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.

First Anniversary of PsychiatryTalk.com

This blog is written to mark the first year of PsychiatryTalk.com being on the Internet. The readership has expanded from 25 hits/week to over 300 hits/day and it is still growing. A followup on the topics of several of the blogs written in the past year was reported.

I started PsychiatryTalk  a little more than one year ago and it has been an interesting experience for me. I have met people from around the world via this blog  and it is very gratifying to see the number of hits on it to continue to grow. Initially, there would be an average of 25 pages /day that were read. Now it is well over 300/day and growing. I originally thought that the blog would generate online discussion.  I was surprised to find that readers are reluctant to put comments on the blog itself, although many people will write to me or people whom I know will speak with me in person about various subjects about which I have written. I still encourage any readers to put comments directly on the blog in the comments section and they will be posted usually within a day or two. It is easier for me to write the blog every other week rather than weekly so I have recently switched to biweekly postings.

I thought that this might be a good time to report some follow-up on various blogs which I have written .

The first blog that I wrote on October 12, 2009 was Review of Fox TV Show Mental. It was a critique of a new television show  which was about a psychiatrist. In my opinion, the program lacked authenticity and missed the opportunity to depict psychiatry and mental illness in a realistic manner.The show was not renewed. There is an excellent program about a psychotherapist on  HBO titled In Treatment which  just began it’s third season. It stars Gabriel Byrne as Dr. Paul Weston who has weekly sessions with patients , including one with his own therapist. This is a scripted show and although the writing is quite good, it is fiction based on a similar Israeli TV show.  I believe that it  would be possible to develop a high quality reality tv show of an actual ongoing therapy which could not only show real therapy sessions but also allow for interesting discussion by experts. There would be some ethical considerations in doing it which but I believe could be overcome and it  could be done in a thoughtful manner.

The second blog on October 19th was titled When a Mother Kills Her Children. It was about post partum psychosis with a discussion of the Proposed bill before the US Congress tiltled the Melanie Stokes Mothers Act . I am pleased to say that in March of 2010 it was passed and signed by the President. This  legislation will establish a comprehensive federal commitment to combating postpartum depression through new research, education initiatives and voluntary support service programs.

In December 2009 I first wrote a blog Condolence for Soldier Suicide where I made the case that it was wrong for the President of the United States not to write a letter of condolence to the families of American soldiers who have died by suicide. Another blog was written on this subject in August  2010 titled We Can’t Avoid PTSD and Suicides . While the President has still not changed his policy, the Secretary of the Army has recently written to some of the families and expressed his regret on the death of the soldiers. Perhaps this may be a sign of things to come. I authored an Action Paper with Dr. Roger Peele of Washington D.C. requesting the Assembly of the American Psychiatric Association to ask the President to reconsider his policy on this issue. It was passed by the APA Assembly and also endorsed by the Board of Trustees of the APA . This makes it the policy of our 38,000 psychiatrists organization. In addition Mental Health America and the American Foundation for the  Prevention of Suicide has passed similar resolutions and also are in the process of gathering signature for a petition to  President Obama. I believe we are getting closer to this long over due recognition to the families of these soldiers .

Another important military issue  and human rights issue was discussed in the February 2010 blog titled Abolishing Don’t Ask Don’t Tell (DADT).  Polls have consistently shown a majority of the public supports letting gays serve, and Defense Secretary Robert Gates and top military commanders such as Admiral Mike Mullen have recently endorsed it. In September 56 Democratic senators voted for the defense authorization bill, which included DADT repeal, but the measure failed to achieve the 60 votes needed to overcome a Republican filibuster.  A recent study conducted by the Pentagon concluded that ” …while a repeal of DADT will likely in the short term bring out some limited and isolated disruption to unit cohesion and retention, we do not believe this disruption will be widespread or long-lasting, and can be adequately addressed. The report, based on responses from 115,000 service members and 44,266 spouses, includes interviews with former gay or lesbian service members, some of whom were discharged from the military under the “don’t ask, don’t tell” policy. Of those surveyed, 69 percent said they had served with a gay service member and 92 percent of those respondents said they were able to work together.Fifty to 55 percent of those surveyed said the repeal won’t have any effect, 15 to 20 percent said it would have a positive effect and 30 percent said the effect would be negative.The report went on to say that  “The reality is that there are gay men and lesbians already serving in today’s U.S. military and most service members recognize this,” the report states. “Much of the concern about open service is driven by misperceptions and stereotypes about what it would mean.”I still like the words of Barry Goldwater on this issue who said, ” It is not important if your are straight , just that you can shoot straight.”

