40th Anniversary of “Homosexuality” Being Removed from DSM

Alfred M. Freedman, M.D>
Alfred M. Freedman, M.D.

DSM-II-Homosexuality1December 15th 2013 is the 40th anniversary of the historic event of “homosexuality” being removed from DSM ( Diagnostic Statistical Manual of the American Psychiatry Association )

In 2007 I interviewed Dr. Alfred M. Freedman who had been President of the American Psychiatric Association in 1973 when this event occurred. He described the details of how this resolution was passed by the APA Assembly . The interview was part of  a video podcast series which I was doing at New York Medical College. It was subsequently transcribed in the Journal of Gay & Lesbian Mental Health Volume 13 Number 1 January -March 2009 pages 62-68. The interview is available on the Internet in 5 short segments. Segments  3-5 deal mostly with this issue. In view of the historical significance of this event. I have put links to this interview below:

Interview with Dr. Freedman – Segment #1 – 6 minutes 20 seconds  http://www.youtube.com/watch?v=jhiyDAprlP4

Interview with Dr. Freedman – Segment #2 – 9 minutes 58 seconds http://www.youtube.com/watch?v=smvDA_9GJyE

Interview with Dr. Freedman – Segment #3 – 8 minutes 41 seconds http://www.youtube.com/watch?v=bmtr5kmpBus

Interview with Dr. Freedman – Segment #4 – 7 minutes 59 seconds http://www.youtube.com/watch?v=zLREZflrQrA

Interview with Dr. Freedman – Segment #5 – 4 minutes 24 seconds http://www.youtube.com/watch?v=z5YsWT48lEE

For more information about Dr. Freedman see an earlier blog .

 

Michael Blumenfield, M.D.

mblumenfield@aol.com

 

 

 

Alfred M. Freedman (1917-2011)

On April 17, 2011 Alfred M. Freedman died in New York at the age of 94. Dr. Freedman had been the 102nd President of the American Psychiatric Association and also had been the Chairman of the Department of Psychiatry at New York Medical College.

A Gentle Giant in American Psychiatry

On April 17, 2011 Alfred M. Freedman M.D. died in New York at the age of 94. He left behind a wife, two children, two grandchildren, innumerable colleagues whose careers were greatly influenced by him as well as a mental health community with untold numbers of patients most of whom will never know how his career has led to improvements in  their care.

I first met Dr. Freedman in 1980 when he hired me to be on the faculty of New York Medical College. He was at an age at that time when one might mistakenly think he was in the twilight of his great career. He had already edited what was clearly the definitive textbook in Psychiatry. Generations of psychiatrists learned psychiatry and prepared for their board examinations by reading Freedman and Kaplan. New psychiatrists to this day read the later versions of this book which he originated. When I met him, six years previously, he had been elected the 102nd President of the American Psychiatric Association after his name had been placed on the ballot through an unusual membership initiative. After his  arrival at New York Medical College, he built the Department of Psychiatry from a part time faculty to a major institution on both the local and national scene with innovative programs in many areas particularly in substance abuse. He had moved the departmental office to Westchester where I would be working in consultation liaison psychiatry  and integrated the department into Grasslands Hospital which would become known as Westchester Medical Center and the Psychiatry Department as the Behavioral Health Center. He also supported the New York Medical College Psychoanalytic Institute. His welcoming words of advice to me were to tell me that I should always remember that we are team players in this department. While there was never a doubt that he was the leader, he ran the department allowing the Associate Chairs and the division heads to all be creative and reach their full potential. He supported and personally encouraged the most junior faculty members. He was always very generous to his faculty.

I recall at one time when I had developed some expertise and experience in disaster psychiatry he decided to make me the head of a small subdivision in the department, which he called an  “institute” in this area and he insisted that I design some stationery to show this. He gave me the opportunity to write a paper with him in 1984 about depression, which was ultimately translated into German. Having my name on paper with him is one of the very special moments of my career. There are many other colleagues who have similar stories as he always made you feel as if you were an equal working together on the same team. The residents always loved him and he was a role model for every young psychiatrist who trained at any of the hospitals, which were part of the New York Medical College consortium.

