Keepers of the Diagnostic Keys

Fifty years ago my father led the psychiatric establishment in declaring that homosexuality was not a mental disorder, changing the tide of how being gay was seen in America.
By | Nov 28, 2023
2023 November/December, Highlights

On August 29, 1956, plainclothes police officers arrested a young Jewish World War II veteran named Franklin Kameny in a bus terminal men’s room in San Francisco. The charge involved what Kameny insisted was unwelcome groping of his genitals by a stranger. The arresting officers watched the encounter through a ventilation grille.

Kameny, a gay PhD astronomer in his early 30s, claimed he was the victim of entrapment. Nevertheless he followed the well-worn path of expediency and pleaded guilty. The guilty plea entailed a $50 fine and six months probation. The following year, Kameny’s federal employer, the U.S. Army Map Service, dismissed him for misstating the charge against him on his employment application, which Kameny argued was just a pretext. In January 1958, the U.S. Civil Service Commission barred Kameny from all future federal employment on the grounds of “immoral conduct.”

The matter might have ended there as just another sad act of sanctioned discrimination in gay history’s Dark Ages. The 1950s were the time of the Red Scare, aimed mostly at liberals and leftists suspected of past communist ties. At the same time, the so-called Lavender Scare targeted closeted homosexuals. In 1953, President Dwight D. Eisenhower had signed Executive Order 10450, declaring any federal employee with “sexual perversion” to be a security risk. Homosexuals (the term “gay” had yet to gain wide usage) were to be denied federal employment, and any current federal employee found to be gay faced automatic dismissal.

Gay people had long been used to living underground. Job dismissals and sodomy-law prosecutions were routine. Until 1967, for example, in New York City bartenders could refuse to serve drinks to persons who said they were homosexual, and cab drivers known to be gay had to undergo psychiatric evaluations until 1972.

If they could recommend defining homosexuality as a “pathology,” they could recommend revoking it.

But Kameny chose to fight. He filed a civil rights suit in federal court in 1959 and took it all the way to the U.S. Supreme Court, the first gay discrimination case to get that far. The Supreme Court declined to review his petition. Unable to find a job, Kameny eked by on 20 cents’ worth of food a day. “It was a great day when I could afford five cents more and put a pat of butter on my mashed potato,” Kameny told an interviewer in 1989.

Kameny, who died in 2011, never held another day job again, instead devoting his life to activism on the then-novel principle that being gay was a human condition, not a disease. “Persecution and discrimination [against homosexuals is] not one whit more warranted or justified than those against Negroes, Jews, Catholics or other minority groups,” Kameny wrote in his Supreme Court brief. Homosexual acts, he wrote, are “moral in a real and positive sense and are good, right and desirable, socially and personally.” (Kameny is credited with coining the phrase “Gay is Good,” which for several years was used regularly by gay rights’ proponents).

These revolutionary thoughts put Kameny and the nascent gay rights movement on a collision course with the world of psychiatry, which at the time considered homosexuality to be a “sociopathic personality disorder.” Kameny and another leading gay activist named Barbara Gittings realized that to escape society’s collective condemnation, they had to strike at the custodian of the diagnostic keys: the American Psychiatric Association (APA).

Their fight proved successful when, on December 15, 1973, the APA’s board of trustees voted to remove homosexuality from psychiatry’s Diagnostic and Statistical Manual (DSM), the profession’s listing of mental disorders. After the trustees’ vote, the president of the APA, Alfred M. Freedman (my father; more on him later), went before reporters gathered at APA’s headquarters to say that the board also had passed a resolution calling for “all public and private discrimination against homosexuals” to cease, and that “homosexuals [should] be given all protections now guaranteed to other citizens.” The next day, a New York Times front-page headline read: “Psychiatrists, in a Shift, Declare Homosexuality No Mental Illness.”

Barbara Gittings and Frank Kameny with “Dr. H. Anonymous” at a panel held during the 1972 APA annual meeting in Dallas. (Photo credit: Photo by Kay Tobin ©Manuscripts and Archives Division, The New York Public Library)

Others had called for equal rights for gays before. The Stonewall uprising of 1969 (named after a police raid on the eponymous Greenwich Village gay bar) caught the attention of the public at large. But the APA vote gave the movement the kind of boost it needed. “At the time, none of us knew how important it would be,” says Lawrence Hartmann, a psychiatrist who played a key role in the decision. “It turned out to be a very decisive, very important event through which a lot of opinions were changed in the United States and internationally.”

