‘Treated’ for being gay: psychiatry’s mid-century ‘fixes’ for homosexuality

Regina Kunzel’s new book explores the psychiatric treatment of queer and gender-variant people, often through patients’ own writing.
Regina Kunzel and the cover of her book “In the Shadow of Diagnosis” over a black and white photo of Saint Elizabeths Hospital.

Regina Kunzel

In 2008, Regina Kunzel learned of an extraordinary collection of case files that had been salvaged from Saint Elizabeths Hospital, a federal institution for the mentally ill in Washington, D.C. These were records of people who had been in treatment with one of the hospital’s psychiatrists, Benjamin Karpman, for being gay or gender-variant, primarily in the 1940s and ‘50s.

What made the files so valuable to Kunzel as a historian was Karpman’s unusual treatment method: He asked his patients to write. Write their life stories, including details of their sexual encounters. Keep journals. Practice free-associative writing. Together, these thousands of pages of patient accounts offered key insights into how patients who were “treated” for being gay or transgender experienced psychiatric scrutiny.

The files inspired Kunzel’s new book, “In the Shadow of Diagnosis: Psychiatric Power and Queer Life” (University of Chicago Press), which delves into the use of psychiatry to treat queer and gender-variant people in the mid-20th century.

At a time when homosexuality was understood to constitute a threat linked ominously to communism and perhaps surpassing it in menace,” Kunzel writes, “psychiatrists’ promise to promote healthy heterosexuality and eradicate homosexuality bought them considerable influence and authority.”

Kunzel, the Larned Professor of History and of Women’s, Gender, and Sexuality Studies in Yale’s Faculty of Arts and Sciences, spoke with Yale News about psychiatry’s curative practices, the revelations contained in patients’ case files, and Karpman’s gradual change of heart.

You explain how psychiatrists’ ideas, about homosexuality in particular, were infused into the culture during this period, even showing up in Ann Landers’ advice columns. Would you expand on that?

Regina Kunzel: American psychiatrists started claiming that they could cure homosexuality around 1940. That required them to revise Freud's concept of universal human bisexuality — the proposition that everybody had within them a mix of masculinity and femininity. They also rejected the ideas of earlier sexologists who argued that homosexuality was innate. Instead, they proposed that homosexuality was a symptom of a deeper pathology, one that could be treated and cured.

Psychiatrists were very good at getting the word out, in part because some of them wrote for popular audiences. For instance, Edmund Bergler, a New York-based psychiatrist, wrote a book titled “Homosexuality: Disease or Way of Life?” in 1956, basically a polemic masked as science, that was a bestseller. Psychiatrist Albert Ellis wrote columns for Playboy and other popular magazines. And then hugely popular magazines like Time and Life picked those stories up and repeated the claims. As a result, psychiatry’s pathologizing ideas about homosexuality became part of mid-century American cultural commonsense.

Why did psychiatrists wield so much clout?

Kunzel: They didn’t always. In the 19th century into the early 20th century, most psychiatrists worked in asylums and oversaw chronically mentally ill or elderly dementia patients. But by midcentury, they had carved out a major role for themselves in American life and medicine. They did so partly by staking jurisdiction beyond severe mental illness, and instead over what they called “problems in living.” Psychiatrists claimed to be able to treat a wide range of personal problems and social issues, such as troubled marriages, male impotence, criminality, and juvenile delinquency.

The thing that made homosexuality different from those other problems was that the U.S. government regarded it in these decades as a serious problem and a threat to national security. And so when psychiatrists said, “Look, we’re the experts at this, we can explain this to you, we can control this, we can treat this,” they amassed extraordinary power.

These cultural notions about homosexuality being a mental disorder were so strong that some people were committed to institutions for treatment by the criminal justice system, some by their families. Some went into institutions on their own because they were desperate to be cured. What were the curative practices?

Kunzel: The most widely recommended form of treatment was psychoanalysis. This was a time of psychoanalysis’s ascendance in American psychiatry. It was also a time of innovation and experimentation with somatic methods like lobotomy and electroconvulsive shock, both mainstream practices in American psychiatry in those decades.

