The de-pathologising of being LGBT+

To put it mildly, healthcare professionals and professional bodies have not historically looked favourably towards the health and well-being of the LGBT+ population. In recognition of LGBT+ History Month's theme in 2024 of medicine, I'm going to focus on some specific examples, and examine how things have gradually changed.

Until relatively recently, anyone who wasn't straight was labelled as deviant and in need of curing. Take this extract from a book published in 1956, written by an American psychiatrist and psychoanalyst:

“I have no bias against homosexuals; for me they are sick people requiring medical help...though I have no bias, I would say: Homosexuals are essentially disagreeable people, regardless of their pleasant or unpleasant outward manner... [their] shell is a mixture of superciliousness, fake aggression, and whimpering. Like all psychic masochists, they are subservient when confronted with a stronger person, merciless when in power, unscrupulous about trampling on a weaker person.” Many of my friends were brought up in this hostile environment.

The American Psychiatric Association (APA published its first edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. This psychiatrists’ bible declared that anyone who was not heterosexual had a “sociopathic personality disorder." People thus diagnosed could be institutionalised, denied a mortgage, have their children taken away, and be barred from certain professions, such as law and teaching. A popular treatment for same-sex desires was aversion therapy, where gay people were shown pictures of naked men accompanied by an electric shock. Pictures were then shown of naked women and no electric shock was given. If that failed, other “cures” included chemical castration, electro-convulsive therapy, and even lobotomy (brain surgery). The UK and other countries eagerly adopted these theories and methods.

Go back even further, and we see more examples of heated debate and disagreement among healthcare professionals and therapists regarding the best ‘treatment’ for homosexuality. In the 1860s, neurologist Jean-Martin Charcot tried hypnosis, but found it didn’t work, and concluded that same-sex attraction was entirely inherited. German psychiatrist Richard von Krafft-Ebing disagreed, believing that all “sexual perversions,” including homosexuality, were the result of a combination of environmental and inherited factors. Those experts who argued that same-sex attraction was a normal human experience were very much in the minority. They included sexologist Magnus Hirschfeld who helped make the 1919 pioneering film Different from the others, and Sigmund Freud, the father of psychoanalysis, who stated that same-sex attraction was not a mental illness. After his death in 1939, many of Freud’s views were dismissed, including this one.

In the second edition of the DSM (1968), homosexuality was re-classified as a “sexual deviation.” That’s in my lifetime. Believing that homosexuality was preventable, Dr Irving Bieber wrote in the 1960s: “I do not believe it is possible to produce a homosexual if the father is a constructive father to his son… a supportive, warmly related father precludes the possibility of a homosexual son; he acts as a neutralising, protective agent should the mother make seductive or close-binding attempts.” This view has been completely discredited by research; even so, the misconception that you can somehow become gay because of how you’re brought up persists.

Frank Kameny, co-founder of The Mattachine Society, an early gay rights group, studied the DSM and found it full of pseudo-science and lacking in evidence. In the programme Cured, Kameny said that the reason gay people went to see psychiatrists was because these were people with mental health problems who also happened to be gay; a happy gay person would have no need to go to a psychiatrist. Dr Evelyn Hooker had made a similar point in 1956. Hooker’s pioneering research studied gay men in the community as opposed to gay psychiatric patients. Sixty healthy men, half gay and half straight, were matched by age, IQ, and education level, and were assessed by two expert clinicians, who unsurprisingly, could not differentiate between the gay and heterosexual men, based on their test results. She showed that happy gay men are not mentally ill.

The Gay Liberation Movement said in 1970 that “There is no cure for that which is not a disease. Psychiatrists who promise a cure with lobotomies, castration, and brainwashing… are sadistic murderers, quacks… and the system that supports them must be abolished.” In other words, you can’t fix someone who isn’t broken.

After years of campaigning and arguing within the psychiatric community, in 1973 the APA finally stated that homosexuality was not a mental illness or sickness. The statement said: “We will no longer insist on a label of sickness for individuals who insist they are well and demonstrate no generalised impairment in social effectiveness.” Whilst not exactly a generous and sympathetic statement, it was at least progress.

