This paper reviews the historical treatment of homosexuality within psychiatric diagnostic frameworks, focusing on its evolution through successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Beginning with early categorizations by Kraepelin, Bleuler, and Freud, the paper traces the political and scientific controversy surrounding the 1973 removal of homosexuality from the DSM II, subsequent reclassifications such as Ego-Dystonic Homosexuality, and its eventual full removal in the DSM IV. The paper argues that despite formal diagnostic changes, negative attitudes and clinical biases persist within the psychological community, the general population, and among homosexuals themselves — with particular concern for the underrepresentation of research on bias in the diagnosis and treatment of lesbian patients.
The paper demonstrates a literature-gap argument: it reviews what existing research shows (bias in treatment and diagnosis) and then methodically identifies what is missing (post-DSM IV bias research; research on lesbian-specific diagnosis). This is a strong technique for justifying further investigation and establishing a paper's scholarly contribution.
The paper opens with a historical introduction to psychiatric classification and the DSM's role in diagnosis. It then narrows to homosexuality's contested diagnostic history across DSM editions. A conceptual middle section addresses the compounding complexity of homosexual identity alongside mental illness. The paper then critiques the DSM as a politically shaped document before arguing that bias persists despite formal removal. It closes with a call for targeted research on lesbian-specific diagnostic bias.
Throughout the history of psychology there has been an attempt to categorize persons with mental illness and assign names to the symptoms they present. Whether it was Emil Kraepelin and Eugen Bleuler's systematized study of schizophrenia (dementia praecox) versus manic-depressive illness, or Freud's pointing to the internal conflicts of childhood as playing a causal role in psychoses, psychology has long attempted to form categories of symptoms and name them (Holzman, 1996).
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been the most prominent tool used by mental health professionals to aid in formulating a diagnosis based on symptoms presented by a patient. The process of diagnosing is an objective, essential first step in the formulation of a treatment plan, and the diagnosis often dictates the course of treatment that will follow.
The DSM has undergone several revisions up to the present-day DSM-IV. A revision particularly relevant to this study is the change, and eventual removal, of homosexuality from the diagnostic categories. In 1973 the American Psychiatric Association (APA) removed homosexuality as a mental disorder from the classifications within the DSM-II. Homosexuality remained part of the DSM system but was placed under the alternate category called Sexual Orientation Disturbance. The diagnosis was again revised for the DSM-III-R to include Ego-Dystonic Homosexuality. The DSM-IV revision contains no category for the diagnosis of homosexuality. Whether mental health professionals agreed or disagreed with these revisions, all changes pertaining to homosexuality were met with considerable controversy and debate (Fink, 1975; Schact, 1985; Spitzer, 1981).
Despite the changing diagnosis and eventual removal of homosexuality from the DSM, the literature indicates that negative attitudes and bias continue within the psychological community, the general population, and within the homosexual community itself (Miguel and Millham, 1976; Walters and Simoni, 1993; Plugge-Foust and Strickland, 2000). This literature suggests that these negative attitudes and biases toward homosexuality have been incorporated into the field of psychology. Homosexuals have a long history in the literature of undergoing differing analyses and treatments aimed at changing sexual orientation. Though homosexuality has been removed from the DSM as a diagnostic category, research continues into reparative treatments and therapies intended to alter sexual orientation. This research indicates a continuing bias within the mental health field toward homosexuality in the context of treatment. Given this continuing bias, it is not unreasonable to be concerned that many people are not receiving a proper clinical diagnosis simply because their sexual orientation varies from what is considered "normal."
Though there is literature specifically addressing biases toward homosexuality within the mental health field regarding treatment and diagnosis, there is a scarcity of research on bias in diagnosis since the DSM-IV, and an even more striking scarcity of research on the diagnosis and treatment of the female homosexual. Given that scarcity, and given that diagnosis often dictates the course of treatment to follow, additional research appears necessary to clarify the present biases among mental health professionals regarding homosexuality in diagnosis — specifically in the case of the female homosexual. Since correct diagnosis leads to correct treatment, examining biases in diagnosis as they relate to homosexuality is crucial.
Historically, homosexuality has been defined as deviant, psychologically abnormal, and even criminal. With this history comes a legacy of potential bias regardless of the efforts professionals make to develop an unbiased professional regard. Tracing the legacy of homosexuality across the psychological literature reveals its history in both a sociological and a scientific sense. With this legacy comes an almost inevitable set of questions regarding the treatment of disorders even remotely associated with homosexuality, or secondarily regarding any individual who is openly homosexual. As Terry (1999, p. 15) notes, even today it is acknowledged by nearly every person with real awareness of the lifestyle differences associated with an alternative sexual orientation that the lives of such people are largely reduced to a simple and degrading set of stereotyped ideas that rarely, if ever, encompass even a small part of the reality of one's life.
The development of identity is one of the most complicated and time-consuming psychological processes that humans experience, and yet most people move through it without much conscious reflection. When, however, a person's identity is shaped by an individual characteristic such as same-gender sexual preference, the process moves much more to the forefront of conscious personal thought. If, in addition to the significant identity characteristic of homosexuality, an individual also carries a chronic psychological disorder, the process becomes exponentially more complicated.
To some, homosexuality and mental illness would be considered mere labels — everything determined by degrees. Yet in the world of diagnostic medicine the significance of the impact of one upon the other is substantial. The historical determination in diagnostic medicine of homosexuality as its own special legacy of a mental disorder means that even today it is often treated as a simple facet of a disorder, if not overtly, then at least to some degree covertly.
Homosexuality and mental illness together create a compounding stigma. The societal and professional biases that flow from centuries of treating homosexuality as deviance do not disappear simply because a diagnostic manual is revised. Understanding social stigma and its effects on mental health care delivery is therefore essential to any honest evaluation of how homosexual patients — and lesbian patients in particular — are diagnosed and treated.
In the relatively recent history of modern psychology there have been many attempts to quantify and regulate the diagnosis of psychological problems so that assessment, treatment, and diagnosis can be centered on a scientific model that is predictable and repeatable. In an attempt to legitimize the practice of psychology, what might be called the "disorder bible" was created. The DSM began its life as an appendix to a larger work that provided classification and nomenclature for diseases of all kinds, and evolved into the politically charged document it is today through five major rewrites credited to the American Psychological Association (Zimmer, 1999). In each subsequent incarnation of the document, politics and propriety are exhibited, depending of course upon one's perspective.
Though there is literature specifically addressing the biases toward homosexuality within the mental health field regarding treatment and diagnosis, this author has found a scarcity of research on bias in diagnosis since DSM-IV, and an overwhelming scarcity of research on the diagnosis and treatment of the female homosexual. Since diagnosis often dictates the course of treatment that follows, additional research is necessary to clarify the present biases of mental health professionals regarding homosexuality in diagnosis — specifically as it applies to the female homosexual.
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