Dr. Freedman’s parents where immigrants from Poland and they worked long hours in a small family store to send all their children to college and two of them to medical school. I only now realize that Dr. Freedman was an undergraduate at Cornell at the same time as was my father in law David Groner. It is a pleasing thought to me that somehow their paths may have crossed.

I would like to  reprint a section about Dr. Freeman’s training and early career from a biographical piece written by Dr. Freedman’s friend Dr. Leon Eisenberg on the occasion of Dr. Freedman’s term as President of the American  Psychiatric Association 1973-1974 (Am J Psychiatry 131:7, July 1974) ….

During his college years, Sir Arthur Eddington’s lectures briefly inspired thoughts of a career in atomic physics, but the call to medicine could not be denied. Yet those were days when an unofficial “numerus clausus” prevailed in American medical schools: a would-be physician had reason for anxiety about his chances for admission despite impeccable grades and recommendations. The list of schools that rejected our future President is long and distinguished. By great good fortune he applied to the medical school of the University of Minnesota and was accepted.

The early years in medical school were somewhat of a letdown in comparison to the exciting intellectual horizons college had opened. What made them more tolerable were the evenings and weekends he spent as research assistant in neurophysiology with Professor Herman Kabat, work which resulted in his first two publications on experimental shock. Once his clinical rotations began, medical school came to life: he can still recall many of his first cases in medicine and psychiatry. His commitment to care for urban poor led him to take his internship at Harlem Hospital, where he became aware of the problems as well as the challenges in providing medical care to neglected populations. The year also began his love affair with New York City. He enlisted in the Army right after Pearl Harbor and was assigned at the end of his internship to Arthur Mirsky’s laboratories at Miami.

The most important consequence of this duty station stemmed from a routine assignment to accompany a troop train to Colorado Springs. On his return journey he had gotten as far as St Louis, where he found himself momentarily stranded. Just before the departure of the next train, the ticket clerk called him frantically to offer him a last –minute cancellation. On that tain he was introduced to a Miss Marcia Kohl, who was returning to her home in Miami from college in Ann Arbor. Neither one had any difficulty recognizing that his chance encounter had been fated. Within six months, they were married and have remained, happily so, to this day….

Alfred’s army years were completed at the station hospital of the Third Air Force in Gulfport, Mississippi and he was discharged as a major in 1946. He undertook training in pathology at Mt. Sinai Hospital in New York City (1946-1947) in pursuit of a plan to prepare himself for the study of the biological basis of human behavior. He briefly contemplated completing his training in pathology but he left it upon receiving an invitation from Dr. Harold Himwhich, whom he had met when he was a medical student, to join him as a medical physiologist at the Army Chemical Center at Edgewood. His studies of acetylcholine and cholinesterase, with the use of diisopropylfluorophosphate as an enzymatic poison led to significant publications in the American Journal of Physiology and the American Journal of Psychiatry on the mechanisms of convulsions. Satisfying as he found laboratory work to be, he was drawn again to clinical activities and began his general psychiatry residency training at Bellevue Hospital in July 1948. Upon completing his basic training, he joined Dr. Lauretta Bender as a Fellow, then as staff psychiatrist on the Child Psychiatry Unit (1950-1954). From that period stem Alfred Freedman’s important papers on childhood schizophrenia and his first publications on pediatric psychopharmacology.

At that point Alfred faced a major watershed in his career. He had a half-time position on the Bellevue staff and spent half time in practice. Wedded to New York, he saw no immediate openings for a full-time academic career, although he was the author of some 20 publications including the first one on the psychiatric aspects of familial dysautonomia. Fate intervened in the person of Professor Richard Day, who invited him to head a pediatric psychiatry service at Downstate Medical Center, Brooklyn, N.Y.  From ground zero, Alfred built a major unit. In addition to the continuation of his earlier research interests in schizophrenia and pharmacology in childhood, he began a major study on the influence of biological and social factors during pregnancy and the neonatal period of child development. He demonstrated the markedly greater effect of neonatal hyperbilirubinemia on male infants in contrast to female infants. In a series of classic papers, Helen Wortis and Alfred Freedman have portrayed in unforgettable fashion the bitter dregs of life for children reared in urban slums; they have drawn attention to the interactions between biological and social factors that are so powerful that the combined biosocial insults have proved to be multiplicative rather than simply additive in effect. The splendid fulfillment of his tenure at Downstate, though only five years in duration was a tribute to Dr. Day’s judgment in selecting for chief of service a man only three years beyond his residency…

