Pathologizing Sexuality and Gender

A brief history

Jacqueline Holler

Reprinted from "LGBT" issue of Visions Journal, 2009, 6 (2), pp. 7-9

What makes us desire partners of one sex or another? What makes us feel “male” or “female”? What is “normal” and what is not? What can be considered “pathological” (i.e., unhealthy or sick)? These questions have taken on great importance over the last hundred years as researchers and the general population wrestle with the diversity of sexual and gender expression.

Sexology in the 1800s

Until the late 1800s, Western society didn’t even have words for “homosexuality” or “heterosexuality.” Before this time, laws and social norms banned sexual acts between people of the same sex. Behaviours such as wearing the clothes of the opposite sex were also forbidden. These acts were usually seen as the result of sin, rather than as an expression of an individual’s personality. At the time, everyone ‘knew’ that God had ordained two sexes, each with distinct roles, and that these two sexes were to “cleave [cling] to one another,” not to members of their own sex.

By 1850, sexologists1 and psychologists were beginning to study human sexual behaviour. They came up with the idea that some men and women were members of a “third sex.” This third sex engaged in same-sex sexual relations and displayed gender-variant behaviour (that is, behaviour that wasn’t viewed as normal for their sex). By 1870, the term “homosexual”—considered to be morally neutral—had been coined to refer to those who had same-sex relations.2

At about the same time, the idea of sexual “inversion” was brought forward to explain both gender nonconformity and same-sex attraction. The “inversion” scholars believed that homosexuality was an inborn tendency. They believed it resulted from changes to an individual’s brain while still in the womb. They thought these changes made both the brain and the behaviour of “inverts” resemble those of the opposite sex. This idea that homosexuality was an inborn deviation from normal gender development was widely embraced. For example, women who fought for the right to vote were sometimes described as “mannish inverts” whose desire for masculine rights went along with their presumed seduction of younger women.3

In the nineteenth century there was little awareness that sexual orientation (the sex a person is attracted to) and gender identity (the gender one feels oneself to be) are not necessarily linked. But today, for instance, we understand that a man who likes “feminine” things may be heterosexual, while a stereotypically masculine man may be gay.

 At the beginning of the twentieth century, a new theory developed by Sigmund Freud rose to the fore. He acknowledged that sexuality was an important inborn drive, but saw both sexual orientation and gender identity as being shaped in early childhood. For Freud, no one was naturally homosexual or heterosexual.

Homosexuality: something to be ‘fixed’?

Some see Freud as the father of clinical ‘treatment’ of homosexuality, but Freud himself did not view homosexuality as a disease. He famously advised the anxious mother of a gay son that homosexuality “is nothing to be ashamed of, no vice, no degradation; it cannot be classified as an illness; we consider it to be a variation of the sexual function.”4

Freud did believe that homosexuality resulted from a disruption of the “normal” pattern of child development. But, since homosexuality wasn’t an illness in and of itself, there was no reason to ‘cure’ it. However, while Freud’s developmental theories were adopted in North America, his attitude toward homosexuality was abandoned.

Homosexuality was included, along with other sexual “disorders,” in the first Diagnostic and Statistical Manual of Mental Disorders (DSM-I), published in 1952. The DSM, published by the American Psychiatric Association, is used worldwide to influence diagnostic, research and public policy decisions.

 Psychologists began to advocate a simple cause for homosexuality: cold, domineering mothers and/or weak or absent fathers. Some professionals began to ‘treat’ the gay “illness,” often seeking to root out experiences once considered innocent or normal, such as youthful crushes on same-sex teachers.5

Treatment approaches ranged from psychoanalytic “reparative” therapies, which aimed to repair these problems supposedly caused by poor relationships with parents in early childhood, to “aversion” therapies.6 In aversion therapy, for example, a patient might be shown pictures of same-sex people engaged in sexual activity. When the patient begins to show signs of arousal, he (or, less commonly, she) might receive a painful electric shock or be given a drug that makes him nauseous. This is meant to “teach” the patient to associate homosexuality with unpleasantness or pain.

The effectiveness of all these therapies has been widely debated. Beginning in the 1960s, American psychiatrist Charles Socarides developed a psychoanalytic approach for which he claimed a cure rate of about 33%, though critics have disputed the permanence of such “cures.”7

Though the period between 1945 and 1970 was dominated by the idea that homosexuality was an illness, some contested the idea that same-sex attraction was abnormal. Alfred Kinsey’s research in 1948 suggested that many American men had had homosexual experiences and that a surprising number of men were consistently attracted to other men.8

In the 1960s, homosexual men and women began to engage in increasingly open advocacy, particularly after the Stonewall riots of 1969. The Stonewall riots took place in response to a police raid on a gay bar and were one of the first instances of gay resistance.9

Gay advocates saw psychiatrists as “gatekeepers” of societal norms regarding human behaviour. An “activist committee”10 lobbied to have homosexuality removed from the second edition of the DSM (i.e., the DSM-II). Activists and many professionals argued that to be regarded as a mental disorder, homosexuality should be reliably associated with mental illness or distress, neither of which was supported by data.

On December 15, 1973, the American Psychiatric Association, accepting this argument, declassified homosexuality as a mental disorder. The new DSM-III, published in 1980, contained a compromise between opposing views of homosexuality as mental illness; the new text introduced “ego-dystonic homosexuality” (i.e., distress about being gay). When a revised edition of the DSM-III (DSM-III-R) was published in the late 1980s, even this diagnostic category was removed.

