Historically, it has been difficult for psychiatrists to agree on how to categorize “homosexuality.” Throughout the nineteenth and into the twentieth centuries, discussion surrounding homosexuality focused on whether it is inborn or acquired, whether it is natural, and, depending on the answer to these first two questions, whether it should be treated as an illness or simply accepted as non-pathological. While discussion of psychiatry’s views on homosexuality over time are clearly valuable to investigating its medicalization, a more thorough exploration of how homosexuality itself became first an identity, then a category, and finally a psychiatric diagnosis might more clearly illuminate why this particular diagnosis came to be.
Unlike many psychiatrically invented and medicalized categories, such as hysteria or multiple personality disorder, homosexuality and the “symptoms” assigned to it have changed little over time. In the midst of a continually heteronormative society, homosexuality somehow managed to not only reach the eventual status of “demedicalized” but to do so relatively intact. Since its emergence as an identity, homosexuality has simply been treated differently by society over time. In light of these historical trends, abnormalities, and the evidence that will be presented shortly, homosexuality provides a somewhat unique example by which to study the progression of identities into psychiatric illnesses. Homosexuality was not created as a category by the field of psychiatry and eventually disbanded as a relic of past, less-advanced diagnostic methods; rather, the viewpoints surrounding this diagnosis were the primary variable and the diagnosis (and then non-diagnosis) was itself constant for most of the process.
To understand how homosexuality became a psychiatric illness, it is valuable to first consider how it somewhat suddenly became an identity during the nineteenth century. The word “homosexuality” itself was derived from the ideas of Karl Ulrichs in the late 1860s after he openly defended homosexuality on the basis of it being one of many natural forms of love. Homosexual himself, Ulrichs’ open acceptance of homosexuality as a factor of his own identity in the public sphere was a stepping stone to its becoming an identity factor for others on a widespread basis. Ulrichs effectively enabled homosexuality to be incorporated into public discourse not simply because he recognized homosexual attraction in himself, as likely thousands of others had as well, but because by announcing it openly, he effectively forced others to legitimize it as an identity. Despite resistance, Ulrichs’ openness was arguably a starting point for the cyclical relationship Hacking described between identities and social categories, or “kinds” (Hacking, “Making Up People”). Once a new social identity had been discovered, it was then left to the public to decide whether to accept it as natural or reject it as pathological. The fact that the public chose the latter for an identity as contrary to previously fixed norms as homosexuality is historically unsurprising, and in this respect, homosexuality serves as an effective model for most identity factors that have been pathologized.
The conservative majorities of both society at large and the field of psychiatry almost instinctually defamed homosexuality simply because it was so contrary to the long-established norm. Stemming from this controversy was discussion focused on how this new identity (about to be turned category) should be considered, and three somewhat fluid camps emerged. The Ulrichs’ and Hirschfield’s naturalist view saw homosexuality as potentially inborn but not pathological. On the opposing side, the degenerationist view saw homosexuality as inborn and definitively pathological. While neither the naturalistic view nor the degenerationsit view held individuals responsible for being homosexual (it is “inborn”), their ideas on whether the condition warranted treatment were drastically different. The naturalistic view was adamantly opposed to treatment because it saw homosexuality as it did any other acceptable quality of human identity: something to be preserved not changed. Opposite, the degerationist view, despite early evidence from researchers like Hirschfeld that homosexuality was actually common, insisted that homosexuality must have been damaging since it wasn’t “the norm.” This engendered a far less sympathetic perspective on individuals with homosexual tendencies, justified by the idea that homosexuality was potentially damaging to the individual and to the society within which they defined their identity. The degenerationists also introduced such statements as “homosexuality results from high social pressure and disease of the nervous system” and “homosexuality is a sign of defective genetics.” While these conclusions were not at all evidence-based, their introduction to an already biased public discourse surrounding this new category was sufficient to extend paradigmatic pathologization to the identity of homosexuality.
The third camp of discussion on homosexuality emerged from Freud and can actually be credited with the long-term depathologization of homosexuality in the late twentieth century, even though it paradoxically viewed homosexuality as pathological. Freud thought, unlike the other two camps, that homosexuality was acquired early in life but that it was not damaging to the individual or to society and should therefore be neither criminalized nor treated (Freud, “Letter to an American Mother”). While by today’s understanding of human biology and neuroscience he may have been mostly incorrect about homosexuality being acquired, the impact of a psychiatrist as influential as Freud, whose omnipresence in psychiatric discourse was especially distinct in the twentieth-century United States, was enough to increase public discussion of homosexuality enough to propel social change. As twisted as Freud’s more sympathetic views on homosexuality became in the American public sphere, the events that followed his entering the discussion are largely in accord with Hacking’s model of identities being reinforced and even proliferated by increased reinforcement of the kind that describes them. The more homosexuality was discussed due to Freud’s popular psychoanalytic perspective on the issue, the more homosexuality there seemed to be. Identity is reinforced by kinds and vice versa, according to Hacking, but does this vicious cycle also follow for the relationship between identities and pathology?
The answer in this case was a resounding “no.” There is no doubt that the prevalence of open homosexuality increased during the twentieth century, but its medicalization did not stick long-term precisely because of this increase. The field of psychiatry, and by extension the public that relied on it for diagnoses, could no longer peg homosexuality as an unnatural and potentially damaging “disease” due the proliferation of this identity. Homosexuality had simply become too widely recognized an identity for it to be pathologized any longer. This fascinating effect of Hacking’s cycle is not often seen in the history of psychiatry (usually medicalization increases after the identity proliferates). The fact that it occurs here seems to suggest that homosexuality is more than just a socially defined category; it is rather a central characteristic of human existence.
Despite the 1980s HIV pandemic being closely associated with homosexuality, the DSM trend was clearly against medicalizing homosexuality during this period. In 1973, homosexuality as a formal psychiatric disorder was removed from DSM II. DSM III then included a softer term for the previously more serious disorder called “ego-dystonic homosexuality,” and this was removed entirely in 1986. As Ulrichs’ coming out is a sensible “starting point” of homosexual identity and by extension pathology, the full removal of homosexuality from the DSM is a formal indication of its no longer being considered a medical disorder and by extension acceptance of homosexual identity. By 1986, despite potentially overwhelming public drive generated by the HIV pandemic to marginalize homosexual rights in favor of public health, society was having exactly the opposite effect on psychiatric pathologization of homosexuality as it did one hundred years prior. The difference between homosexuality and other examples of medicalized identities was that homosexual identity had simply become too prolific to be contained by a single social category, much less a DSM diagnosis.