Prior to the APA decision, employers and others discriminating against gays “hadn’t had to defend it,” says George Chauncey, a history professor at Columbia University and author of two books on gays in America. “They could point to homosexuality as a sickness. But once the APA declared that homosexuality was not a sickness, it undermined the basis of discrimination.”

The APA was founded as the Association of Medical Superintendents of American Institutions for the Insane in 1844, a time when treatments included bleeding, blistering, straitjackets and other forms of restraint. It became the American Psychiatric Association in 1921. By the 1930s, it had formulated a “Standard Classified Nomenclature of Diseases,” a list of what was—and by elimination what was not—a mental disorder. Over time the list evolved into the DSM, which is now in its fifth edition.

From the 1930s through the 1970s, outside of mental hospitals, psychoanalysis was psychiatry’s predominant form of treating individual patients. Its calling card was the deep probing of the unconscious to pinpoint insights that, once recognized, would be liberating for the patient. Although psychoanalysis is still practiced, it has lost some of its luster over the past 50 years, giving ground to a model that mixes biology with examination of social surroundings and advice to avoid negative thinking along with improved medications. The advent of managed care also relegated “talk therapy” to cheaper non-MD therapists and assigned psychiatrists the more mundane task of writing prescriptions for psychotropic drugs.

Alfred Freedman; Robert L. Spitzer; Judd Marmor. (Photo credit: Courtesy of Dan Freedman / Psychiatric News / Courtesy of Vernon Rosario)

Psychoanalysis took aim at homosexuality practically from its point of origin in Vienna in the late 19th and early 20th centuries. Sigmund Freud, the father of psychoanalysis, laid out a complex theory, neither embracing homosexuality as normal nor stigmatizing it as what was then called degeneracy. Rather, he saw it as a derailing of sorts of the human journey to mature (hetero) sexuality. Freud labeled homosexuality an “inversion,” which he described as “a variation of the sexual function, produced by a certain arrest of sexual development.” But it was not an illness, Freud argued, and he believed that efforts to reroute homosexuals to heterosexuality were unlikely to succeed.

“Freud was tolerant for his time,” Jack Drescher, a New York psychiatrist and psychoanalyst who has published extensively on psychological issues of homosexuality, wrote in 2008. He noted that Freud signed a 1930 petition to decriminalize homosexuality in Austria and Germany. “Although he did not consider homosexuality an illness, his theory did not quite constitute a clean bill of health.”

A study in 1962 concluded that homosexuality was the result of childhood experiences with overbearing mothers and distant or detached fathers.

The rise of Adolf Hitler sent Freud and virtually his entire psychoanalytic community into exile. Freud left Vienna for London in 1938 after the abrupt Nazi seizure of Austria, while many of his acolytes went to the United States. One of the most prominent, Sandor Rado, broke from Freud’s nuanced view of homosexuality. He argued that homosexuality was an aberration, caused by faulty parenting. Rado’s views were incorporated into psychiatry’s diagnostic manual—the DSM—in 1952 when homosexuality was labeled as “sociopathic personality disturbance.” In 1968, it was recategorized as “sexual deviation.” Another refugee protégé of Freud, Edmund Bergler, wrote a book in 1956, Homosexuality: Disease or Way of Life? Its publication turned him into the godfather of the psychoanalytic assault on homosexuality: “Homosexuals are essentially disagreeable people…[their] shell is a mixture of superciliousness, fake aggression, and whimpering…[they are] psychic masochists,” he wrote.

A group of activists held one of the first major organized gay civil rights demonstrations on July 4, 1965, in front of Independence Hall and the Liberty Bell in Philadelphia. (Photo credit: Photo © Mattachine Society, Courtesy of The Pew Center for Arts & Heritage)

Rado and Bergler both heavily influenced Irving Bieber, who authored an influential study in 1962 that concluded homosexuality was the result of childhood experiences with overbearing mothers and distant or detached fathers. At the time, this view of homosexuality was widely popular, enough so that Philip Roth worked it into his notorious 1969 novel Portnoy’s Complaint. The book’s protagonist ruminates on how the miracle of his life is that his mother’s domination didn’t turn him into a “fruitcake,” i.e., gay.

In 1961, Kameny founded the Washington, DC chapter of the Mattachine Society, a gay rights organization started in 1950 in California. Kameny helped organize a picket line in front of the White House in 1965, with signs such as one that demanded “First Class Citizenship for Homosexuals.” In addition to the government, Kameny also mounted an attack on psychiatry, calling psychiatrists “a biased group” in a 1964 television interview.

