A. The Charge. For centuries, psychology rightly viewed homosexuality as a form of mental illness. Yet as a result of pressure and intimidation on the part of gay activists, professionals have wavered in this conviction. Instead of steeling themselves in the face of pressure, they lost their nerve. In 1973 the American Psychiatric Society unwisely began the process of declassifying homosexuality as a mental disorder. This retreat cannot change the stubborn fact that this aberrant behavior has always been pathology, and remains such now.
B. Historical Background. In order to grapple with what is sometimes termed the medical model of homosexuality, some preliminaries are required.
The term “neurosis” refers to a class of mental disorders involving distress but neither delusions nor hallucinations. This status does not take the neurotic outside the realm socially acceptable norms. As a rule the individual can cope. The term was coined by the Scottish physician William Cullen in 1769 to refer to "disorders of sense and motion" caused by a "general affection of the nervous system."
The contrasting term “psychosis” designates a more radically abnormal condition of the mind, involving a loss of contact with reality In this state, hallucinations and delusions, together with impaired judgment typically occur.
While the two terms, neurosis and psychosis - important in the psychiatric theories of Sigmund Freud - are no longer much used today as diagnostic tools, they have been historically influential.
In that light older approaches were compelled to ask the following question. If homosexuality is in fact a disorder, which is it: neurosis or psychosis? Most advocates of some version of the sickness theory have favored the lesser option of neurosis, because the “sufferer” is usually able to function normally. A few alienists, though, flatly identified homosexuality with psychosis.
Among professionals, the tendency to apply the medical model to same-sex behavior has faded in recent decades. especially after the removal of homosexuality from the list of disorders of the American Psychiatric Association in 1973. Yet the old stereotype still survives in some professional circles, as well as in the folk notion that the “condition” requires a “cure.”
In fact, recent years have seen the rise of a dubious procedure called “conversion therapy” (also known as "reparative therapy"). Associated with Christian fundamentalist groups, such interventions have been derided by critics as "pray the gay away." The main organization advocating conversion therapy is the National Association for Research and Therapy of Homosexuality (NARTH); ostensibly secular, this organization often partners with religious groups. Some procedures involve aversive treatments, such as the application of electric shock to the hands and genitals, and nausea-inducing drugs accompanied by homoerotic stimuli; masturbatory reconditioning; visualization; social-skills training; psychoanalytic therapy; and spiritual interventions, such as prayer and group support and pressure. American medical and scientific organizations have expressed concern over conversion therapy and consider it potentially harmful.
Ultimately, the notion that homosexual conduct (“sodomy”) is a disorder goes back to the early modern period when the special discipline of forensic medicine emerged, gradually supplanting the role of theologians - with their castigation of the “sin against nature” - in this sphere.
The tradition begins with Paulus Zacchias (1584-1659), a physician at the papal court, who in his Quaestiones medico-legales (1621-50) dealt with the forensic evidence for submission to anal sodomy, notably the so-called funnel-shaped anus. His views were parroted by a score of writers down to the last quarter of the nineteenth century.
In the course of the nineteenth century psychiatry adopted a number of concepts that were for a time to prove crucial for the understanding and classification of homosexuality. The French psychiatrist J. D. E. Esquirol (1772-1840) invented the concept of monomania in 1816 for a specific type of partial insanity in which only one faculty of the mind is diseased. Two main subdivisions of the category were recognized. The first was instinctive monomania, in which only the will is diseased. The second was affective monomania, in which the emotions are excessive or "perverted," and therefore distort behavior. In addition, a quite specific type of the illness was erotic monomania, in which the sexual appetite was diseased and abnormal.
In 1857 Benedict-Auguste Morel (1809-1873) introduced the term degeneration to serve as a vehicle for a complex of religious, anthropological, and pathological assumptions, in particular the belief that acquired defects of the organism can be transmitted to later generations. This innovation led to the psychiatric hypothesis that a range of abnormal mental states could be explained by "degeneration of the central nervous system."
In Germany Ernst von Feuchtersleben (1806-1849), a physician and author, introduced the term psychopathy for "illness of the mind" in general, implying that there could be a pathological state of the mind without a lesion of the brain or central nervous system.
Alongside these contributions, the word perversion had come to be employed in medicine in the sense of "pathological alteration of a function for the worse." Then deviation had in French assumed the meaning of "a departure from the normal functioning of an organ." In England, James Cowles Prichard (1786-1848) coined the expression "moral insanity": "a morbid perversion of the natural feelings,... moral dispositions, and natural impulses, without any remarkable disorder or defect of the intellect or knowing and reasoning faculties, and particularly without any insane illusion or hallucination."
In Germany Johann Ludwig Casper (1796-1864), an expert in forensic medicine, had occasion to examine individuals accused of "pederasty" (= anal intercourse) for the purpose of determining whether their persons revealed that the crime had been committed. In a note appended to a paper of 1833 by the anatomist Robert Froriep, he casually remarked that he had observed a subject in whom sexual desire for the opposite sex was absent - the first such instance to be noted in modern medical literature.
The full-fledged medical concept of homosexuality could not, however, have arisen without the contribution of the pioneer gay scholars Karl Heinrich Ulrichs (1825-1895) and Károly Mária Kertbeny (1824-1882). All the early physicians whose papers introduced "sexual inversion" to the medical world had read the works of one or both of these authors; none arrived at the notion by his own reasoning or by pointed interrogation of a patient with the condition. If they rejected the suggestion that the condition was an idiosyncrasy, a normal variety of the human sexual drive, it was largely because their case material was small and atypical; it usually amounted to one or two individuals examined in prisons or insane asylums. These medical experts were confronted with what was for them an unknown and paradoxical state of mind.The absence of the urge to procreate one's kind, linked with an attraction to members of the same sex with whom coupling could only be sterile, could for the mainstream psychiatrists of that era only be a pathological condition.
