Dismantling a Diagnosis — Episode Three: Out of the DSM & into the Present — A Conversation about LGBTQ+ Mental Health

Dr. Laura Erickson-Schroth, credit: Margarita Corporan; Dr. Ilan H. Meyer, credit: UCLA School of Law.

Episode Notes

Eric is joined in conversation by Dr. Laura Erickson-Schroth and Dr. Ilan H. Meyer to delve into the past and present of mental health for LGBTQ people.

They discuss historical stigma, the ramifications of the American Psychiatric Association’s declassification of homosexuality as a mental disorder 50 years ago, and shifting psychiatric understandings of LGBTQ mental health in relation to societal pressures and prejudice. They also explore the continued pathologization of trans people, and the barriers that exist to finding accessible, safe, and informed care.

Episode first published December 29, 2023.

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Learn more about the experts featured in the episode by exploring the links below.

Dr. Laura Erickson-Schroth:

Dr. Ilan H. Meyer:

  • Brief bio (Williams Institute, UCLA School of Law). 
  • Generations Study, a U.S. national probability study of stress, identity, health, and health care utilization across three cohorts of sexual minorities, of which Meyer is the principal investigator. 
  • TransPop Study, the first national probability sample of transgender individuals in the U.S.  
  • Primer on Meyer’s minority stress theory (Sara Williams, PhD, MSSW, CSW/YouTube). 

Other MGH episodes about some of the people referenced in this episode, with accompanying episode notes:

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Episode Transcript

Eric Marcus Narration: Welcome back to our Making Gay History miniseries, “Dismantling a Diagnosis.” I’m Eric Marcus. Fifty years after the American Psychiatric Association voted to remove homosexuality from its list of mental disorders in the Diagnostic and Statistical Manual, we’ve been looking back at what that change meant.

And in this episode, we’re gonna be talking about the current realities of mental health for LGBTQ people. I was 15 at the time of the vote in 1973 and just coming into an understanding of my own sexuality. I wasn’t aware the vote had happened. It didn’t filter down to Kew Gardens in Queens. All I knew was that what I was feeling was wrong according to every signal and message I’d received from the world around me.

When I began researching homosexuality for my freshman year sociology paper, many of the awful books that were on the shelves when Barbara Gittings, Kay Lahusen, and Frank Kameny entered the battle with the APA were still there, and I found them horrifying. There were also a handful of books that reflected the change to the DSM, and others that simply assumed it, and moved on from there.

When I wrote the paper, “Marginal Men: The Homosexual and the Alcoholic,” the language I used echoed so much of the literature of the recent past. LGBTQ people as “inverts” with “arrested development.” “Maladjusted.” The language has moved on since then. The Diagnostic and Statistical Manual of Mental Disorders has been revised many times since then, but the harmful effects of stigma have been longlasting and remain profound.

Fifty years after 1973’s reclassification, we wanted to open up a conversation on Making Gay History about mental health today in our LGBTQ communities. And to do that, I’m joined by a couple of leaders in the field. Dr. Laura Erickson-Schroth (she/they) is a psychiatrist committed to improving mental health through education and resource creation.

She’s the chief medical officer at the JED Foundation, a nonprofit focused on emotional health and suicide prevention for teens and young adults. Laura has provided thousands of patients with crisis intervention and mental health support in over 10 different emergency rooms in New York City. Much of her career has focused on LGBTQ mental health, and she continues to see clients at Hetrick-Martin Institute for LGBTQIA+ Youth. Laura is the editor of Trans Bodies, Trans Selves, a resource guide written by and for trans communities. 

Dr. Ilan H. Meyer is the Williams Distinguished Senior Scholar for Public Policy at the Williams Institute and professor emeritus of sociamedical sciences at Columbia University. Meyer is the principal investigator of the Generations Study, a U.S. national probability study of stress, identity, health, and healthcare utilization across the three cohorts of sexual minorities, and TransPop, the first national probability sample of transgender individuals in the U.S. 

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Eric Marcus: Welcome, both. Thanks so much for joining me. 

Um, Laura, how far has psychiatry come in relation to homosexuality since the DSM-III in 1973? 

Dr. Laura Erickson-Schroth: Well, thanks so much, first of all, for having me on the show. You know, I think there are, uh, some ways that psychiatry has changed quite a lot, um, and there’s still a long way that we have to go. I think it’s been a really big turning point to see the field go from thinking about queer and trans people as inherently pathological to the idea that society’s treatment of LGBTQ people is what damages their mental health. And that’s what Dr. Meyer articulates in his minority stress theory, which I think has been really useful to the field.

