychological problems among gays, offered examples of questionable psychiatric categories in the past, and argued that the psychiatric diagnosis of homosexuality was just society's moral judgment dressed up as medicine ³ . Nevertheless, the Committee remained largely unpersuaded regarding removal.

Keeping his promise, Spitzer organized and chaired a debate on homosexuality at the APA's May meeting in Honolulu. Afterwards, R. Gold – a gay activist on the panel ⁴ – took Spitzer to a secret meeting of the “Gay‐PA”, an organization of closeted gay psychiatrists. Spitzer was struck by this group of high‐functioning colleagues and, in light of his recent thinking about the concept of mental disorder and the nature of psychiatric diagnosis, he was finally convinced that it made no sense to label their condition a mental disorder. Within weeks, he submitted to the Nomenclature and Statistics Committee a position statement proposing that the category of homosexuality be eliminated from the DSM and offering a conceptual rationale for doing so.

When the Committee refused to endorse his proposal, Spitzer forwarded the unendorsed proposal to higher levels of the APA hierarchy anyway. He also drafted a policy statement declaring that the APA supported civil rights for gays, which the Committee did endorse. In December 1973, both the proposal for removal and the civil rights statement were passed by the APA's Board of Trustees. During the subsequent referendum, when it looked like the Trustees might be overruled, Spitzer drafted a letter detailing the arguments for removal and had it sent out to all APA members.

Spitzer's rationale for removal consisted of a proposed requirement for mental disorder and an argument that homosexuality did not satisfy that requirement. Specifically, Spitzer proposed: “For a mental 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” ⁵ . If the impairment was not generalized but limited to one area, that must be judged an “important” area of functioning, which – Spitzer acknowledged – involves a value judgment ⁶ , ⁷ . This logical approach cut through the many inconclusive arguments and counterarguments on both sides. It also addressed Spitzer's other preoccupation to counter the anti‐psychiatric position that there is no such thing as mental disorder. He pointed out that psychoanalysis had influenced psychiatry to label any non‐optimal functioning as disorder, but disorder has a narrower meaning, requiring a condition to be significantly harmful in the form of distress or impairment ⁸ .

Spitzer argued that what is important is the ability to have satisfying intimate sexual and emotional relations with another person, but that whether the person is of the same or a different sex is not important. Thus, homosexual individuals are not impaired. However, if distressed, they could qualify as disordered. Consequently, when homosexuality was removed, another category – “sexual orientation disturbance” in the DSM‐II or “ego‐dystonic homosexuality” in the DSM‐III – was added to the manual for homosexual individuals distressed by their sexual orientation. Spitzer's analysis allowed him to retain the categories of sexual paraphilias because, he argued, they all impair the ability to experience satisfying intimate sexual and emotional relations with another person.

Clearly, a great many homosexual individuals were distressed due to social persecution or because of “internalized homophobia”, i.e., accepting and internalizing negative social judgments. Spitzer blocked that kind of distress from indicating disorder status by requiring that, in order to qualify as mental disorder, the condition should be “intrinsically associated with subjective distress”, meaning that “the source of the distress or impairment in functioning must be the condition itself and not the manner in which society reacts to the condition” ⁸ .

The removal of homosexuality is a long‐settled historical episode, but Spitzer's rationale is still influencing us. The notions of distress and impairment as Spitzer used them did not appear in the DSM‐II, but were introduced into the DSM‐III as a result of Spitzer's analyses and have played multiple roles since. Spitzer's “distress or impairment” criterion was incorporated into the DSM's definition of mental disorder: “Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities”. In the DSM‐IV, to reduce implausibly high prevalence rates of mental disorders emerging from epidemiological surveys, the “clinical significance criterion” was added as an additional diagnostic requirement in most major diagnostic categories. For example, the diagnosis of major depressive disorder requires that “the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning”. The notion of “significant” or “clinically significant” distress or impairment appears to be a stand‐in for Spitzer's idea that the degree of harm must be above some substantial threshold and not just a matter of non‐optimality.

Spitzer's idea that a condition itself might not be a disorder per se, but that an individual's distress about having the condition might be a disorder, finds several manifestations in the DSM‐5‐TR. For example, “gender identity disorder” in the DSM‐IV was renamed “gender dysphoria” in the DSM‐5, which “focuses on dysphoria as the clinical problem, not identity per se”, to suggest that those undistressed by gender identity incongruence do not have a disorder.

In sum, fifty years after Spitzer's conceptual resolution to the homosexuality dispute, the fruits of his analysis have penetrated into many areas of our diagnostic manuals. Yet, the analysis leaves us with unfinished business in sorting out the meanings of distress and impairment, and in acknowledging and clarifying the challenging value judgments that inevitably are involved in diagnostic decisions ⁹ .