In the early 1980s, it felt like attitudes were beginning to shift towards gay men, but then came AIDS and Thatcher's Clause 28, reigniting rampant homophobia once again. My next blog article will look at the AIDS crisis in more detail, including the impact it had on my friends, and the appallingly slow global response to this terrible disease.

Unfortunately, the approach of many mental health professionals remained unchanged, and studies in the 1970s and 80s revealed that family doctors and psychiatrists in western countries continued with their negative attitudes towards same-gender desire and behaviour. An American study in 1986 showed that thirty per cent of doctors would not admit highly qualified gay students to medical school and forty per cent would not allow gay doctors to specialise in paediatrics or psychiatry. This was right in the middle of the AIDS crisis.

It took The World Health Organisation until 1990 to declassify homosexuality as a “disease.” Shocking.

The Royal College of Psychiatrists (RCP) issued a position statement on sexual orientation in 2014, saying that people have a right to protection from therapies that are potentially damaging, particularly those that purport to change sexual orientation, and that there is no scientific evidence that homosexuality is a disorder. The statement also talks in detail about about equal rights and freedom from any harassment or discrimination in any sphere. This aspirational statement is encouraging, and yet these potentially harmful practices of conversion therapy can legally continue, while the issue of whether or not they should be banned is still being debated at the highest levels.

Even though the establishment has established categorically, at last, that not being straight is not a mental health problem, we know that sadly, LGBT+ people are more likely to have mental health issues than straight cisgender people (people happy with their birth gender). The UK Government’s LGBT survey, the largest national survey of LGBT people in the world to date, was completed by 108,000 people and published in 2019. Twenty-four per cent of all the respondents had accessed mental health services in the preceding year. Those most likely to access services were bisexual people and trans people, including a staggering forty per cent of trans men. Tragically, suicide attempts are also much higher in the LGBT+ population than in the population as a whole, especially among young people.

Discrimination just makes it worse; it’s a key risk factor for LGBT+ youth who are depressed, abusing alcohol or drugs, self-harming, or attempting suicide. And for LGBT+ people of colour or with disabilities, discrimination remains an even bigger issue.

Transgender people have long been the recipients of moral and medical disapproval. “Gender identity disorder” was the American umbrella term used to “diagnose” trans people in the 1990s. This gave mental health professionals complete control over who could access transition. Thankfully, the notion that being transgender is a mental disorder is gradually being dropped.

Most people are content with the gender they were assigned at birth: they are cisgender. Some people feel that they have characteristics of the opposite gender, and this doesn’t trouble them. However, a small but significant minority develop gender dysphoria, which is the unease that a person has because of a mismatch between their biological sex and their gender identity. They may be aware from childhood that they have a sense of being different, whereas for others, it may be in adulthood that these feelings manifest. This feeling may be so intense that it can lead to depression and anxiety and have a harmful impact on daily life. People with gender dysphoria may suffer from low self-esteem, become withdrawn or socially isolated, experience depression or anxiety, take unnecessary risks, and neglect themselves. I know all about this from personal experience. It happened to someone in my family.

The UK government’s 2019 LGBT survey found that thirty-eight per cent of trans people accessing general healthcare services reported a negative experience because of their gender identity, and that twenty-one per cent said their specific needs were ignored or not considered. Imagine the courage it takes to build up to telling your family and friends what you are doing. Imagine stepping outside your front door for the first time as a different version of yourself.

I am full of admiration for people who go through so much just to be able to be themselves. With hate speech on the rise, the equality that was so bravely fought for can't be taken for granted. It's really time to stop discriminating; the fight for the right to be different goes on.

This blog is based on an excerpt from my book Bent Is Not Broken. Buy the eBook (various platforms) or get the paperback on Amazon via:

www.books2read.com/BentIsNotBroken

To read more about LGBT+ culture and history, and find out more about the author, head to www.bentisnotbroken.com