Being gay was no longer officially a sickness, but conversion therapies (attempts to “treat” or change homosexual orientation) have continued. In 1992, Socarides co-founded NARTH (National Association for Research and Homosexuality), which continues to advocate for voluntary treatment.7,11 Christian approaches to conversion also remain prevalent in the United States. These use counselling, prayer and other techniques to treat a condition many Christians deem sinful.12

Gender identity: controversy prevails

Today, most of the LGBT community regards the idea of treatment for homosexuals as an offensive relic of the homophobic past. However, the idea of conversion is alive and well in therapies to treat gender identity disorder (GID).

GID was introduced into the DSM-III (previous editions had included only transvestism, or cross-dressing). Its first criterion for diagnosis is a “strong and persistent cross-gender identification.”13 (In other words, one’s gender identity differs from one’s anatomical sex.)

Activists have lobbied for the removal of GID from the DSM, most recently demonstrating at the April 2009 meeting of the American Psychiatric Association.14 However, some people within the transgender community fear that removing the disorder from the DSM might limit access to sex reassignment surgery and hormone therapy. For this and other reasons, the removal of GID from the DSM remains controversial.

 Meanwhile, transgendered and gender-variant children and youth remain targets for treatment. Efforts toward a ‘cure’ can be quite aggressive. The most common treatment for young people requires parents to police their children’s behaviour, attempting “to make the child comfortable with the sex he or she was born with.”15 For example, a young boy might be forbidden to play with girls or with so-called girls’ toys.

Often parents seek a cure because they fear their children will be hurt by others. For instance, one mother decided to seek treatment for her young son after two 10-year-old boys threw him off some playground equipment because he was playing with a Barbie doll.15 In a world where transgendered people—and people who are different—are targeted for violence, and where being “like a girl” is a source of shame for boys, we shouldn’t be surprised that parents seek to protect their children in this way.

There is, however, strong evidence that GID in children is not a mental disorder, and some scholars recommend removing this diagnostic category from the DSM.16 Scholars and LGBT activists argue that gender-variant children are as mentally healthy as anyone else—or would be if they weren’t persecuted by hostile bullies and well-meaning ‘treatments.’

History: a red flag on the side of caution

The history of how we frame sexuality and gender as “healthy,” “normal,” “natural” or “pathological” makes it clear that we have an incomplete understanding of this complex human experience. Our former simple idea—two sexes, with two distinct gender roles and a sexual orientation toward one another—has been complicated by research findings and social change. But this history of our evolving understanding should make us cautious about what we consider pathological—and about the ethics and consequences of ‘treatments.’

About the author

Jacqueline is Associate Professor of History and of Women’s Studies, Chair of History, and Coordinator of Women’s and Gender Studies programs at the University of Northern British Columbia. She is a historian of gender and sexuality, and co-author of The Gendered Society: Canadian Edition, forthcoming in 2010.

  1. Sexology is the scientific study of sexual behaviour. The field was pioneered by scholars in Germany, Austria and Britain in the late nineteenth century, and has had a tremendous influence on both scholarly and popular views of sexuality. Today, though the term “sexology” is seldom used, sexuality studies remain an important academic field.

  2. Hekma, G. (1994). “A female soul in a male body”: Sexual inversion as gender inversion in nineteenth-century sexology. In G. Herdt (Ed.), Third sex, third gender: Beyond sexual dimorphism in culture and history (pp. 213-239). New York: Zone Books.

  3. Chauncey, G. (1994). Gay New York: Gender, urban culture, and the making of the gay male world, 1890-1940. New York: BasicBooks.

  4. Abelove, H. (1993). Freud, male homosexuality, and the Americans. In H. Abelove, M. Barale. & D. Halperin, The lesbian and gay studies reader (pp. 381-394). New York: Routledge. (Original work published 1985)

  5. Faderman, L. (1991). Odd girls and twilight lovers: A history of lesbian life in twentieth-century America. New York: Columbia University Press.

  6. Haldeman, D. (2002). Gay rights, patient rights: The implications of sexual orientation conversion therapy. Professional Psychology: Research and Practice, 33(3), 260-264.

  7. Drescher, J. (2001). I’m your handyman: A history of reparative therapies. In J. Drescher, A. Shidlo & M. Schroeder (Eds.), Sexual conversion therapy: Ethical, clinical, and research perspectives (pp. 5-24). Binghamton, NY: Haworth Medical Press.

  8. Kinsey, A.. (1998). Sexual behavior in the human male. Bloomington, IN: Indiana University Press. (Original work published 1948.)

  9. Carter, D. (2004). Stonewall: The riots that sparked the gay revolution. New York: St. Martin’s Press.

  10. Silverstein, C. (2009). Letter: The implications of removing homosexuality from the DSM as a mental disorder. Archives of Sexual Behavior, 38(2), 161-163.

  11. NARTH (National Association for Research and Homosexuality):

  12. Haldeman, D. (1994). The practice and ethics of sexual orientation conversion therapy. Journal of Consulting and Clinical Psychology, 62(2), 221-227.

  13. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Arlington, VA: Author.

  14. Wingerson, L. (2009, May 19). Gender identity disorder: Has accepted practice caused harm? Psychiatric Times.

  15. Spiegel, A. (2008, May 7). Two families grapple with sons’ gender preferences. All Things Considered. Washington, DC: National Public Radio.

  16. Bartlett, N., Vasey, P. & Bukowski, W. (2000). Is gender identity disorder in children a mental disorder? Sex Roles: A Journal of Research, 43(11/12), 753-785.