And I think that understanding started a lot earlier than we sometimes talk about. You know, it started to permeate the American public in the forties and the fifties with the Kinsey reports, you know, finding that same-sex attraction and sexuality were more common than people thought. And then in the late fifties, there was a psychologist named Evelyn Hooker, who published a study where she compared gay and straight men on a series of projective tests like the Rorschach.

And she had blinded reviewers rate participants’ overall adjustment. And she found that it was the same for gay and for straight men, and that the reviewers couldn’t tell any better than by chance which of the tests were from gay men or straight men. And so I think that kind of work was really setting the stage for change. 

But I think it’s actually important to remember that trans people are still pathologized in the DSM. You know, if we look back at the DSM initially, there was no mention of gender-related diagnoses in the DSM-I, but in the DSM-II in 1968, we saw the introduction of the diagnosis of transvestism, and then when the DSM-III came along in 1980, it introduced a category, gender identity disorders. 

And because this was the first new edition of the DSM since the vote to remove homosexuality, some people have speculated that was kind of a backdoor strategy to allow for the continued use of conversion therapy on gay people, especially teenagers, because the new criteria were kind of broad enough to include young people who had attitudes or behaviors that were outside those that were expected for their gender roles. 

And I think it was also an interesting time to be including a new diagnosis of this type because the DSM-III was also supposed to be a move towards kind of more rigorous empirical evidence for disorders, but the gender identity categories didn’t seem to have to go through that same process.

So if we follow it forward, in the DSM-IV, they carried over similar diagnoses, um—you know, gender identity disorder—and then there was more controversy as the DSM-V was being planned. And in the end, the DSM-V includes this diagnosis of gender dysphoria, which to me is pretty similar to the approach the DSM took with ego-dystonic homosexuality.

You know, the idea is that being trans itself doesn’t qualify someone as having a disorder, but it’s their discomfort with it, you know, the dysphoria that it causes—and I think the same way that it did with ego-dystonic homosexuality, that put the onus on the individual, you know, rather than society for causing that dysphoria.

It’s really hard not to have dysphoria about being trans if you’re living in a society that tells you every day that being trans is wrong. So I think there are so many, you know, ways that we continue to use the gender dysphoria diagnosis that are really harmful to trans communities, that distance trans communities from psychiatrists and from mental health providers.

And the takeaway for me is that in psychiatry and in all of medicine, it’s a product of people, right. The DSM was created through expert consensus. It’s always gonna carry with it these sort of social biases that permeate society, and that’s why we need to change the way society thinks about queer and trans people, which I think is actually happening.

EM: And I, I really wanna talk more about the pathologizing of, of some gender identities in this conversation. But first I’m gonna ask Ilan—as, as Laura you’ve just raised—there’s this really important distinction that having a mental disorder is something quite different from being a mental disorder. And it sounds obvious in a way, but Ilan, can you explain why some people lost sight of this distinction in the efforts to delist homosexuality as a disorder?

Dr. Ilan H. Meyer: Yeah. Thank you for inviting me, um, Eric. Um, yeah, I think that’s a really important distinction that somehow got lost, and when, when I started working on this, uh, issues many years ago in the nineties, I realized, wait a second, all the debate was, do LGB people have more or less disorders than straight, cisgender people? And that really says nothing about whether homosexuality itself should be a disorder any more than if I said to you that women have more depression, that means that being a woman is a disorder. 

And as I realized, I thought it was, like, a brilliant observation on my part, but then I read further and realized that Judd Marmor, who was the head of the American Psychiatric Association at the time, made that point quite clearly and argued that it has nothing to do with whether we should include homosexuality as a mental disorder.

And I think that heritage of trying to defend LGBT people from stigma by removing homosexuality from DSM-II led to years, really—all the way through my schooling—of having the statement everywhere, “Gay people are not more mentally disordered than straight people,” and honestly led to us ignoring some of the issues that now thankfully we are dealing with.

And what happened in the time in between this, after the removal of homosexuality—as Laura mentioned, my model of minority stress has really tried to change the focus from looking at what’s wrong with the person to looking at what’s wrong with the environment. Again, that wasn’t my invention in the sense of kind of being this shift; this was a shift that came with stress research, which really started after World War II, where people began to observe especially the harms of war, and change from the more psychoanalytic theory that predated World War II as the primary way of explaining mental health—which was focused on, within the person, anxieties and conflicts, and, and, et cetera—to thinking at what the environment is doing.

So what my minority stress work has done is basically say, look at stigma and prejudice and look at how it exposes LGBT people to excess stress. And if we agree, as research has shown, that stress can lead to diseases or certain diseases, especially mental health, then there would be no surprise that LGBT people would have more mental disorder.

And even that, when I started writing, was controversial because people said, “Oh, you are airing problems in public that can damage and actually further stigmatize LGBT people,” which of course I didn’t agree with. I thought we need to actually address the stressors, the stigma and prejudice, and their mental health impact. 

