Homosexuality in the DSM

Homosexuality is not classified as a mental disorder in the current Diagnostic and Statistical Manual of Mental Disorders (DSM); it was removed in the 1970s after activism and research showing it to be a normal variation of human sexuality rather than a pathology. The current DSM does not include any category diagnosing homosexuality, reflecting a broad scientific consensus that non-heterosexuality is not a disorder.

Homosexuality was classified as a mental disorder in the first edition of the DSM, published in 1952 by the American Psychiatric Association (APA). This classification was challenged by gay rights activists during the gay liberation movement especially following the 1969 Stonewall riots, and rendered problematic by research especially by Alfred Kinsey and Evelyn Hooker suggesting homosexuality is normal and non-pathological. In December 1973, the APA board of trustees voted to declassify homosexuality as a mental disorder, and in 1974, the full APA membership voted to confirm this. The DSM was thus updated: in the 1974 seventh printing of the second edition (DSM-II), homosexuality was replaced with a new diagnostic code for individuals distressed by their homosexuality, termed ego-dystonic sexual orientation. Distress over one's sexual orientation remained in the manual, under different names, until the DSM-5 in 2013.

The DSM's direct predecessor was the Statistical Manual for the Use of Institutions of the Insane, first published in 1918 (by its 10th edition in 1942 it had become called the Statistical Manual for the Use of Hospitals of Mental Diseases). The Statistical Manual was ambiguous on the topic of homosexuality; it included a condition called "constitutional psychopathic inferiority (without psychosis)" that was described as "a large group of pathological personalities" including "sexual perversions". Meanwhile, in the 1935 Standard Classified Nomenclature of Disease, homosexuality was classified as a "pathological sexuality" under the category of "psychopathic personality".

When the APA published the DSM-I in 1952, homosexuality was classified as a "sexual deviation" within the larger "sociopathic personality disturbance" category of personality disorders. The sexual deviation diagnosis included "homosexuality, transvestism, pedophilia, fetishism and sexual sadism" as examples.

Four years prior to the publication of the DSM-I, the first Kinsey Report was published by Alfred Kinsey and his fellow researchers, which found that "only 50 percent of the adult population is exclusively heterosexual throughout its adult life," based on a study of 5,300 men, but the psychiatry field was hostile to the Kinsey Report and the implications that same-sex sexual behavior was far more common than mainstream society had previously believed. In 1957, psychologist Evelyn Hooker published the results of a study that compared the happiness and well-adjusted nature of 30 self-identified homosexual men with 30 heterosexual men and found no difference, which similarly stunned the medical community. Hooker argued that researchers who claimed homosexuality was a mental disorder were drawing a false correlation by only studying homosexuals who had a history of treatment for mental illness. Meanwhile, a study of 106 homosexual men by Irving Bieber and other researchers, published in 1962, was used to justify the inclusion of homosexuality as a pathological hidden fear of the opposite sex caused by traumatic parent–child relationships, a view that was influential in the medical profession.

The DSM-II, published in 1968, expanded the "sexual deviation" diagnostic category (now located within the larger category of "personality disorders and certain other nonpsychotic mental disorders") so that different "sexual deviations" were listed under ten individual diagnostic codes: homosexuality, fetishism, pedophilia, transvestitism, exhibitionism, voyeurism, sadism, masochism, other sexual deviation, and unspecified sexual deviation. While the DSM-I and its precursor the Statistical Manual included ambiguity in terms of whether homosexuality was a mental disorder, the DSM-II removed that ambiguity and clearly presented homosexuality and the other "sexual deviations" as mental disorders.

After extensive organizing by gay rights activists during the gay liberation of the 1960s and 1970s, the seventh printing of the DSM-II in 1974 renamed the code "homosexuality" as sexual orientation disturbance, and added descriptive text that noted that homosexuality "by itself does not constitute a psychiatric disorder" and that the renamed code should be used for "individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation." This was considered a major victory by gay activists, because it clearly articulated a shift from considering homosexuality a mental disorder to only characterizing people as unwell if their sexual orientation caused them distress. The change was a compromise between competing schools of thought within the psychiatry field: the view that homosexuality was a pathological condition and the view that homosexuality is a normal variation of sexuality.

The activism that resulted in changing the seventh printing of the DSM-II began in earnest in the wake of the Stonewall riots in 1969. Specific protests by gay rights activists against the APA began in 1970, when the organization held its convention in San Francisco. The activists disrupted the conference by interrupting speakers and shouting down and ridiculing psychiatrists who viewed homosexuality as a mental disorder. At the 1971 conference, gay rights activist Frank Kameny, working with the Gay Liberation Front to demonstrate against the convention, grabbed the microphone and yelled: "Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you." At the 1972 conference, gay psychiatrist John E. Fryer spoke to the audience about what it was like for the many gay psychiatrists in the APA who had to hide their sexuality due to anti-gay prejudice within the field; he wore a mask and a wig and used a voice distorter to conceal his identity. This activism occurred in the context of a broader anti-psychiatry movement that had come to the fore in the 1960s and was challenging the legitimacy of psychiatric diagnosis. Anti-psychiatry activists protested at the same APA conventions, with some shared slogans and intellectual foundations.