A working group evaluating sexual orientation-related disorders listed in the International Classification of Diseases (ICD), a publication of the World Health Organization (WHO), has recommended the disorders be deleted, a move that will make getting health care easier for gays and others who may identify with non-heterosexual orientations. The recommendation echoes policies of the leading U.S. psychiatry and psychology societies.
“It is not justifiable from a clinical, public health, or research perspective for a diagnostic classification to be based on sexual orientation,” Susan D. Cochran, PhD, of the University of California Los Angeles, and other members of the working group wrote in the Bulletin of the World Health Organization.
The WHO is the world body charged with deciding what is a disease and more than 170 countries, including the United States, follow their recommendations. The organization is currently revising the 10th edition of the ICD for release of the 11th edition in 2017.
Cochran, a professor at the UCLA Fielding School of Public Health, said the recommendation, if adopted, resolves “a human rights issue.”
“In California, gay people may have the right to marry, but in most of the world, being gay can be dangerous. There are at least six countries that criminalize homosexuality with a possible death sentence,” said Cochran, who is a clinical psychologist and epidemiologist. “This recommendation, to remove diagnoses that have no scientific basis, is a way of cleansing our public health apparatus of the social animus directed at a group of people for reasons that have no health justification.”
The recommendation must survive several layers of approval, the final being a vote by the member countries. Earlier this month, the American Psychological Association wrote to the WHO with a similar recommendation.
The Long Process of De-Pathologizing Human Sexuality
In 1974, the American Psychiatric Association decreed that homosexuality would no longer be considered a mental illness, though it created a new disorder, ego-dystonic homosexuality, as a political compromise. That disorder was later dropped as a diagnosis, and the American Psychiatric Association’s fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, released in May 2013, did away with all associations of sexual orientation with mental illness.
In 1990, the ICD made the same declaration, but retained several purported disorders, Cochran said. Five diagnostic codes pertaining to sexual orientation appear in ICD-10, which is tentatively slated for adoption in the U.S. late next year after long delays. All carry the designation ‘F66.’ They include “sexual maturation disorder” (F66.0), described as anxiety or depression due to uncertainty over one’s sexual orientation or gender identity, and “ego-dystonic sexual orientation” (F66.1) for individuals who express unhappiness with their sexual preference and wish it were different.
The ICD-10 codes also include F66.2, “sexual relationship disorder,” to describe “difficulties in forming or maintaining a relationship with a sexual partner” because of the person’s gender identity or sexual orientation.
In a statement, Cochran said this last category could be used to apply a medical diagnosis to a married man who realizes that he is homosexual and, as a result, finds that this causes difficulties with his wife.
Other categories could be also used to pathologize normal human sexuality. For example, if a teenager was unsure if they were gay, straight or bisexual and were distressed about that, that also is considered mental disorder. Or if a person were gay, and for whatever reason wished not to be, that also is considered a disorder.
“It doesn’t make any sense. If a person were short and wished they weren’t, that is not a disorder. Or if someone was a lousy singer and wished they weren’t, that is not a disorder,” Cochran said. “In other words, the ICD takes content that is sexual orientation-related and attaches a diagnosis to it in ways that it does not do for other aspects of people.”
‘An end to the medicalization of homosexuality’
If the recommendation is adopted it will have an immediate and important impact on access to health care, she said. Every health care event and every doctor visit has an ICD code attached to it. These codes that are used for insurance billing, for public health surveillance and for medical records.
Dropping the codes would mean “that gay people can feel free to seek care, to share their concerns, and not fear that they will diagnosed with a mental illness simply because the content is about homosexuality or gender atypicality,” Cochran said. “It would mean an end to the medicalization of homosexuality.”
By removing these codes related to sexual orientation, the health care that gay people receive will be improved, Cochran said. For example, if a gay man is depressed and seeks care he is vulnerable to being mistreated by the health system. Currently, he could be diagnosed with ego-dystonic homosexuality if he says he is upset about how he is being treated as a gay man and wishes he were straight. There are discredited treatments, such as conversion therapy, that have been deemed unethical but sometimes are justified by this diagnosis. With the codes removed, it will be more likely that his complaints will result in a proper diagnosis of depression and treatments for that depression.
An article published in the latest issue of the Bulletin of World Health Organization outlined the scientific basis for the recommendation to delete the sexual orientation-related disorders from the ICD. The group’s findings emerged from a review of literature published in recent decades that, in general, has indicated that sexual preferences are formed very early in life and that, while nonheterosexuals tend to report greater distress, it results from “greater experiences of social rejection and discrimination.”
For example, studies have found a range of risk factors associated with parental disapproval or rejection of LGBT youth sexual orientation. A 2012 study published in the Journal of Homosexuality found that “parents who react non-supportively when their children disclose LGB sexual orientation may contribute to children’s increased odds of depression and hazardous substance use.”
Other studies have found an increase in psychiatric disorders among LGB populations living in states that instituted bans on same-sex marriage, indicating that institutional forms of discrimination have significant deleterious effects on the mental health of LGB individuals.
Additionally, the controversial and discredited conversion therapy has proven to be extremely harmful for those who undergo it. Though most of the country’s medical associations have opposed conversion therapy for years, some licensed therapists still practice it. Conversion therapy has already been banned in some states — including New Jersey and California — but it remains legal in most of the country, despite the consequences.
A 1994 Journal of Consulting and Clinical Psychology article by Douglas Haldeman describes conversion therapy methods as including “electric shock, nausea-inducing drugs, hormone therapy, surgery,” and “visits to prostitutes and excessive bicycle riding.”
In 1998, the American Psychiatric Association issued a decision on conversion therapy, stating that it opposes any psychiatric treatment based upon on the assumption that being gay is a mental disorder. The APA’s decision continued to state that such “reparative” therapies are ineffective and carry great risks, “including depression, anxiety, and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient.”
In the new recommendations, the ICD working group wrote, “retention of these categories may also be construed as supporting ineffective and unethical treatment that aims to encourage people with a same-sex orientation to adopt a heterosexual orientation or heterosexual behavior.” Cochran and colleagues said that removing sexual orientation disorders could help bring an end to the harmful practice.