And it was not until about 2000 and after that—really, 1999 was the first major paper that showed health disparities—and at the same time, Healthy People 2010 was being written and showed a focus on health disparities, which we now accept and recognize. And what health disparities says is, there are disparities in health and mental health that are caused by social conditions and situations in the environment, which is going back to where we started.

It is not the LGBT person’s fault that they are, uh, experiencing depression, that they’re thinking about suicide. It is stigma and prejudice that is perpetrated by society. 

EM: It makes so much sense to me. Um, I, I, one of the things I was aware of early on in terms of statistics was that gay and lesbian people—and this is back to when I was first looking at gay and lesbian people, we weren’t LGBTQ people yet—that we have such higher rates of drinking, of alcoholism, and smoking, um, because it’s stressful.

Um, I, I think of the levels of anxiety I experienced around being a closeted gay kid, and then when I came out, even going to the grocery store with my partner, worrying that someone’s gonna ask us if we’re brothers or what. So it makes—it’s so obvious, but it wasn’t so obvious. Um, so Laura, our series so far is focused on, uh, gay men and lesbians because that was the focus of, of the fight for reclassification in 1973, but for trans and gender non-conforming folks, there is also a complicated history with the DSM that you talked about a bit at the start of this conversation. But has psychiatry been friend or foe to trans folks, and is the field moving in the right direction? 

LE: Yeah, I think the short answer is it is moving in the right direction, but I, as I said, I think there’s a lot of room, um, for improvement.

I think, you know, one, one of those is obviously, to me, taking gender-related diagnoses out of the DSM. I think we’re at a turning point the way that we were with, uh, ego-dystonic homosexuality, where relatively soon this is gonna be a thing of the past. 

I’ve seen some really major changes in the approaches within the psychiatric community to trans clients, and I think some of them have to do with work being done within psychiatric communities. And some of them sort of just happened based on other societal changes or changes within the medical system. 

So one example is the informed consent model for access to hormones for trans adults. That didn’t come from within psychiatry, but it’s really affected the way psychiatrists work with trans clients. So when gender-related care moved out of academic institutions and into community health centers, you know, mostly because academic centers were shutting down their work in this area, community health centers were taking over the work and changing the approaches. 

Informed consent is the idea that people have the ability to make choices for themselves about their medical care and should be given the options and educated about the risks and the benefits instead of providers choosing what options are available to them, which was what was happening for trans people before that. And now informed consent has become the norm for adult hormone prescriptions and community health centers across the United States, and it’s such a step forward.

You know, trans people used to have to perform for their doctors to convince them they were really trans. Sometimes that meant lying about things like their sexual attractions, because if you transitioned, you were supposed to be straight in the gender that you transitioned to. And now there are many different groups that are moving farther toward informed consent models.

So the World Professional Association for Transgender Health puts out, uh, standards of care and those have changed so that there are no longer requirements for trans people. Things like living full-time as someone’s gender that they identify with before they have hormones or surgery if they want those.

And that requirement used to cause real distress for people. And psychiatrists weren’t necessarily the ones who pushed for informed consent models. But they’ve made a really big impact on the way psychiatrists relate to trans clients. At least for hormone therapy they’re no longer in the role of gatekeepers to the care, which opens up much more space for kind of genuine connection.

And I think the same thing is happening for surgery. It’s a lot slower. But along with informed consent, this other leap forward in this kind of relationship has been moving to capacity evaluations for gender-affirming surgeries. And the old model was basically evaluating whether the psychiatrist thought someone was trans and should be able to have a surgery.

Now many psychiatrists approach evaluations for gender-affirming surgeries the same way they do evaluations for any other type of surgical procedure for anyone. They use certain criteria to determine what we call capacity to make a medical decision, and in most cases, adults do have the capacity to make decisions for themselves about their medical care as long as they’re thinking properly, there’s nothing going on like an acute medical illness that is, is causing difficulty with that, or dementia, or something like that. And so moving to using that same criteria for gender-affirming surgeries is a really important shift from my standpoint. 

And then I would say one last thing in this area is that there are more queer and trans people entering the field of psychiatry. You know, there have always been groups of queer and trans people in psychiatry, but initially they had to be underground and for many years it was really hard to be out. That’s why you see the examples of things like Doctor Anonymous, you know, speaking at the APA convention about what it was like to be a gay psychiatrist at the time. You know, he was worried about losing his job if people knew that he was gay.

And one organization that’s been really important historically to support queer and trans psychiatrists is called AGLP, which is the Association of LGBTQ Psychiatrists, and it started in the 1960s when LGBTQ members of the APA met secretly at the annual meetings. 

