49 - Restoring Sanity - On Sexuality

In the last edition of R4R, we reviewed the history of how transgender identification was removed from the DSM[1] and reminded readers that trans-identifying activists were following the example of gay and lesbian-identifying activists who campaigned to have homosexuality removed from the DSM as a disorder in 1973.[2] Here we will examine how that came to pass.

When the first edition of the DSM (DSM-I) was published in 1952, homosexuality was listed as a form of Sociopathic Personality Disturbance. The psychiatric profession at the time regarded same-sex attraction as a moral or character defect rather than a psychological variation.

In 1968, the DSM-II reclassified homosexuality under the category “Sexual Deviations” alongside disorders such as fetishism and pedophilia. Although the terminology changed, the underlying assumption remained the same: that same sex attractions represented a pathological condition, consistent with Freudian theories that described it as an arrested stage of psychosexual development.

In December 1973, the APA Board of Trustees voted unanimously (13–0, with two abstentions) to remove homosexuality from the DSM-II as a mental disorder. The new terminology introduced a replacement diagnosis called “Sexual Orientation Disturbance,” to be applied only if a person experienced distress about their same sex attractions or wished to change them. This was a compromise intended to balance scientific data and the perceived clinical needs of individuals seeking help. It marked the first time a major medical organization de-pathologized homosexuality.

Because the decision was controversial, the APA held a membership referendum in 1974, where approximately 58% of psychiatrists voted to uphold the Board’s removal. This confirmed the change and solidified it as official APA policy, though some psychoanalytic groups continued to resist the decision for years afterward.

When DSM-III was released in 1980, the transitional diagnosis was revised as “Ego-Dystonic Homosexuality.” This label was used only when a person’s same sex attractions caused them significant distress and they wanted to seek change. The diagnosis reflected a partial shift away from viewing homosexuality as inherently pathological but still allowed for its inclusion under limited circumstances. By 1987, even this category was removed from the DSM-III-R. This means that when I went to an individual counselor in the 1990s/early 2000s for help, they had to be creative in finding a diagnosis code that met my circumstances.

Since then, same sex attractions have been treated in the subsequent DSMs as “a normal variation of human sexuality.” In the mid-1980s, “internalized homophobia” became common in therapeutic and academic literature, often in discussions about mental health, depression, and self-esteem among clients. Research into this supposed phenomenon increased through the 2000s, replaced by “internalized homonegativity” in the 2010s. “Internalized negativity” emphasizes that negative attitudes are learned, rather than due to a “phobia.” Thankfully, this has not become a DSM diagnosis, being considered a reaction to stigma rather than a pathology in itself. (You can see where this could be heading, however. Anyone with a “negative attitude” about same sex sexual behavior could be considered as having a mental health disorder, should this become recognized as an official diagnosis.)

Arguments can be made for a restoration in the healthcare field of the idea that homosexuality is not a normal variant of human sexuality. There are general diagnostic categories that would cover those seeking therapy to explore the possibility of fluidity in their attractions. These code for associated distress, anxiety, or conflict, and examples include:

F43.22 — Adjustment Disorder, with anxiety or mixed emotional features

For distress caused by conflict between attractions and personal/moral values.

F43.23 – Adjustment Disorder with Mixed Anxiety and Depressed Mood

When both anxiety and low mood are present due to internal conflict.

F41.1 — Generalized Anxiety Disorder

F41.9 – Anxiety Disorder, Unspecified

For clinically significant anxiety not fitting another anxiety disorder.

F48.9 – Other Specified Somatic Symptom and Related Disorder

For somatic symptoms (e.g., tension, fatigue) caused by internal conflict.

F32.A – Depressive Disorder, Unspecified

When depressive symptoms dominate, linked to internal conflict.

F32.x — Depressive Disorder (if criteria met)

F99 – Mental Disorder, Not Otherwise Specified

Used when distress is significant but doesn’t meet criteria for another disorder.

ICD/Z codes for psychosocial or contextual factors:

Z60.4 – Social Environment Problems: Social Exclusion or Rejection

Captures societal, cultural, or religious conflicts that contribute to distress.

Z60.8 – Other Problems Related to Social Environment

For internal conflict caused by social or community factors.

Z65.8 – Other Specified Problems Related to Psychosocial Circumstances

Broad category for moral, ethical, or identity conflicts.

In clinical documentation, a practitioner could note that the source of distress relates to unwanted same-sex attractions or conflict between sexual feelings and personal, moral, or religious values — but that would be part of the case formulation, not the diagnosis itself. For example:

“Client presents with anxiety and depressive symptoms related to conflict between personal values and same-sex attraction. Diagnosis: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23). Contributing factors: social/religious stressors (Z60.4).”[3]

Supporting exploration and coping aligns with the ethical standards of the APA. Again, more research in this area would be beneficial.

[1] DSM is the Diagnostic and Statistical Manual of Mental Disorders, a handbook published by the American Psychiatric Association that provides a common language for healthcare professionals to diagnose mental disorders. It specifies diagnostic criteria, symptoms, and other features to help clinicians make consistent and reliable diagnoses.

[2] Gay rights advocates began protesting the American Psychiatric Association (APA) at its annual meetings. In 1972, Dr. John Fryer, speaking in disguise as “Dr. Anonymous,” gave a historic address to the APA, describing the discrimination faced by gay psychiatrists and calling for reform.

[3] Disclaimer: Note that mental health care professionals will need to verify these suggestions according to their state professional guidelines.