It was against the background of these concepts and notions that Carl Friedrich Otto Westphal (1833-1890), Richard von Krafft-Ebing (1840-1902), and Arrigo Tamassia (1849-1917) introduced the concept of die conträre Sexualempfindung (sexual inversion) to psychiatry in articles published between 1869 and 1878. They agreed to define the condition in this way: absence of sexual attraction to members of the opposite sex, with a substitutive attraction to members of one's own sex. The reasoning that underlay their definition was that in normal subjects sexual contact with members of the opposite sex excites pleasure, while with members of the same sex it elicits disgust, but in the cases which they had observed the reverse was true. The condition itself, they concluded, was an "affective monomania," since the rest of the personality of the subject was unaffected.
In 1886 Richard von Krafft-Ebing published the first edition of his celebrated Psychopathia sexualis, in which sexual inversion figured in a whole gallery of sexual variations. The author stressed that the sexual act itself, however aberrant it might be, is no proof of the mental abnormality of the person who has committed it, but only that some individuals engage in forbidden sexual acts because they are driven by an involuntary urge.
A long and futile controversy ensued over whether homosexuality deserved to be classified as a "disease." Often the physicians who debated this issue argued that they were taking a sensible middle ground, standing apart from both the religious attitude toward homosexuals as depraved and vicious individuals; and the claims of homosexual apologists that their condition was normal.
In practice, the medical concept of homosexuality as disease was a double-edged sword. On the one hand it served to deny the legitimacy of homosexual expression by labeling the condition pathological; and on the other if offered a ploy to exculpate defendants caught in the toils of the law by labeling them "sick individuals" in need of treatment rather than punishment.
For a long time the psychoanalytic school originated by Sigmund Freud fostered the belief in homosexuality as a mental illness. Psychoanalysts rejected the theory of an innate and unmodifiable condition in favor of a search for its origins in the psychodynamics of the human personality. As a rule the patient universe into which the psychotherapist has delved has not been typical of the overall homosexual population, consisting mainly of subjects with acute moral and legal, if not psychological, problems.
For a good many years, however, Freudian psychoanalysis has been in retreat. By contrast, recent studies by academic psychologists have been able to break out of this vise by producing the experimental or statistical evidence in the wake of Alfred Kinsey to the effect that homosexual subjects were, on standard tests and by a multitude of criteria, indistinguishable from heterosexual ones.
Much of the history of the medicalization of same-sex conduct has to do with psychic characteristics. Yet there is an old tradition that there were also physiological markers. Already, in the seventeenth century Paulus Zacchias had reported that men given to passive sodomy developed funnel-shaped anuses. By the nineteenth century this claim had become commonplace among forensic physicians. It recurs, for example, in the work of the influential Ambroise Tardieu in his Étude médico-légale sur les attentats aux moeurs (Paris, 1857). Tardieu also notes features ostensibly found in the penis and the mouth. Of the former organ. he asserts that in the case of active sodomites it becomes long and thin, resembling a dog’s member. He also speaks of certain deformations in the mouth of individuals who are given to fellatio.
One must ask whether all these putative cases were common, or simply a projection on the part of the medical examiner who found what he was seeking. This is to say, we may be dealing with urban legends that had very little correspondence to reality. In fact modern medical examinations do not confirm the presence of these physiological deformities.
C, Response. The first major study that challenged the conventional view that homosexuality was intrinsically abnormal summarized the work conducted in the 1950s by the American psychologist Evelyn Hooker. She administered psychological tests on a group of healthy homosexuals and compared those results with results from a control group of heterosexuals. Much to the surprise of the mental-health establishment, skilled psychologists who were adept in making such diagnoses could not distinguish the heterosexuals from the homosexuals on the basis of their test results alone. The test findings indicated that homosexuals were no different from, and had no worse problems than the heterosexuals.
As we have noted, the conventional wisdom at that time was that to be homosexual was to manifest obvious signs of mental disturbance. If this assumption was to be sustained, homosexuals must be shown to be clearly different from the heterosexuals. Yet Evelyn Hooker's study challenged this conventional wisdom. In her study Hooker refuted the generalization that all homosexuals are manifestly disturbed.
After a first 1973 effort, in 1980 the American Psychiatric Association finally decided to remove homosexuality per se from its nomenclature of mental illnesses, and in 1986 even the compromise "ego-dystonic homosexuality" was stricken from the list. But the issue lingers among the bitter-enders within the psychiatric profession. Now mostly advanced in years, these individuals resist these changes.
Regrettably, decades of controversy echoed in the mass media have left some members of the general public with the ill-defined belief that "homosexuality is a disease that must be treated." Now, however, this notion is singing its swan song.
BIBLIOGRAPHY. Georges Lantéri-Laura, Lecture des perversions: Histoire de leur appropriation médicale, Paris: Masson, 1979; George Chauncey, Jr., “From Sexual Inversion to Homosexuality: Medicine and the Changing Conceptualization of Female Deviance,” Salmagundi, No. 58-59 (1982-83), 114-46; Gert Hekma, Homoseksualiteit, een medische reputatie: De uitdoktering van de homoseksueel in negentiende-eews Nederland, Amsterdam: SUA, 1987; Vernon A. Rosario, The Erotic Imagination: French Histories of Perversity, New York: Oxford University Press, 1997; Harry Oosterhuis, Stepchildren of Nature: Krafft-Ebing, Psychiatry, and the Making of Sexual Identity, Chicago: Chicago University Press, 2000.