EM: Yeah. It was called the, the GayPA. 

LE: The GayPA, that’s right. And we sometimes still call it that, you know? And that organization now is this really robust group of psychiatrists that are doing all this advocacy and educational work. They run meetings and sessions. They have a free online curriculum for psychiatry residents. So I think it’s exciting to see this next generation of queer and trans psychiatrists moving into this space.

EM: Um, as a follow-up, Laura, I just wanna ask you as a clinician, when we talk about minority stress, how have you seen that showing up in your work?

LE: I think this is a really important question. So my clinical work currently is at a place called Hetrick-Martin Institute for LGBTQ Health, and I’ve been there part-time for about eight years now.

And I would say the majority of the young people that I see at Hetrick-Martin are living with that sort of legacy of minority stress. So, um, the most common diagnosis for me for the young people that I see there is PTSD. Many of the young people that I work with have really significant histories of chronic trauma that have led to difficulties with interpersonal relationships, with trust, feelings of abandonment and rejection sensitivity, things like that. Because they’ve experienced violations of their trust and felt rejected by their families, by society. Many of them are in youth shelters in New York City. So, you know, I think that, uh, it’s really important to talk about how minority stress actively affects people right now, here and now, and not to forget that continues to happen.

EM: Laura, I interviewed both Damien Martin and Emery Hetrick, the co-founders. 

LE: Oh, that’s so cool. 

EM: Yeah. And Joyce Hunter, who was one of the first counselors working with Hetrick-Martin. 

LE: I know Joyce. Yeah. 

EM: Yeah. So, um, I just wonder what Damien and Emery would think of how things have evolved and the fact that people have so benefited, especially given that when Hetrick-Martin was founded, it was a time when people were terrified of working—well, gay people were terrified of working—with young people, because we were afraid of being accused of being, well, in the old days, uh, pederasts and, uh, recruiters, and now groomers.

And I wonder, is that still an issue that people, you find people in your profession are at all nervous working with young people? 

LE: I do think that comes up, uh, especially in, in youth services, and I don’t think it’s specific to mental health providers. I think, um, a lot of especially gay men working with young people in LGBTQ youth services worry about that.

It’s a little bit less of a worry, I think, for queer women working in those spaces, though it’s not, you know, it’s not off the table to worry about that. But I do think that that’s been passed along through generations, that worry. 

EM: Ilan, earlier this year, we released our season about coming of age during the 1970s, and someone we heard quite a lot from was Dr. George Weinberg. He was the psychologist who first coined the term homophobia. Um, what is homophobia and what are its effects on mental health? 

IM: The term homophobia has been subject to all kinds of criticism and debate, and I feel that, before I even get into it, I feel like this debate is a little bit too much in the weeds, and ignoring the fact that it’s a term that is very well-known, used in newspapers, so I, I go with the term homophobia. Some people say, well, it’s not a phobia, uh, and, and have all kinds of objections to the term. They have other terms. I think of homophobia as akin to sexism, to racism. Basically, the attitude and the belief that homosexuality or being LGBT—well, of course we differentiate between homophobia and transphobia, which are, uh, similar terms—but, uh, in general, homophobia and transphobia are attitudes, beliefs against LGBT people, stereotypes about them. And basically that’s the definition of prejudice and stigma about LGBT people. So when we say homophobia, I think what we mean is negative, hostile attitudes and beliefs and policies that are, stem from those attitudes. 

EM: There seems to be this tension then, from what we’ve been talking about, between diagnoses as a way of accessing treatment, but then also as ways of stigmatizing, even oppressing people—pathologizing some things rather than others as a mode of oppression.

How do you think about that tension in the work you do, and am I wrong in thinking that some medicalization may be driven in efforts to qualify people for treatments or insurance? Um, I’m thinking of my own therapist and discussions we had, uh—uh, um, my former therapist, therapist, I should say—when my insurance provider, uh, came back with a list of questions, if they were going to continue covering me, and they were only going to continue covering me if there was the threat of suicide involved, that I was in danger of killing myself.

So we had these discussions: “Do you want me to write that, you know, that this is a possibility that you have, you know, suicidal ideation?” which I don’t. But that would have meant losing my coverage for, for my insurance, um, which is crazy. Laura, can you take a stab at answering that first? 

LE: Yeah, I mean, I think the most obvious problem here, the elephant in the room, is that we’re, you know, using insurance and coverage of medical care in a financial way to determine how we carry out that care. Uh, so, you know, we have, uh, labels for diagnoses mostly now because that’s how we bill, that’s how we get reimbursed, and that’s what’s leading the way that we, you know, do care in a lot of ways, uh, including in the example that you just gave. 