After Dr. Freedman stepped down from Chairmanship at New York Medical College he seemed to be as active as ever. I would frequently see him and Marcia at various gatherings and psychiatric meetings. He was always warm and friendly. He was also quite vigorous and had taken up the cause of human rights, which I know was never far from his heart. During his APA Presidency he had led a delegation to the Soviet Union and had spoken out about the detention of political prisoners in psychiatric hospitals in the USSR. In his later years he became one of the leading spokespersons, along with his friend and colleague Abe Halpern, in advocating that psychiatrists do not take part in execution in any manner and also that psychiatrists do not take part in the interrogation of prisoners. Their well reasoned ethical arguments continues to influence discussion on this very important topic. Dr. Freedman made very important contributions to revising the World Psychiatric Association Code of Ethics. He also received the APA’s Human rights Award. In the course of his academic work and his advocacy of human rights, Dr. Freedman has lectured all over the world.

It is well known that during Dr. Freedman’s presidency of the APA, homosexuality was eliminated as a designated psychiatric disorder in the official diagnostic statistical manual (DSM). At the time this was a momentous change with far reaching social and legal  implications for people with a homosexual orientation. The beneficial effects is still being played out today as we see the armed forces finally eliminating discrimination of gays and lesbians in the military. Four years ago I had a Podcast on the Internet where I would interview various psychiatrists. During one of his visits to Valhalla (New York Medical College) I invited Dr. Freedman to be my guest on the Podcast. He was then 90 years old and  graciously accepted the invitation.  He shared with me the behind the scenes activities on how he influenced this important event in American Psychiatry. He also spoke of other important issues in his career. I would like to provide the links to the full audio broadcast of that interview and the You-tube video presentation which is divided into segment one, two and three. In it you will hear and see Alfred M. Freedman, a modest, gentle giant of American psychiatry.

Don’t Ask Don’t Tell-Not Psychiatric Topic

There are very few reasons that a psychiatry blog should discuss the recent change in policy of “Don’t Ask Don’t Tell.” After all, homosexuality is not a mental disorder and this is a case of righting a wrong of discrimination and an example of social justice. However, until 1973 American psychiatry considered homosexuality as a psychiatric diagnosis. The behind the scenes story of how the American Psychiatric Association reversed it’s official policy towards homosexuality is explained in an interview that Dr. Blumenfield had with Dr. Alfred M. Freedman who at the time was President of that organization. There are links to a transcript of that interview as well as a 3 part video broadcast on You-Tube or the entire audio of the interview on Shrinkpod which is a podcast.

Recently the US Congress passed a law and the President signed it repealing Don’t Ask Don’t Tell. We are told that it is on fast track for implementation. This means that that another discrimination barrier has been broken and gay Americans will be able to serve our country in the US military as other Americans may do.

There is very little reason that I should have to mention this in a psychiatry blog. After all homosexuality is not a mental disorder. Except perhaps for the fact that Don’t Ask Don’t Tell has caused a great deal of psychological pain to those who have had to hide their identify for fear of being kicked out of the military or  suffering other repercussions. This should not be minimized, but overall it is a discrimination issue and one of social justice but not a significant psychiatric one.

However, it was not always this way. Up until 1973, the psychiatric profession considered homosexuality a mental disorder. There was a DSM code for it. The predominant official psychiatric thinking included various theories how certain types of child rearing may have brought about this sexual orientation. Many psychiatrists believed that therapy could change homosexuality and bring about “normal heterosexuality.”

Obviously there were many psychiatrists and other mental health professionals who did not hold this view. There was an increasing amount of research which did not support it . In fact, some experts believed  that homosexuality was founded on genetic and  biological determinants. There was also a great deal of clinical experience which supported the idea that sexual orientation could not be altered by therapy.

