Zucker’s Methods and DSM

“In 2017, the World Professional Association for Transgender Health hosted its inaugural U.S. based conference in Los Angeles, California. Amongst the many presenters was Kenneth Zucker, a psychologist from Toronto, Canada. Zucker is amongst the leading researchers in gender dysphoria, particularly concerning youth. He ran a gender clinic at the Centere for Addiction and Mental Health and gained notoriety within the Toronto trans and gender diverse (TGD) community for his therapeutic approach that encouraged gender diverse children to live as their gender assigned at birth.

This practice is considered by many professionals and TGD people to be a form of conversion therapy (Zucker denies this). Community activism and a review of practices led to Zucker being ousted from the gender clinic (The Canadian Press, 2018), prior to his appearance at the conference in Los Angeles. At Zucker’s first scheduled talk, a group of trans women interrupted the session to protest his science and inclusion at the conference. They criticized WPATH for elevating Zucker’s methods and the lack of input of TGD people’s involvement in WPATH. Ultimately Zucker’s second talk was cancelled and the activists garnered a meeting with WPATH leadership. This approach of LGBT activists disrupting medical and psychological conferences is not new. The psychiatric and psychological professions have a substantial history of marginalizing LGBTQ individuals, leading to activists clashing with the psychological and psychiatric institutions. Perhaps the most monumental example of LGBTQ issues and activism interacting with the mental health field was the removal of homosexuality from the Diagnostic and Statistical Manual in 1973.

Brief History of Homosexuality in the DSM

The Diagnostic and Statistical Manual (DSM) is the handbook for mental disorders published by the American Psychiatric Association (APA) and in use by most behavioral health providers. In 1973, the APA Board voted to remove homosexuality from the DSM, declassifying it as a mental disorder. Across psychology and psychiatry, this date stands out as the depathologizing of homosexuality and a substantial milestone in LGBTQ rights. However, the narrative is far from straightforward.

Sigmund Freud is the father of psychoanalysis and left a legacy of psychoanalytic psychiatrists who were involved in APA. Freud did not believe homosexuality was pathological because homosexual people were able to live unimpaired. However, the following psychoanalysts did not hold this view (Drescher, 2015). The first version of the DSM published in 1952 (APA) identified homosexuality as a “sexual deviation” in the “sociopathic personality disturbance” category of personality disorders. It was not until the late 1950’s when research, particularly that of Evelyn Hooker, began to reveal no pathological difference between heterosexual and homosexual individuals. DSM-II followed in 1968 and homosexuality was no longer termed “sociopathic” but was still considered a personality disorder and sexual deviation. The ‘removal’ of homosexuality occurred between DSM-II and DSM-III.

Several articles detail the removal of homosexuality from the DSM and most start the saga in 1970 when the APA conference in San Francisco was disrupted by gay activists, particularly events with psychiatrists who were critical of homosexuality (Kirk & Kutchins, 2003). Drescher (2015) and Zachar and Kendler (2012) also identified gay activists disrupting the 1970 conference as the impetus for APA considering removal of homosexuality from the DSM. These protests spurred “scientific and professional debate” in journals and convention events for the next few years (Zachar & Kendler, 2012). One such event was a session called “Psychiatry: Friend or Foe to Homosexuals: A Dialogue” at the 1972 APA Conference where John Fryer as Dr. Anonymous shared his experience as a gay psychiatrist (Byne, 2014). Activists were also able to partake in panels at conferences including Frank Kameny and Barbara Gittings leading a panel in 1971 called “Gay is Good” (Drescher, 2015).

Activism also occurred from within the APA. The GayPA was a group of gay psychiatrists who secretly met at APA conferences. The GayPA supposedly met with the Nomenclature Committee in early 1973 along with members of the Gay Activists Alliance to encourage the removal of homosexuality from the DSM (Anderson & Holland, 2015). The Nomenclature Committee was led by a straight psychiatrist, Robert Spitzer, and was responsible for naming of diagnoses in the DSM. Spitzer became involved with efforts to remove homosexuality after he attended a conference event that was interrupted by over 100 activists. Spitzer stayed to talk with one of the group’s leaders, Ron Gold, and invited the activists to participate in the 1973 conference in Honolulu. Spitzer was also invited to attend the GayPA meeting at a bar during the 1973 conference. Along with scientific discourse and turning to research evidence, protestors were able to convince key personnel, particularly Robert Spitzer, that the inclusion of homosexuality as a mental disorder led to social discrimination and elicited support via meetings with the activists and gay psychiatrists.