You know, I think maybe it’s helpful to talk a little bit about gender dysphoria, and some of the arguments around that and how they relate to accessing care. Looking into how the gender dysphoria diagnosis is being used now, where it’s used actually most often is by mental health providers writing letters for people for surgeries. So the surgeon will require a letter or two letters, depending on what the surgery is, to be written by the mental health provider and to, uh, say explicitly that the person meets criteria for gender dysphoria.

And so you wonder, where does that come from? Did the surgeon come up with that, or did a group of surgeons come up with it? And they didn’t. It’s insurance companies that are requiring that. And that goes back to how our guidelines are written. So some insurance companies create their guidelines based on the WPATH standards of care; others create their guidelines internally by deciding what they think is appropriate or that they should need. 

And so it’s interesting to see how this cascades. So you, you go from insurance companies requiring something in particular to then surgeons needing to ask for it from a different group of healthcare providers. And then we have, you know, mental health providers using a diagnosis that, you know, they mostly don’t use on their own. Mostly when they see, uh, trans and non-binary clients, they’re using things like adjustment disorder. If they’re going through a transition in their life or the diagnoses that they actually, uh, have, maybe they have major depressive disorder or generalized anxiety disorder, or PTSD, or whatever it is.

Interestingly, the ICD, the International Classification of Diseases from the World Health Organization, has gone in a different direction, and I think it’s the direction that we should be going in. So the ICD-11, which was released in 2019, took gender-related diagnoses out of the behavioral section and put them in something called “conditions related to sexual health.” And that to me was depathologizing ’cause it was putting them in a medical section for billing purposes. And in the ICD, it’s called gender incongruence, and this has been accepted by the WHO Assembly. It went into effect at the beginning of 2022. 

Now the U.S. is a little bit behind, so we’re still using ICD-10, which was made available in 1990 and first used in other countries in ’94, but it wasn’t implemented in the United States until 2013.

EM: Sounds like a mess. Um, Ilan, did you wanna take a stab at that?

IM: Well, I’ll just add, I think that the problem that you’re raising is really not a psychiatry problem or a medical problem. It’s a really an insurance system problem that we have in the United States, and it’s absolutely ridiculous. And you know, we don’t provide mental health services. There’s no parity that have been promised for decades, for good and for bad psychiatrists and other mental health or even healthcare providers have to use diagnosis to justify treatment, as you described with your therapist, Eric. And it constrains us, but it also adds to stigma and adds to difficulties of receiving care, as Laura mentioned. 

And regarding gender, I would also add to the issues that Laura raised regarding the need for diagnosis, uh, prisons. And for transgender people in prison, it’s not going to be a consent issue, it’s gonna be: you have a medical diagnosis and, and therefore the prison is required to provide you services—which is of course not yet, uh, settled everywhere in the United States. But here in California, uh, prisons are, reluctantly sometimes, providing care. 

But the, the whole, uh, issue of diagnosis becomes an important part of the care delivery and sometimes, many, many times, um, to the disadvantage of the patient who needs the services. 

EM: Yeah. So these, these insurance problems become medical problems because they become access problems. Do you think that contributes to some of the disparities, uh, you’ve been talking about, Ilan? 

IM: I mean, I don’t have any evidence specifically on how the insurance, you know, this whole chain of, uh, connections that you just, uh, alluded to work in terms of increasing health disparities.

LGBT people actually do use health services more than cisgender, heterosexual people, probably because they need it more, because they have more health issues because of the health disparities. So they do have access to care—especially since Obamacare there is pretty good access. What we find, again, especially with transgender individuals, that there is access to care, not necessarily access to quality care, or care of, uh, professionals who are knowledgeable about the issues. So that transgender people report that, um, the healthcare provider is not well-versed in the issues, and they often have to train the healthcare provider so that they can receive care. So that’s one big issue. 

And we can talk about medical training and, and how much medical schools spend on LGBT issues, which is very little, if at all. For LGB people, we did find that, especially when it relates to mental health services and for men, things related to sexually transmitted diseases, they prefer an LGBT provider. So that’s another element of adding to disparities. If you cannot find quality care or if you don’t find care from a person that you can trust, even if a straight cisgender provider may be very well-qualified, if an LGBT person is more comfortable with an LGBT service provider, that becomes an obstacle to service.

EM: Hmm. Laura?

LE: Yeah, I mean, I would just add that, you know, like Ilan is saying, there are so many barriers to care for LGBTQ people across the spectrum, and particularly for trans people who may have to come into contact with medical systems more often, uh, you know, so there’s everything from what you were talking about every step of the way.

You know, insurance barriers that come from, you know, lower levels of employment, that come from societal discrimination, right. And then, you know, not being able to find people who know about what’s going on with you and have treated anyone else like you. Not being able to find people who you trust and feel safe with.