There was an historic meeting of the American Psychiatric Association in 1973 where the APA Assembly debated and passed a position paper stating that homosexuality was not a disorder and an equally historic debate within the Board of Trustees which took this position. It then became the official position of the American Psychiatric Association which has been reflected in subsequent DSM publications.

A few years ago I was broadcasting a podcast on the Internet and I interviewed Alfred M. Freedman who was the President of the American Psychiatric Association in 1973. I asked him about the background and the details of this famous debate. It was a very revealing interview in which he shared with me the behind the scenes activities involved with this event. A transcript of this interview was reproduced in theJournal of Gay & Lesbian Mental Health 13(1) 2009.

Alfred M. Freedman, M.D.

Dr. Freedman was Chairman of the Department of Psychiatry of New York Medical College and hired me on the faculty there in 1980. He is now in his 90s living in Manhattan and still attends meetings of the APA.

I am pleased to be able to provide the links to this video interview which can be seen on You Tube in three sections or heard on Shrinkpod in it’s entity.

Abolishing Don’t Ask, Don’t Tell

President Obama in his State of the Union Address stated that he wanted to abolish the Don’t Ask, Don’t Tell policy in the military service. Admiral Mullen, Chairman of the Joint Chief of Staff as well as the President of the Americann Psychiatric Association have issued similar statements. The history of this policy in the 20th century was briefly reviewed. In addition the concerns that have been expressed about letting gays serve openly in the military were discussed as was the experience of other countries where gays serving in the military has not been a problem.

President Obama Wants to Abolish Don’t Ask, Dont Tell

alg_obama_dont_askPresident Obama in his State of the Union Address stated that he wanted to abolish policies that prohibited gays from openly serving in the military.  I am also glad to see that just this past month the American Psychiatric Association finally got around to supporting this position. “The U.S. should repeal Don’t Ask, Don’t Tell and allow capable men and women to serve without regard to sexual orientation,” said APA President Alan F. Schatzberg, M.D. Even more important a few days ago Admiral Mike Mullen, Chairman of the Joint Chief of Staff said it was his personal belief that “allowing gays and lesbians to serve openly would be the right things to do.”

I thought this would be a good time to consider the history of this issue and what if any psychiatric implications would there be to such a change.

Early 20th Century – Gays Not Welcome in Military

There is evidence that the US military had a policy dating back at least as far back as pre World War II that recruits were not welcome in the military service if they were homosexual.  There were indications as early as the 1940s that some psychiatrists (in this case Harry Stack Sullivan) tried unsuccessfully to get the US military to accepts gays into military service .

         Harry Stack      Sullivan
Harry Stack Sullivan

No doubt there were gays in the military but it would have to be hidden and secret. The identification of homosexuality would be grounds for discharge. I believe in the earlier years that would have been a dishonorable discharge. During my time serving as a psychiatrist in the Air Force during the Viet Nam War it would have an administrative discharge.

Psychiatrists in the military were in an ethical bind. If they put information about sexual orientation into the  chart the patient could be removed from the military. Should military psychiatrists ask and should they write it in the psychiatric record? Of course during about the first ¾ of the 20th century homosexuality was officially considered a psychiatric disorder that in many cases was thought to be a condition that deserved treatment. Therefore one could understand if military leaders and even a compassionate military medical establishment would not want soldiers who were considered to be ill, to be in the military. Even though there was an increasing amount of understanding that this was a misconception and in fact the overwhelming majority of such soldiers did not feel in conflict and were not in need of therapy.

APA Eliminates Homosexuality from DSM

    Alfred M. Freedman
Alfred M. Freedman

In 1973 the American Psychiatric Association eliminated homosexuality from the official diagnostic manual. The history of how this came about and the implications of it for American psychiatry are quite significant. I had the opportunity to interview Alfred M. Freedman who was President of the APA at that time and he shared with me the behind the scenes activities which can be seen on You Tube in three sections or heard on Shrinkpod in it’s entity.

This acknowledged the changes that were taking place in most of the psychiatric community. It would still be some time before openly gay psychiatrists were accepted into the psychiatric establishment and were allowed to become professors of psychiatry or candidates at psychoanalytic institutes. Things were evolving…but not very much in the military.