As a militant movement leader, Kameny was hardly a diplomat. The authors of Out for Good, a 1999 history of the gay rights movement, described Kameny as having the “manner of a snapping turtle, a voice like a foghorn, and the habit of expressing himself in thunderous bursts of precise and formal language.” He was, according to authors Dudley Clendinen and Adam Nagourney, “George Patton as gay activist.”

Gay rights advocates’ assaults on APA meetings during this period began in 1970 when a group of Bay Area activists discovered that Bieber, a despised figure for his 1962 study, would be participating in a panel discussion at the APA annual meeting in San Francisco. Protesters sought out Bieber and struck hard, shouting at him and the other analysts and calling them “pigs.” The confrontation shocked Bieber. “I never said homosexuals were sick,” he responded. “What I said was they had displaced sexual adjustment.” Bieber was not the only target of the disrupters. At the same APA meeting, an Australian doctor described his use of electroshock therapy as a way of diminishing same-sex attraction. “Where did you take your residency? Auschwitz?” one demonstrator shouted.

Kameny and a band of other activists were on hand for the 1971 APA meeting in the cavernous Shoreham Hotel in Washington, DC. Gay-rights protesters and psychiatrists came to physical blows. “You Nazis!” one psychiatrist yelled at the legion of activists. During a large meeting, Kameny seized an open microphone. “Psychiatry is the enemy incarnate,” he thundered, according to the Clendinen-Nagourney book. “Psychiatry has waged a relentless war of extermination against us…You may take this as a declaration of war against you!”

Bit by bit the APA’s defenses were eroding. The organization agreed to sponsor a panel discussion at its next annual meeting in Dallas to be titled “Psychiatry: Friend or Foe to Homosexuals?; a Dialogue.” Kameny, Barbara Gittings (who founded the New York branch of the lesbian group “Daughters of Bilitis”) and a psychoanalyst, Judd Marmor, would participate. Marmor was the London-born son of a Yiddish scholar. He became an early advocate of depathologizing homosexuality based on his own experience with trying to change the sexual orientation of gay patients, which he came to view as futile. Joining Kameny, Gittings and Marmor would be a mystery panelist disguised in a rubbery Halloween mask and an oversized tuxedo. Distorting his voice, “Dr. H. Anonymous” intoned, “I am a homosexual; I am a psychiatrist.” As recounted in the Clendinen-Nagourney book, the masked figure lamented that homosexuals within psychiatry had to “know our place” or face excommunication. “We can’t be seen with our real friends, our real homosexual family, lest our secret be known and our doom sealed.” (“Dr. H. Anonymous” did not reveal his true identity—John Fryer, a Philadelphia psychiatrist—until 1994.)

It was gripping guerrilla theater, part of a crescendo of disruption that injected high drama into the meetings of staid, pipe-smoking psychiatrists. The calm collegiality of (mostly) men accustomed to veneration by the public went into a tailspin.

Gay protesters were not the only ones challenging the APA’s hidebound ways. In 1970, a cadre of young reformers in the APA came together calling themselves the Committee for Concerned Psychiatrists (CFCP). Initially formed as a reaction to the United States invading Cambodia (thereby widening the unpopular war in Vietnam), the group pushed the APA to be outspoken on women’s rights and progress for minorities. Its chief organizer was Lawrence Hartmann, now 86, one of the few psychiatrists active in the APA during this period still alive. Hartmann, who later came out as gay, describes the APA as “conservative, white, too much like the AMA [American Medical Association], guild-oriented, tradition-bound, money-bound.”

The CFCP picked my father, Alfred M. Freedman, as its choice for APA president in the association’s 1972 election. His days of private practice had mostly come to an end in 1960, when he was appointed chairman of the Department of Psychiatry at New York Medical College. At age 55, he was senior enough to be looked upon as part of the “establishment.” But the CFCP also viewed him as a progressive, sympathetic to their views. My father, who had coedited a major text, the Comprehensive Textbook of Psychiatry, was an indirect beneficiary of the 1960s effort to halt warehousing of psychiatric patients in mental hospitals. Deinstitutionalized patients were to receive care in newly opened community mental health centers instead. My father helped establish an early one in East Harlem. Sadly, these centers were never fully funded, and released mental patients in the 1970s wandered the streets of New York and other cities with nowhere to go. But the profession viewed my father as a forward-thinking leader, not consumed by private practice and the riches it could bring.