The other major treatment was “aversion therapy,” a practice that took off in the 1960s and 70s.  Rather than agreeing with psychoanalysts that homosexuality and gender nonconformity were the consequence of psychic trauma, often in infancy or very young childhood, aversion therapists believed that homosexuality was more like a bad habit, like smoking or drinking to excess, one that could be “unlearned” through aversive methods employing nausea-inducing drugs and electric shock.

Something that I found in the course of my research was that some of the most violent treatment methods were used with behavior-managing and punitive aims rather than even aspirationally curative ones, and often in carceral settings rather than the clinic.

What were your big takeaways from reading the written work of Karpman’s patients? Were you constantly surprised?

Kunzel: Case records are extraordinary historical documents, but they often tell you more about the people who were writing them than the people they’re about. Karpman’s patients wrote biographies, they recorded their dreams, they wrote their own reviews of psychiatric texts. And so they made it possible for me to see how psychiatric ideas were put into practice, and even more remarkably, how people experienced psychiatric scrutiny, sometimes using this new science to make sense of themselves.

There were revelations on every page. The most striking examples, of course, are the moments when you see people push back against psychiatry’s pathologizing ideas, sometimes using the language of psychiatry itself to speak back to psychiatrists. But the records also forced me to reckon with less heroic aspects of this history, especially the way that, for many, these ideas instilled and compounded a sense of shame. Historians of marginalized groups are often more comfortable talking about resistance and resilience, and much less comfortable thinking about those darker, sadder feelings.

Over time, Karpman becomes more sympathetic toward his patients, right?

Kunzel: He does. It’s possible to track that shift in both his published writing and in his unpublished memoranda. Karpman lived and worked in Washington, D.C., which was ground zero for what historians have called the “Lavender Scare”: the purge of gay men and lesbians from jobs in federal employment and the wave of postwar repression that linked communism and homosexuality. Among Karpman’s patients were those who experienced the dramatic increase in the policing of gay life in D.C. Through his work with queer patients, Karpman became more aware of the hostile conditions under which they lived. And you can see in Karpman’s writings that his faith in his ability to cure gay people, and perhaps his confidence in the wisdom or ethics of those practices, began to fade.

I came across an extraordinary line in one of Karpman’s memos, in which he wrote: “Perhaps the best way to treat them is to leave them alone.” That was a stunning proposition in this period when no one was leaving homosexuals alone.

In 1973, gay activists succeeded in getting the American Psychiatric Association to declassify homosexuality as a mental disorder. This held great personal significance for you as a gay teen.

Kunzel: It did mean something to me — less for my own peace of mind and more for what I hoped might be its persuasive power to the adults in my life. I learned, though, when I tried to wield that information in my own defense, that it wasn’t the magic wand that I wanted it to be. And that was true for psychiatry, too. The 58% of APA members who voted in 1973 to declassify homosexuality as a mental disorder was a majority, but not an overwhelming one. And there are surveys that suggest that most psychiatrists, especially psychoanalysts, continued to believe that homosexuality was a form of pathology. 1973 was an important moment, but it didn’t change everything.

You end the book trying to take stock of what’s happened since. What are your thoughts about where we are now as a culture?

Kunzel: For decades, homosexuality and gender variance were bound up together in the minds of psychiatrists: They basically thought one was the main problem and one a subset of the other. The first edition of the “Diagnostic and Statistical Manual on Mental Disorders” (DSM) that didn’t include homosexuality was published in 1980. It was also the first edition that included a new diagnosis of “gender identity disorder.” That diagnostic category remains in the current DSM under the name “gender dysphoria.” And its inclusion there is now being weaponized by the right, who point to the DSM to support their belief that transness is a form of mental illness. We see the effects of that position in the recent spate of anti-trans legislation, especially in arguments about expanding the role of psychiatrists as gatekeepers to gender-affirming care.

And so while mainstream psychiatry has renounced their pathologizing position on homosexuality, we’re still living with the consequences of the adhesive connection between sickness and queerness forged by psychiatrists in the mid-20th century.

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