When there was a proposal for a 39% hike in healthcare rates purposed in California by private insurance companies, I raised the question in a March 2010 blog titled  Stockholders Must Vote CEO Pay whether  there should be  law where stockholders,not Board of Directors of Compensation Committees, should be required to approve any compensation packages more than 200 times the minimum wage in the US. That controversy seems to have been revived just this past month when compensation at Wall Street firms was reported to be  expected to hit $144 million . A column in the Wall ll Street Journal raised the question I brought up that since the 2008 financial crisis profits remain 20% below the 2006 level while the pay at these firms rose an astonishing 23 % over that time frame,  shouldn’t the owners of these firms be the ones to decide if they want to spend their money raising the compensation of their executives. ?

The May 12th 2010  blog titled Autism & FragileX- New Treatment has become the most looked at blog of PsychiatryTalk of the year so far. In it,  two new research projects concerning Autism Spectrum Disorder and Fragile X Syndrome are briefly reviewed. In the first, a random controlled study of children with Autism Spectrum showed that the Early Start Denver Model showed statistically improvement over a control group in regard to intellectual development and adaptive behavior. In the second study, preliminary research showed that a new medication improved behavior associated with Fragile X Syndrome compared to the control group. There is also some belief that such medication would be effective with children with Autism Spectrum.  As a followup I don’t find any announcements of new breakthrough research. However, there is  a $211 million HHS-wide initiative that would invest an additional $1 billion over the next eight years in autism related activities, the NIH budget includes $141 million in FY 2010 for research into the causes of and treatments for autism spectrum disorders (ASD). The funded research will  include identifying biomarkers; improving ASD screening; establishing ASD registries; understanding genetic and environmental risk factors, as well as interactions between the immune and central nervous systems; and enhancing services that can help people with ASD across the lifespan.


Also in May I wrote two blogs addressing financial issues in the  American Psychiatric Association and they were Impact of APA Budget Cuts and  Increase APA Budget $1.5 Miilion. In the the former I discussed the expected impact of the cuts on the APA Assembly and APA Components particularly the Communications Committee and the Disaster Committee. In the second blog I outlined several specific suggestions how I felt that the APA could gain this large increase in it’s budget. Certainly the APA continues as a very vigorous organization representing 38,000 psychiatrist and speaking out on important issues concerning mental health. It is still too early to determine if the cutbacks will seriously hinder it in it’s effectiveness. I understand that some of my suggestions are being considered by some of the leadership but as far as I know no steps have been taken to implement any of them

In a July 14th blog titled I would Like to Thank My Psychiatrist It was stated that Los Angeles Laker Ron Artest after his team won the NBA Championship thanked his psychiatrist on national television. This is was noted to be  example how an increasing number celebrities are comfortable publicly discussing their psychiatric history. Television programs, movies, the Internet and the new media have all contributed to the reduction of stigma about mental health problems and treatment. My colleague Bill Arroyo informed me that Artest was mistaken in that his therapist was not a psychiatrist but another mental health professional. While I appreciate the correction, the changing attitudes towards discussing therapy still  holds and is a good trend.

Last month I wrote my first blog on Miners in Chile anticipating any psychological issues that people who have gone through  a traumatic event may experience. As the miners began to emerge from the successful rescue efforts asecond blog was written in conjunction with a blog that I wrote for  CNN.com which I suggest that in this situation I believe that resiliency will be the default and most if not all of these miners will not have any long lasting psychological effects. In fact this brush with death may end up being a positive experience for them . It is obviously too early to tell  but it is very gratifying to see the good feeling around the world for these miners. However, just recently  29 miners  died in an explosion in New Zealand and we are reminded how such tragedies occur all the time and so cause great mental anguish for so many people. In this regard still another report of a recent tragedy caught my eye and that was the traumatic event in Cambodia where more  more than 378 people died and hundreds more were injured in a stampede at the end of the annual Water Festival late Monday in Phnom Penh. So many of these victims  were young people , many in their teens. I hope that there are mental health professionals and others available to help the survivors, families and friends deal with their grief.

Needless to say, I am still enthused about continuing this blog. I do appreciate the growing readership and I would want to encourage each of you to feel free to comment directly on the blog with your own views are particular topics. Whenever I have had occasion to give a talk whether it has been at a national meeting, a Grand Rounds or even a local group, I am always very pleased if there are 25 people in the audience, as it is privilege to share my interest with others. So it becomes a special opportunity to use the Internet to reach much larger numbers throughout the world through this wonderful medium. Thank you all for your continued interest.

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.”

Your Comments Are Welcome