Author Dan Freedman, center, with his father, Dr. Alfred Freedman, and mother, Marcia K. Freedman, in 1974. (Photo credit: Courtesy of Dan Freedman)

My father could almost be considered an accidental APA president. In a brief memoir written before his death in 2011, he recounted how the CFCP sought him out to run against the “old boys’ network” that ruled the APA. Such an insurgency was unheard of within the APA; virtually all presidents were handpicked by a nominating committee, and elections were simply affirmations of the status quo. He initially demurred, offering several reasons why he could not run, including an upcoming sabbatical. But the CFCP assured him that he was unlikely to win more than 45 percent of the vote so he needn’t worry. Finally my father said yes. When the results came in, he had won by two votes. The petrified establishment demanded a recount, which resulted in his winning by three votes. He soon warmed to the task. A lifelong leftist, he loved nothing better than being on the right side of an issue. And if it involved something like homosexuality, where an oppressed population was demanding justice and equality, so much the better.

At the time he was elected, there had only been one Jewish president of the APA out of 74 serving in the 20th century. And although anyone raised on a steady diet of Philip Roth novels and Woody Allen movies could be forgiven for thinking psychiatry was Jewish-dominated, it was not. And yet, the CFCP recruited numerous other psychiatrists to take leadership positions. Among them: Marmor, John Spiegel, Viola Bernard and Jack Weinberg, all of whom were Jewish and were eventually elected to APA leadership posts. “It wasn’t a Jewish issue,” recalled Hartmann, who also later served as APA president. “But at least half our candidates were Jewish liberals.”

Psychiatry’s tectonic plates on homosexuality began to shift in 1972 when Ronald Gold, a veteran disrupter who once gave a speech to psychiatrists that he titled “Stop It, You’re Making Me Sick!”, met psychiatrist Robert L. Spitzer. Gold had been an entertainment writer for Variety and considered himself an adroit publicist. He had been subjected to “aversion therapy” (as it was called) from age 13. Subsequently Gold became a heroin addict and spent three years at the Menninger Clinic in Kansas. He emerged free from heroin but still very much a homosexual. Now age 42, he was in New York at a meeting of behavior therapists—the practitioners who believed electroshock therapy and other such techniques could trigger abandonment of homosexuality. Gold and others shouted down the speaker and effectively brought the meeting to a close.

Spitzer recalled in an interview in 2003 that they were shouting things like, “We can’t take this anymore! You’re pathologizing us!” Spitzer, agitated over the protesters’ disruption, rose from his seat and sought out Gold. Gold, who had just discovered that Spitzer was a member of the APA Task Force on Nomenclature and Statistics, brushed Spitzer’s anger aside, recognizing that the task force formulated the diagnostic manual’s definitions. If they could recommend defining homosexuality as a “pathology,” they could recommend revoking it as such, Gold reasoned. “Gee, could my group talk to your group?” Spitzer recalled Gold asking him. From that moment on, Gold “fastened on to Robert Spitzer and never let go,” Clendinen and Nagourney wrote in Out for Good.

Spitzer and Gold may have seemed like an odd couple of sorts. In their book, Clendinen and Nagourney described Brooklyn-born Gold as “short, hyperactive, slightly effeminate.” Spitzer was a taciturn Manhattan-raised intellectual, who described his mother as a “chronic outpatient in psychoanalysis,” which inadvertently inspired his own interest in psychiatry. Spitzer “wasn’t an activist, but he liked the attention,” says Regina Kunzel, a professor of history at Yale who specializes in gender and sexuality studies. “He saw himself as a troublemaker.” Spitzer would later say it was the first time he had any personal contact with someone openly gay. “It was quite a different experience for me because they became human people,” he recalled in a 2003 interview. “I started to think, ‘What could be done with this?’”

Four months after Spitzer’s first meeting with Gold, the nomenclature task force met with Gold and his allies. Among them was Charles Silverstein, a gay psychologist who cited the research of Evelyn Hooker at UCLA. In the 1950s, Hooker had administered psychological tests including ink blots to 30 homosexual males and 30 heterosexual males, none of whom had ever been in therapy. She submitted the results to two psychoanalysts, challenging them to identify who was gay and who was not. They couldn’t do it. The research had mostly been forgotten until that moment.

Spitzer investigated the definitions of the DSM and realized that for a particular condition to be labeled a psychiatric disorder, it had to cause subjective distress, impairment or dysfunction. Gay people happy with themselves suffered none of these. “Clearly, homosexuality per se does not meet these requirements,” Spitzer wrote in his initial proposal, which bounced around various APA committees before ending up at the fateful board of trustees meeting on December 15, 1973.