A lot of trans people avoid care, and so if you look at studies, you can see that, you know, high numbers say that they won’t, for example, go into emergency rooms when they’re experiencing something that really you should go to the emergency room for because they’re worried about the way that they’re gonna be treated.

And I think that it’s realistic to be worried about the way that you’re gonna be treated. Because when you look at studies of the kinds of experiences people have had, a lot of them are very negative. I mean, people have even been assaulted in emergency rooms, in hospitals, in clinics. And certainly, you know, even if things are not to that level of being assaulted, the way that people are treated, the language that’s used around them and about them, the way that, you know, medical students and other students will be brought in to sort of meet this, you know, special type of case of person…

You know, you just wanna be treated like a normal person. So within trans communities, there’s something called the “trans broken arm syndrome,” which basically is the idea that if you go into an emergency room as a trans person and you have a broken arm, they’ll find pretty much anything else to say that is going on with you, when really all you have is a broken arm.

And so, you know, sort of everything gets attributed to your trans identity. You know, they wanna know, you know, what organs you have, they wanna know what hormones you’re on. And, and some of these things are important for certain medical diagnoses to figure out what’s going on with someone. And some of them are not important.

If it’s just your, your arm got hit and now it hurts, you know, you don’t need to know every detail of someone’s medical history. 

EM: So, Ilan, uh, we’ve been talking about where we find ourselves today in light of the past 50 years or so in psychiatry in the LGBTQ civil rights movement. But I’m gonna go way further back, to Germany in 1897, when Dr. Magnus Hirschfeld founded the Humanitarian Scientific Committee, whose slogan was “Justice through Science.” 

Um, first, can you talk about your connection to Dr. Hirschfeld? And I only discovered this over lunch with you and your husband in Berlin when we were all there for Magnus Hirschfeld’s 150th birthday. And just as an aside, I urge listeners to go back and listen to our episode on Dr. Hirschfeld if you haven’t heard it yet—we’ll be linking to that episode in the show notes. 

So, Ilan, this connection to the absolute beginning? 

IM: Yeah, I mean, that is actually been a discovery that I made while I was still a student, I think in the early nineties. My father was born in Berlin and left just before the war, after the Nazis came into the power. So our family is kind of spread all over the world. And a family member from Australia mentioned something like, “Oh, I don’t know if you know, but we’re related to Magnus Hirschfeld.” Well, of course, I, I completely, uh, um, jumped in joy, in, in disbelief. 

But my father’s mother’s family is related to Hirschfeld’s family. He has several sisters. And I won’t get into the exact family tree because it’s a little complicated, but of course it’s a great, um, pride for me to have any association with him. As you mentioned and, and, and Laura mentioned before, like, there had been a lot of gay-affirmative work in the United States, maybe forties even, but in Germany, as you said, Magnus Hirschfeld, who was a medical doctor, had an incredibly LGBT-affirmative clinic and writings.

It’s interesting to me and, and maybe to us today that his first cases that prompted him to pay attention to LGBT people at the time was the suicide rates that he observed. Uh, many of them were related to blackmailing, but of course related to the stigma and prejudice that somebody who was exposed as a gay or having, uh, same-sex relations at the time was completely destroyed.

One more interesting thing about Hirschfeld is, he talked about “the third sex” as a way of thinking about LGBT people. So the distinctions between LGB and transgender people weren’t as pronounced as we tend to see them now. His clinic included many transgender people, maybe even cross-dressing people, as well as, um, LGB people who are cisgender.

And, uh, he advocated for the rights of LGBT people in Germany, trying to overturn an anti-, um, gay bill that he saw as one of the causes of the blackmail, and therefore the suicides. So he made the same connections that basically I wrote about kind of later as minority stress between stigma, prejudice, pressures on LGBT people and their health.

EM: I just, I love that connection. It’s just, you, you couldn’t, if, if, if this were a novel, no one would believe it. Um, so, uh, uh, but also of, of note regarding Dr. Hirschfeld, he and his institute were one of the first targets of the Nazis. Hitler attacked Hirschfeld as early as the 1920s. So the kinds of attacks we see now, a hundred years later, have precedence. 

IM: And, Eric, if I may add, like, some of the attacks involve the burning of the institute, the burning of the materials and books and, and records that were in it, and some of the most famous photos that we see of the burning of books in Berlin by the Nazis and by, uh, uh, youth, uh, students at the university there, those are pictures actually that’re of the Institute of, the Sexual Research Institute that was destroyed at the same time. And luckily for him, Hirschfeld was out of the country at the time, so he survived it, but, uh, was never able to return to Berlin. 

EM: And in fact, the, um, I visited the site of where his institute was. It’s, um, it’s, um, a, it’s a park. There’s no building there anymore. 

