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Sexual Orientation

Setting the Record Straight: Homosexuality and DSM

Thomas Szasz was the first psychiatrist to oppose medicalizing homosexuality.

Yesterday, the American Psychoanalytic Association (APsaA) issued a formal apology for its past views on homosexuality as a form of mental illness. This represents the first formal apology on this matter from a national mental health organization in the United States.

Homosexuality was classified as a mental disorder in DSM in one form or another until the publication of DSM-III-R in 1987, chaired by psychiatrist Robert Spitzer, M.D. The diagnosis was first removed by the APA in 1973 under great external pressure, but a condition called "ego-dystonic homosexuality" remained in the manual until 1987. Ego-dystonic homosexuality was defined as having a homosexual orientation that is at odds with one's idealized self-image, or ego. The psychiatrist-psychoanalyst Charles Socarides, M.D., among others, continued to write on the "disease" of homosexuality long after it was removed from DSM. Still today, some clinicians—unethically, and in some cases illegally—practice "conversion therapy," an attempt to change a patient's sexual orientation via psychotherapy or counseling.

 Public domain
Thomas Szasz was the first American psychiatrist to oppose the classification of homosexuality as a mental disorder.
Source: Public domain

While Spitzer, who passed away in 2015, is often credited with the declassification of homosexuality as a mental illness (as chairman of the DSM-III Task Force), another psychiatrist—Thomas Szasz—voiced his disagreement with the medicalization of homosexuality at least twenty years earlier. Szasz, an analyst by training, went on to become internationally known for his best-selling 1961 book The Myth of Mental Illness: Foundations of a Theory of Personal Conduct and remained professor of psychiatry at the State University of New York Upstate Medical Center until his death in 2012.

Szasz's first remarks specific to homosexuality appear to have been made in 1965 in a chapter in a book edited by psychiatrist Judd Marmor. Marmor also advocated against the view that homosexuality is an illness, though it was Szasz who was the first to express these ideas (see Schaler, 2004). Writing in The Manufacture of Madness, published in 1970, Szasz stated,

My contention is that the psychiatric perspective on homosexuality is but a thinly disguised replica of the religious perspective which it displaced, and that efforts to "treat" this kind of conduct medically are but thinly disguised methods for suppressing it (pp. 170-171).

He continued,

There is a fundamental similarity between the persecution of individuals who engage in consenting homosexual activity in private, or who ingest, inject, or smoke various substances that alter their feelings and thoughts—and the traditional persecution of men for their religion. … What all of these persecutions have in common is that the victims are harassed by the majority not because they engage in overtly aggressive or destructive acts, … but because their conduct or appearance offends a group intolerant to and threatened by human differences (Szasz, 1970, pp. 208-209).

Because Szasz did not limit his argument to homosexuality (he asserted that mental illness in general is merely a metaphor)—and because he remains perhaps the most controversial figure in the history of psychiatry—his position on homosexuality is often ignored. Instead, others are credited with spearheading psychiatry's removal of homosexuality from DSM.

Yet, we must give credit where credit is due: Thomas Szasz was the first American psychiatrist to speak out publicly against the classification of homosexuality as a mental disorder. And when historians of psychiatry look back one hundred years from now, it may be Szasz's rejection of the disease concept of homosexuality for which he will be most remembered.


Schaler, J. A. (2004, February 21). Giving Marmor credit for the idea that homosexuality is not an illness is undeserved [Letter to the editor]. British Medical Journal.

Szasz, T. S. (1970). The manufacture of madness: A comparative study of the inquisition and the mental health movement. New York: Harper & Row.