Spitzer recommended removal of homosexuality from the DSM to the Nomenclature Committee based on logic that homosexuality was “suboptimal,” but not totally pathological and functionally impairing (Kirk & Kutchins, 2003). Ron Gold opposed this logic as it would not entirely depathologize homosexuality and there was discontent among APA membership, many of whom believed homosexuality was a mental disorder and should remain in the DSM. Ultimately in 1973 the Nomenclature Committee, led by Spitzer, and APA Board agreed the homosexuality on its own was not worthy of a diagnosis. There was a compromise diagnosis of “sexual orientation disturbance” that would remain. At a press conference to announce the change, Spitzer emphasized “that the board had not declared that homosexuality was normal,” upsetting gay activists. Serious backlash ensued from within the APA leading to a referendum on the Board’s decision to remove. Spitzer worked with the APA Board and hay and lesbian groups, who funded an educational campaign sent to all members. Kirk and Kuchins (2003) noted that the participation of gay and lesbian groups in the referendum campaign was hidden. In the end, 58% of APA’s voting membership voted to uphold the removal of homosexuality from the DSM (Drescher, 2015).

While the DSM shift occurred in 1973, the next version, DSM-III, was not released until 1980 and the presence of some diagnosis related to sexual orientation continued for decades. Additional copies of DSM-II printed after 1973 included “sexual orientation disturbance” rather than “homosexuality” and finally DSM-III included “ego-dystonic homosexuality.” Ego-dystonic homosexuality was grouped with psychosexual disorders, rather than personality disorders, and involved a desire to engage in heterosexual relationships in conjunction with sustained and distressing “overt homosexual arousal.” Ego-dystonic homosexuality essentially captured distress of experiencing homosexuality, which remained in some form of the DSM until the current DSM-5 published in 2015.

Across the several sources that detail the history of the 1973 decision, Spitzer is a primary figure. Kirk and Kuchins (2003) identify Robert Spitzer as the primary informant in these histories. In Zachar and Kendler’s (2012) article, Sptizer is hailed as the intermediary between gay activists and the APA board, which ultimately voted to remove. Yet without gay activists and the gay psychiatrists, Spitzer is unlikely to have taken the helm within the Nomenclature Committee.

Evelyn Hooker is another name that appears in histories of homosexuality and psychiatry/psychology, however she is not referenced to the extent of Spitzer. Evelyn Hooker was a psychologist working at UCLA in the 1950s (Kochman, 1997). Her research is cited as among the first that identified not pathology or difference between homosexual men and heterosexual men. Spurred by her relationship with a former gay student, Sam Fromm, Hooker received a grant from the National Institute for Mental Healthto conduct a study where homosexual and heterosexual men completed Rorschach tests and then three different clinicians interpreted the results, blind to the subjects’ sexual orientation. The results of this study (Hooker, 1957) were the scientific basis for arguments to remove homosexuality from the DSM. Kochman (1997) briefly notes that all of Hooker’s participants were members of the Mattachine Society and ONE – homophile groups operating in California.

Beyond Spitzer, the impact of activists at the 1970 APA Conference are identified as the origin of the DSM controversy, but rarely are particularly groups or names of activists mentioned in these histories. The GayPA and Dr. Anonymous receive the most recognition for their activism within APA at large. Several sources identify Dr. Anonymous at the 1972 conference (e.g. Anderson & Holland, 2015; Byne, 2014; Kirk & Kutchins, 2003), but only one mentioned that prominent gay liberation activists Frank Kameny and Barbara Gittings were also present with him on stage. Occasional references to the Mattachine Society, Ron Gold, the Gay Activists Alliance, Frank Kameny, and Barbara Gittings indicate the protests and activism surrounding the DSM required broad involvement of gay and lesbian organizations and potential alliances amongst psychiatrists and community members, but those exact histories are rarely detailed.

Research indicates the influence of homophile groups, gay liberation activists, researchers like Evelyn Hooker, and groups of gay psychiatrists as vital to the successful removal of homosexuality from the DSM. However, the extent of their efforts and potential alliances have not been uncovered and a feminist analysis has not been applied. Daley and Mule (2015) offered a critical queer analysis of APA’s stance on gender diagnoses leading up to DSM-5, but a similar approach has not been taken surrounding the 1973 removal. Drescher and Merlino (2010) published an oral history of interviews, American Psychiatry and Homosexuality, which includes a section on the 1973 APA decision. However, all six interviews are with individuals with MD or PhD behind their name. The interviews include gay psychiatrists, like John Fryer as Dr. Anonymous, but there are no attempts to center voices of lay gay activists who have been identified as the origin of the 1973 decision. Marcus’ Making Gay History (2002) includes interviews with a broader subset of actors in the 1973 decision, including Evelyn Hooker and Barbara Gittings, but the broad nature of this history does not permit a narrow focus on the dynamics amongst gay activists, researchers, the GayPA, and APA. Most arguments about whether or not to remove homosexuality within the APA centered on the scientific validity of the diagnosis (Schact, 1985). However, the science and this decision did not occur in a vacuum. In the decade following the removal, Spitzer wrote “the controversy over the diagnostic status of homosexuality did not involve disputes about facts but rather about basic values” (1985). The limited exposure of gay activists, gay psychiatrists, and affirming research in the dominant psychiatric and psychological narrative created the need for a nuanced, feminist understanding of how this momentous change occurred.”

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