Laura, when I was writing this script, I initially described my sexuality as immutable. And I’ve often quipped that I’m a Kinsey six plus. But what do we understand now about sexuality and gender identities that is maybe less rigid than the language of “born this way” implies?

LE: Yeah. I think some of the language, uh, that we used to make arguments that being gay isn’t pathological did really lean into this idea that it’s not your fault if you’re gay. And so that’s sort of what’s been in the atmosphere for the last couple of decades. 

You know, I think that view was especially popular in the late ’90s, the early 2000s. There was the hunt for the “gay gene,” if you remember it, I think it was, you know, on the cover of magazines. And during that time, there were all kinds of, what they called, quote, biological studies, you know, of gay identity, of trans identity. Studies that were comparing identical twins on their sexual orientations or gender identity. There were brain scans. There were these studies looking at genes, theories about prenatal hormones, or—I don’t know if you two remember the, the proxy markers that were being used to demonstrate the exposure to different hormone levels in utero. So if your, you know, index finger and your middle finger are the, the, a certain ratio, then you’re gay, and yeah, um… 

And these were all sort of aiming to show that LGBTQ people couldn’t help being who they were because, you know, it was, quote, biological. And I think that really was something that a lot of queer and trans people stood behind for a while there because, when it’s one of the only arguments that’s working with people who are initially sort of against your identity, you can see how that would be something that people would rally behind.

I recently participated in a review article with some colleagues—so, uh, Rachel Levin out at Pomona, and Kale Edmiston in Pittsburgh, and Kristie Mak—and we looked at all the studies that have been done attempting to link trans identity to sort of, quote, biological causes. And there’s, there’s really not much there-there, at least right now. It looks like, from everything that we know, if you’re gonna piece it all together, it’s probably something like a bio-psychosocial model, where there’s a biological contribution, uh, to gender identity and sexual orientation, but it certainly isn’t as simple as, we’re all born this way. 

And I think the problem is that the argument often works. Like I said, it gets people who aren’t on your side on your side. I have a favorite quote from John d’Emilio’s essay, uh, “Capitalism and Gay Identity.” And he says, “Lesbian and gay identity and communities are historically created. We’re not a fixed social minority, composed for all time of a certain percentage of the population. Claims made by gays and non-gays that sexual orientation is fixed at a certain age; that large numbers of visible gay men and lesbians in society, the media, schools will have no influence on the sexual identities of the young are wrong. And to be sure this argument confirms the worst fears and the most rabid rhetoric of our political opponents. But our response must be to challenge the underlying belief that homosexual relations are a bad, poor, second choice. We must not slip into the opportunistic defense that society need not worry about tolerating us, since only homosexuals become homosexual. At best, a minority group analysis and a civil rights strategy pertain to those of us who already are gay. It leaves today’s youth—tomorrow’s lesbians and gay men— to internalize heterosexist models that it can take a lifetime to expunge.”

EM: Yep. We are way more complicated than, than… I liked it—it was so simple when I was young, but it didn’t actually, it didn’t match who we are as humans. 

Um, um, so to both of you, I have a, a final question. I’m not young anymore—just got my Medicare card, nice thing to have—but one of the great privileges of hosting this podcast and doing the work that I do is that it puts me in touch with many, many young people, um, through our work in education and through all the emails and messages we receive.

And while so much of our work focuses on the progress we made, we, we tell the stories of the wins, of what activists achieved, and what previous generations survived. I’m also so conscious that young people are facing so many challenges on many fronts, and we’re having to fight some similar battles again and some new ones.

Uh, the U.S. Supreme Court just tossed out a case arguing that conversion therapy bans are an unwarranted limit on free speech. The wedding website case opened the door to discriminating against LGBTQ people in public accommodations. Book bans, drag bans, sports bans, bathroom bans, and it’s, it’s a lot. Um, where do you find hope and how do you communicate that hope to young people, uh, Laura? 

LE: I’m excited for young people today. And I’m also excited for what the future of LGBTQ communities are gonna look like. I can’t wait to get old and to hear all the new words young people are using, the ways they identify, you know, the fun clothes they wear.

A lot more young people in this generation are identifying as part of queer and trans communities. If you look at the most recent Gallup poll, it’s 21 percent of Gen Z, you know, and that’s compared to 10 percent of millennials, and 4 percent of Gen X, and even smaller percentages of other generations. 

I love seeing young people, they’re speaking out. They’re talking about things like mental health in ways that previous generations weren’t. And they care about a lot of the important issues in the world, the kind of things that you were talking about. They care about racial justice. They care about taking care of our planet, and they’re creating their own language around all of these types of things.

And in terms of interactions with the mental health field, they’re joining the field and they’re making it better. And they’re also finding providers who support them, and they’re refusing to go to those that don’t. So I kind of can’t wait to see what they’re gonna do next. 

