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A History of the Intersection of American Healthcare and the LGBTQ+ Community By: Erica Cherian

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A History of the Intersection of American Healthcare and the LGBTQ+ Community By: Erica Cherian A History of the Intersection of American Healthcare and the LGBTQ+ Community By: Erica Cherian Introduction The LGBTQ+ community and the American healthcare system have an intricate relationship within the context of history. It is important to know the origins of various medical perspectives on the LGBTQ+ community, in order to understand how the community stands in terms of healthcare today. Patients of this community are among some of the most marginalized groups and experience a great number of health disparities. For example, LGBTQ+ teenagers are at much higher risk of depression and suicide than heterosexual teenagers.1 Much of the present- day marginalization by society is rooted in the outright discrimination and stigmatization of the past. Those discriminatory views of LGBTQ+ community, in particular, have been deeply affected by past medical perspectives on patients who belong to this population. In order to better care for these patients today it is imperative to look at the context of LGBTQ+ healthcare in the past. This paper deals with select topics related to the intersection of American and western healthcare with the LGBTQ+ community, with focus on concepts such as the changing medicalization of the LGBTQ+ community, and how it affected perceptions of the community by society, with specific focus on the changing medical definition of the LGB community, healthcare and therapies available to transgender individuals, as well as the AIDS epidemic. Changing Medical Definitions of the LGB Community The Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) community has long been a part of human history, and in more recent Western history, the community has undergone vast changes in terms of both medical definitions, as well as how the community is perceived and treated by healthcare providers. Current understanding focuses on “attraction, behavior, and identity”.1 In regard to sexual orientation and attraction, modern definitions focus on a spectrum, which encompasses homosexuality, bisexuality, and heterosexuality. Additionally, there is a separation between biological sex, which is assigned at birth, from gender identity-within this distinction arises the transgender definition and community.Error! Bookmark not defined. However, these definitions have not always existed, and the field of healthcare has had an enormous influence on how the LGBTQ+ community has been defined. This is especially important to consider when treating members of the LGBTQ+ community, as in the past, the medical field has contributed to the stigmatization of the community. Western medicine’s first known attempt to define homosexuality was the discussion of the “sexual invert”, established by Karl Heinrich Ulrichs in the 1860’s.2 He postulated that individuals who were attracted to people of the same sex as them were “inverts”, because their sexual orientation did not match the typical orientation of their biological sex. He believed that men who were attracted to other men had a “female psyche” within their body, and women who were attracted to women had a “male psyche” in their body. Later, Kertbeny created the term “homosexual”.3 However, the person who came to be most associated with the current definition of sexual attraction was Sigmund Freud, in the 1920’s and 1930’s. He had a complex definition of sexual attraction, as he stated that he did not think that homosexuality was an illness, but instead thought that homosexuality was a part of normal development, and so persistent attraction to same-sex individuals was an arrest of normal development.4 5 6 7 While Freud did not believe that homosexuality was a pathological condition, a number of psychoanalysts began to consider homosexuality to be a mental illness. An example was Sandor Rado, who did not believe that homosexuality was a normal part of development, and instead was a deviation from the norm that could be “cured”. His work informed others who developed “cures” which had little empirical evidence.Error! Bookmark not defined. According to the Institute of Medicine (IOM), “During this time, many psychiatrists and psychologists attempted various ‘cures’(i.e. attempt to change homosexuals into heterosexuals), such as psychotherapy, hormone treatments, aversive conditioning with nausea inducing drugs, lobotomy, electroshock, and castration…”.Error! Bookmark not defined. While there was not universal agreement on this, in the World War II Era, many American psychoanalysts believed that homosexuality was a pathology, and ultimately it was included as a diagnosis in the first iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952.7 8 This inclusion paved the way for a number of laws that prohibited members of the Lesbian, Gay, and Bisexual (LGB) community from participating fully in society. Based on the new diagnostic terminology, which labeled homosexuality as a class of sociopathic personality disturbance, many people were prohibited from being employed, laws were