A diagnosis is a word or phrase that labels a condition. “Diagnosis” also has a second meaning: the process of collecting and abstracting data to arrive at a diagnosis. Because the validity of many psychiatric diagnoses (as distinct from other medical diagnoses) has been questioned over the years, we should try to evaluate our whole system of classifying. This, however, is a loaded subject. Homosexuals, victims of the use of diagnosis for oppression—from insult to denial of civil rights—will not be concerned with the esoterica of criteria for diagnosis; instead most of them will wish the term "homosexual” removed, not because it fails as a diagnosis, but because it can be used malevolently. (Since even using the term might suggest a diagnostic impulse, I note that “homosexual” is used herein only to imply that the person prefers sexual relations with someone of the same sex.)
But we really should separate out in our thinking these two trains of thought—diagnostic precision and diagnoses as social forces—or we shall suffer the kind of rambunctious discussion that makes a good show but overrides more serious purposes; for while both lines of argument are worthy, each is a different subject requiring different data and logic. If the two get mixed together, we shall blunder about as we usually do when social issues—matters of passion and action—are disguised as scientific or procedural issues. Being trained to think about phenomenology and the process of making diagnoses but not trained to unravel social issues, I shall concentrate especially on the former, leaving to those more knowledgeable the exciting revelations of Social Truth.
Criteria for Diagnosing
Were we not driven to it, we would no more choose homosexuality than any other alleged diagnosis as the subject upon which to fight the battle about the validity of psychiatric diagnoses. On resolving the general issues, we could then easily judge the claim to existence of most items within each category of the nomenclature: psychoses, neuroses, character disorders, or the jumble of loose pieces, including sexual disorders, that these three cannot contain. Most are just labels.
For instance, the neuroses, the sexual deviations, alcoholism, or drug dependence. In a painfully simple-minded fashion each of these is named for a distinctive feature; to tag someone, we come down hard on whatever catches the eye most, unable to deal with much of the rest that occurs inside the patient. Of course such a system is doomed to an unhappy life; tinkering every decade or so has not helped. It is comparable to a classification designed for the rest of medicine that would feature such “diagnoses” as cough, fever, headache, chronic indigestion, general weakness, vapors, or dyspepsia. No more and no less should most psychiatric “diagnoses” also be dropped. But if they are dropped, there is no more nomenclature. With no nomenclature, we have no place to start communicating about treatment or research.
Let me review what I think a diagnosis is, and in doing so show not only why no system of classification at present works in psychiatry but also why one does pretty well for the rest of medicine. A diagnosis is supposed to be a highly compact explanation. To make a proper diagnosis in any branch of medicine there should be: (i) a syndrome—a constellation of signs and symptoms shared by a group of people, visible to an observer; (2) underlying dynamics (pathogenesis)—pathophysiology in the rest of medicine, neuropathophysiology or psychodynamics in psychiatry; (3) etiology—those factors from which the dynamics originate. When these exist, we can save time by using shorthand, knowing that a word or two—a label, a diagnosis—communicates to others what we know. Unfortunately for psychiatrists, we are usually not confronted with people whose thinking, feelings, and behavior can be so categorized. Except for the disorders that are "diseases” in much the same sense as the term is used in the rest of medicine—such as the organic brain syndromes, which may include some of the schizophrenias and affective psychoses—the conditions for which our specialty was developed do not usually fulfill these three criteria. And so, should foregoing be a proper way to look at the structure of diagnosis (others think so [49]), the present system of classification is deeply flawed.
We might even debate whether the diagnostic system should be junked entirely, as a few have suggested. The price might be too great, but I must admit a flickering temptation to see that happen; it seems logical that if the shorthand that is a diagnosis is not a shared communication among those who use it, then it can only serve to confuse and might be better replaced for a time by descriptions. We shall not wipe out the classification system, however, and so psychiatry will persist, going down the list of the diagnoses one by one, year after year, testing the popularity of the items—the priorities determined as much by social as by scientific issues. Our problems with the nomenclature measure how far we must still travel for psychiatry to be grounded in scientific methodology. But it is too bad we go about the task piecemeal; to isolate homosexuality from the rest of the tottering system—unless everyone understands that the particular example is to serve only to illuminate the general issues—is to ignore the palsy from which the whole, necessarily inept, structure suffers.
So, we should not single out “homosexuality” because that diagnosis brings anguish to those diagnosed. The latter effect indicates important social issues, but our argument will be confused if we claim to talk of diagnosis and in fact turn out to be talking about the way diagnoses can be used corruptly. Many homosexuals today feel that the very diagnosis “homosexuality” serves, in the hands of psychiatrists (who should know better) and the public (which does not care to know better), as a hammer to oppress people whose only crime is their sexual style. I agree: to the extent that society does this and psychiatrists allow themselves to serve in this way, an injustice is committed that injures homosexuals and degrades psychiatrists. But a diagnosis should not be invalidated for that reason.
If one uses the three criteria above for considering a condition a diagnosis, homosexuality is not a diagnosis: (1) there is only a sexual preference (so noticeable because it frightens many in our society), not a uniform constellation of signs and symptoms; (2) different people with this sexual preference have different psychodynamics underlying their sexual behavior; and (3) quite different life experiences can cause these dynamics and this behavior. There is homosexual behavior; it is varied. People with all sorts of personality types prefer homosexuality as their sexual practice: people without overt neurotic symptomatology, schizophrenics, obsessive-compulsives, alcoholics, people with other perversions— almost every category in the nomenclature. But there is no such thing as homosexuality. In that sense it should be removed from the nomenclature.
As regards pathogenesis, probably no one these days —not even among those favoring the diagnosis—believes in a unitary cause for homosexual behavior; that would make it a thing. The fine reviews of the literature on etiology by Bieber et al. and Socarides, plus their own findings (3, 130), reinforce the impression that many paths lead to one’s preferring members of one’s own sex. This is true even, and especially, with analytic theories of etiology.
Should a diagnosis be dropped because it causes pain?
There is something disreputable in using our feeble method of diagnosis and psychiatrists en masse as the whipping boys for the cruel manner in which homosexuals have been and still are treated. These are not the real source of the mistreatment of homosexuals, (though they can be borrowed for such use). At our best, we, since Freud’s lead, are partly responsible for the fact that homosexuals can begin fighting back against society. Even when we are inaccurate in calling homosexuality a diagnosis, doing so has signified that the homosexual is part of the natural realm and not a member of the species of damned sinners.