EM:  Ilan?

IM: Oh, boy. I was afraid you will ask me to say something optimistic.

I agree with everything Laura said, and for me, where I find hope is that I think back to how things were and, um, recognize both in my own life and, and before that, how much things have improved. Things have improved for LGBT people in ways that were not even imaginable, uh, um, you know, a hundred years ago or 50 years ago.

But at the same time, I’m very, very worried. You know, when we saw a lot of the improvements, there was a certain time, maybe during Obama Administration that everything seemed to be going our way. And, um, at that time we started the study that looked at how younger generations of, uh, LGBT people fare in terms of—because everything has changed, everything is changing, marriage equality, and all that.

And we wanted to see how well they’re doing because I actually had doubt about it. So even then I was a little bit doubtful that all the positive changes that we read about and feel are actually making the impact that we think it should. And then Trump was elected and things started to roll back into attacks and, you know, all the things you described—literally book burning, back to that. You mentioned before the attack on gay people as pedophiles, the resurrecting of old stereotypes. And so, for me, I feel that there’s a lot more to do. We’re fighting here in California in school boards about things that, really, I didn’t think we would have believed even 10 years ago that we would have to be fighting about. School boards want to eliminate Harvey milk—because they say he was a pedophile—from books. Because here in California we have a law that requires schools to teach actually about, as it’s called, the, the contribution of LGBT people to California’s history. And even with that, we’re not doing great job. 

So I, I do have a lot of hope and I do see all the positive things, and, as Laura said, young people are energized. I think young people are more accepting, we know that, as compared to older people. That is all on the optimistic side. 

I still look every time the CDC publishes their youth survey, the first thing I look at that is suicide of, uh, LGBT people. And it continues to be high. And looking at that makes me sad, because I still see young LGBT people struggling. Again, as Laura mentioned before, with, uh, her, her clients, her, uh, patients, um, struggling with families that are not accepting, struggling with societies that are not accepting, struggling with schools that are rejecting—so count on me to bring down this conversation to a depressing note. Um, bring it up again.

EM: I’m often asked where I think things are, and I feel confident with what I’ve said over the decades—it’s now decades—whatever the challenges, these are the best of times because, look where we were when we were kids and we’re having this conversation. And look where you’re employed, the two of you. Um, and look what I’m getting to do by sharing these stories. 

I think that long after we’re gone, we’ll go through these cycles of progress and regression. The mistake we make is that the battle is ever over. It is a forever battle. Um, and that is part of our jobs as long as we are here on this planet. 

Dr. Laura Erickson-Schroth is a psychiatrist committed to improving mental health through education and resource creation. She is the chief medical officer at the JED Foundation. And Dr. Ilan H. Meyer is the Williams Distinguished Senior Scholar for Public Policy at the Williams Institute and professor emeritus of sociomedical sciences at Columbia University.

Thank you both for your time and for helping bring this conversation about mental health in our communities absolutely into the present moment, and for helping us understand what’s changed for the better and what we need to do so much better in the future. 

LE: Thank you so much for having us, and it’s great to be fighting this fight together.

IM: Thank you, Eric.

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EM Narration: This Making Gay History miniseries was produced and written by Making Gay History‘s founding editor, Sara Burningham, and Anne Pope. Anne also mixed this episode. Our studio engineer was Michael Bognar at CDM Sound Studios. Our music was composed by Fritz Myers. 

Many thanks to our hardworking crew at Making Gay History, including deputy director Inge De Taeye, photo editor Michael Green, and our social media producers, Christiana Peña and Nick Porter.

Thank you to the New York Public Library Manuscripts and Archives division for their ongoing assistance. Making Gay History is made possible thanks to the ongoing support of the Jonathan Logan Family Foundation, Broadway Cares/Equity Fights AIDS, the Calamus Foundation, and Christopher Street Financial.

We’re deeply grateful to Patrick Hinds and Steve Tipton for their two-year grant in support of Making Gay History’s mission to bring LGBTQ history to life through the voices of the people who lived it. And thank you, as well, to Ty Ashford and Nicholas Jitkoff, Christine and Bryan White, Bill Kux, the Kipper Family Foundation, the Marcus Family Foundation, and the late Linda Hirshman for their generosity.

To learn more about the people and stories we’ve featured over the past seven years, please visit making gay history.com, where you’ll find links to additional information, archival photos, as well as full transcripts for all our episodes. 

I’m Eric Marcus. So long until next time. And until sooner if you’re a Patreon member. Head to patreon.com/makinggayhistory if you want to hear from us between seasons. We’ll be there, and I hope you will be, too. That’s patreon.com/makinggayhistory.

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