created that criminalized certain sexual practices (“sodomy laws”), sexual psychopath laws that typically applied to rapists and pedophiles were also applied to people of the LGBTQ+ community, and there were even recommendations to incarcerate individuals until they were “cured” of their homosexuality.1, 7 One of the most famous examples of this is the story of Alan Turing, a gay British mathematician, who helped de-code secret German ciphers, which helped turn the tide of World War II towards victory for the allied forces. His work also led to the development of the modern computer. In 1952, due to his sexual orientation, he was charged with “gross indecency” and underwent hormonal castration. He ultimately committed suicide, possibly due to the forced chemical castration.9 It can be argued that these medical definitions of this community tremendously affected how this population was stigmatized and mistreated by society. Ultimately, there was pushback on these concepts. One important source of contrast to the research and findings of the American Psychological Association (APA) and their DSM, was the research of Alfred Kinsey in 1953. His work established the spectrum of sexual attraction, and through surveying thousands of Americans, his team established that same-sex attraction was far more common than was believed at the time.10 11 Despite some statistical errors, this research laid the groundwork for further research and questioning about whether homosexuality should be considered a disease. Additional studies by Ford and Beach looked extensively into data on other species, as well as other cultures and demonstrated that same-sex attraction was far more common in both humans and animals than was previously understood, providing further support for Kinsey’s work.12 Another important study that came about due to his work was the work of Evelyn Hooker in 1957. Her research challenged the idea that all gay men were severely psychologically disturbed. In her research, she compared thirty gay men to thirty straight men, and found no more evidence of psychological dysfunction in the gay men than the straight men.13 These researchers helped establish a new perspective on the LGBTQ+ community, both in the world of science and with the general public. This work helped LGB activists at the time to begin challenging the concept that homosexuality was a disorder, and groups such as the Washington Mattachine Society were established to work on attaining civil rights for members of the community.1 14 These activists were able to achieve minor victories, but the major turning point for LGBTQ+ rights in America were the Stonewall Riots in NY in 1969, in response to police raids and brutality on patrons of LGBTQ+ spaces. This rebellion forced society to examine their treatment of members of the community, and helped draw a great deal of support from previously “closeted” (individuals who had not revealed their status as LGBTQ+ individuals) members of the community.1 14After the riots, many activists in the community began to perceive the DSM criteria as possible cause of some of the stigmatization of the community, which lead to activists interrupting the 1970 and 1971 APA conventions. Due to these protests, gay activists were allowed to attend the 1972 APA meeting, and were granted a panel to discuss their perspective on the medicalization of homosexuality. This included a discussion of the resultant stigmatization due to the definition of homosexuality as an illness.7 Resultantly, there was an investigation into what exactly constitutes a psychological disease, and whether homosexuality should be considered a diagnosis. This ultimately led to the re-defining of a psychological disease as one that causes significant distress to the individual, or one that causes impairment, such that the individual is not able to participate in society.15 As a result of thorough investigation by the Nomenclature committee of the APA, as well as the input of numerous other committees, the APA Board of Trustees voted to remove homosexuality from the DSM in 1973.1 7 While the activists did succeed in having homosexuality removed from the DSM, there was still some pathologizing of some forms of homosexuality; in the DSM II, there was a diagnosis called “Sexual Orientation Disorder” (SOD). It stated that if a person who was attracted to the same sex and was distressed by it, they would be diagnosed with SOD, and ultimately this led to the continued rationalization of conversion therapy. In the DSM III, this was changed to the diagnosis of “Ego Dystonic Homosexuality” (EDH), but in 1987, psychologists realized that neither SOD nor EDH qualified as a mental illness under the new definition of a mental illness, and EDH was also removed from the DSM.7 Western medicine has had a complex and ever-changing medical definition of homosexuality, which has had far-reaching consequences for society’s treatment of LGB individuals. This discussion is also divorced from the discussion of defining transgender individuals, which will be discussed in the next section. History of American Healthcare for Transgender Individuals The medical history of transgender individuals and their therapies is complex.
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