President Clinton Officially Establishes Don’t Ask Don’t Tell

In 1993 President Clinton officially established the Don’t Ask Don’t Tell policy which essentially was saying that a gay person was welcome in the military as long as nobody knew about it. It did mean that recruiters were not allowed to ask nor were  military superiors allowed to do so.

It may not be so easy to picture the dilemma that a gay soldier who wanted to serve in the military would still have. They would be forced to lead a secret life and accept that the people around them would view them as a criminal worthy of punishment or at least banishment, should their true identify be known. It reminds me of the Muranos, the secret Jews who lived during the Spanish Inquisition. They had to pretend that they were someone else and would always have the fears of the dire consequences that would occur if they were discovered.

This policy has hit women in the military especially hard. Statistics on members of the military discharged under the ban showed that, though women accounted for just 14 percent of the armed forces in 2007, they made up more than 46% discharges for sexual orientation in 2007. Over all, the number of gay men and lesbians discharged from the military in 2007 rose to 627 from 612 a year before, according to Pentagon statistics.This is all occurring at a time when the military is having difficulty recruiting personnel , especially those with specialized language skills.

What Are the Concerns About Letting Gays Serve Openly in the Military ?

As with any piece of human behavior there can be conscious and unconscious determinants. No doubt some of the opposition to allowing gays into the military comes from underlying homophobia where there is a fear of close proximity to people who are gay. This can very well be based on unconscious latent homosexual impulses. Utilizing this line of reasoning to try to bring about change in US policy would not be very productive and most likely would only harden the resistance to reexamination of it.

However it may be useful to look at some of the rational arguments that have been raised. These concern the idea that soldiers, particularly in combat zones or where there are close quarters would be uncomfortable if they knew their comrades might have sexual attraction to them. This might lead to anxiety, poor morale and less military effectiveness. The same question was raised in regard to women in the military and as far as I know it has not been a problem.

More important there are many other countries which have gays serving openly in the military with no such problems reported. In one report 4 countries were studied in depth and they were Israel, Germany, Canada and Sweden. Military officials in each of these countries stated on the basis of their experience, the inclusion of homosexuals in their military has not adversely affected unit readiness, effectiveness, cohesion or morale. For example Israeli officials said that homosexuals have performed as well as heterosexuals and have served successfully in all branches of the military since 1948. Canada where problems in these areas were predicted said none had materialized

John M. Shalikashvili, a retired army general, who was Chairman of the Joint Chiefs of Staff from 1993 to 1997, spoke out on this issue. He described having  a number of meetings with gay soldiers and marines, including some with combat experience in Iraq, and an openly gay senior sailor who was serving effectively as a member of a nuclear submarine crew. He said that these conversations showed him just how much the military has changed, and that gays and lesbians can be accepted by their peers. He also quoted a Zogby poll of more than 500 service members returning from Afghanistan and Iraq, three quarters of whom said they were comfortable interacting with gay people.

One interesting question has been raised and that is whether or not such soldiers if they acknowledge their sexual orientation while on leave in certain Moslem countries could be subject to criminal prosecution there as some places have quite harsh laws against homosexuality. That reminds me that female military personnel in Saudi Arabia at one point were suppose  must wear black head- to-foot robes called abayas and ride in the back seat when off base. They could only leave base if a man accompanied them. The Air Force’s highest-ranking female fighter pilot sued to overturn this policy.  That is another story and such issues should not determine how the US decides to constitute our military forces. Good judgment obviously needs to be used when visiting  potentially hostile environments.

Conclusion

I do believe that we can take President Obama at his word and expect the Don’t Ask, Don’t Tell policy to be lifted. His Secretary of Defense stated recently that that the President and he can take this process only so far, as the ultimate decision rests with Congress. I believe we will see a change in policy this year and it will go smoothly. We will look back on previous policies as we look back on the history of other prejudices and discrimination, which have existed, in our history.

Barry Goldwater
Barry Goldwater

I don’t find myself in agreement with Senator Lieberman from Connecticut too much these days, but I thought he put it very well when he echoed the words of  Barry Goldwater who said, “It’s not important if you are straight, just that you can shoot straight.”

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