Although the proposal received a generally positive review among psychiatrists, many wondered: What about homosexuals who were unhappy with their sexual orientation, who did feel stress and anguish? Did they not suffer from a malady that warranted treatment? For such cases, Spitzer and his nomenclature colleagues came up with the diagnosis of “sexual orientation disturbance,” which would morph into “ego-dystonic sexual orientation” before it was removed from the DSM altogether in 1987.

The 1973 task force recommended a statement that homosexuality was “a normal variant of human sexuality.” The APA Board of Trustees pushed back and suggested releasing a statement that homosexuality “by itself does not constitute a disorder.” In his memoir, my father credited himself with forging “minor compromises” at the closed-door trustees meeting. He didn’t spell them out, but Clendinen and Nagourney said the main one was the insertion of the word “necessarily.” The proposed resolution ended up as: Homosexuality “by itself does not necessarily constitute a psychiatric disorder.” With that addition, the proposal won unanimous board approval with two abstentions.

The decision evoked an immediate backlash. Psychoanalysts, who were a faction of the APA, collected petition signatures calling for a vote of the entire APA membership and not just the trustees. The APA authorized the vote, and 58 percent sustained the board’s position. The defeated psychoanalysts continued to insist homosexuality was a perversion that could be cured through psychoanalytic techniques. The psychoanalytic group didn’t ultimately reverse course until 1991 and issued a full apology to the gay community in 2019.

Other organizations followed suit—eventually. However, historian Chauncey says that while “it took many years for change to occur, it would have been much harder without the APA decision.”

Activists (from left) Ronald Gold, Charles Silverstein, Frank Kameny and Barbara Gittings celebrating victory at APA headquarters in Washington, DC on December 15, 1973—the day that the APA Board of Trustees announced its decision to remove homosexuality from the organization’s manual of mental illnesses. (Photo credit: Photograph by George Tames. Courtesy of McGovern Historical Center, Texas Medical Center Library with permission of the George Tames Estate, IC 077 Medical World News Photograph Collection, MW-8130A)

Agreeing, Yale professor Kunzel adds: “The story gets told in a triumphalist way,” but it wasn’t “a magic wand.” The American Psychological Association (non-MD therapists) endorsed the psychiatrists’ position in 1975. The Democratic Party endorsed gay rights in its 1980 platform. The World Health Organization declassified homosexuality as a disorder in 1992. And the “Lavender Scare” that cost Kameny his job was halted in 1995 when President Bill Clinton ended the Eisenhower-era ban on federal employment for gays. Clinton also implemented the halfway measure “Don’t Ask, Don’t Tell” for military personnel in 1994. Finally, under President Barack Obama, the military in 2011 reversed course and allowed gays to serve openly. Meanwhile, the Supreme Court struck down sodomy laws in 2003 and legalized gay marriage in 2015. In 2020 it ruled that discrimination based on sexual orientation or gender identity is barred by the 1964 Civil Rights Act.

In a remembrance in the APA’s publication, Psychiatric News, in 2000, my father wrote that the board’s decision “made history, and for most of the board it was a gratifying moment, and one of the high points of my APA presidency.” He never claimed to be the only one behind the decision, but he was happy with the limited role he played as the closer of the deal.

I was 21 when the APA trustees reversed course on homosexuality and I honestly don’t remember much about it. But I do recall reading The Washington Post in 1999 and marveling at its daily reproductions of front pages featuring the most important story of the 20th century for each particular day. Some were obvious: November 23 featured the assassination of JFK; December 8 reported on the previous day’s bombing of Pearl Harbor. But the headline for December 16 stood out: “Doctors Rule Homosexuals Not Abnormal.”

I picked up the phone and called Dad, then 82. The news that the APA decision was the biggest story of the 20th century for that particular day floored him. He’d done much in his professional career—leading a delegation of psychiatrists to the Soviet Union to expose the wrongful commitment of political dissidents to mental hospitals, for example, and fighting the practice of doctors injecting psychotropic drugs into psychotic death-row inmates so they’d be deemed competent for execution. Adulation of my father had gone a little over the top in 1977 when the New York Daily News ran a story labeling him a “Supershrink” and noting that some colleagues referred to him as “Saint Alfred.”

But like so many aging people, he looked back on his life and wondered if he had accomplished anything of real value. The Washington Post recognition of the APA homosexuality decision seemed to settle it for my father. He died on April 17, 2011, and three days later his New York Times obituary began: “Dr. Alfred M. Freedman, a psychiatrist and social reformer who led the American Psychiatric Association in 1973 when, overturning a century-old policy, it declared that homosexuality was not a mental illness, died on Sunday in Manhattan. He was 94.”

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