Sexuality and Psychiatry

How and when scientists, doctors, and society started conceiving of the physical and emotional components of same-sex desire as a psychiatric condition of the mind? This was neither an ancient belief nor a postmodern (aka, post-1950) one, and it wasn’t an exclusively American phenomenon either. Rather, the classification of same-sex desire as a “disorder” had its roots in the foundations of psychiatry as a profession in the 19th century. Over the last 100+ years, that classification impacted individuals all across the world. You’ve heard of Sigmund Freud, whose work in the 1920s standardized a form of talk therapy that sought to interpret actions, thoughts, and desires through a particular lens of analysis. “Psychoanalysis,” though short-lived as a psychiatric practice, was certainly part of the longer-term framing of queerness and transness as “mental illness.” But Freud is just the tip of the iceberg. Today we’re digging into the history and relationship between psychiatry and sexuality; the scientific theories of sexuality that helped shape modern ideas about the relations between gender, genitals, desire, and identity; and the consequences of the medicalization of sexuality.

Averill: In our recent episode on the Lavender Scare, I mentioned that the American Psychiatric Association decided to add “homosexuality” to the Diagnostic and Statistical Manual of Mental Disorders in 1952. The formal classification of same-sex desire as a mental illness suggested that it was a disorder or disease that either needed to be managed or cured, like depression or cancer. For some people who lived in the daily homophobic reality of American society, receiving psychiatric treatment was helpful. Some psychiatrists helped their patients deal with the stress of their “hidden identity,” rejection from their family, or the other external factors that made being gay or lesbian challenging. For others, having society treat homosexuality as a disease was disastrous; many queer people were institutionalized, where a range of physical therapies like electroshock and lobotomies were employed to “cure” the “unnatural” desires out of them. Homosexuality remained in the DSM until the 1970s, after years of evidence-based protest and activism on the part of individuals like our old friend Frank Kameny.

What we didn’t talk about in that episode was how and when scientists, doctors, and society started conceiving of the physical and emotional components of same-sex desire as a psychiatric condition of the mind. This was neither an ancient belief nor a postmodern (aka, post-1950) one, and it wasn’t an exclusively American phenomenon either. Rather, the classification of same-sex desire as a “disorder” had its roots in the foundations of psychiatry as a profession in the 19th century. Over the last 100+ years, that classification impacted individuals all across the world. You’ve heard of Sigmund Freud, whose work in the 1920s standardized a form of talk therapy that sought to interpret actions, thoughts, and desires through a particular lens of analysis. “Psychoanalysis,” though short-lived as a psychiatric practice, was certainly part of the longer-term framing of queerness and transness as “mental illness.” But Freud is just the tip of the iceberg (a metaphor that I feel certain he would appreciate). Today we’re digging into the history and relationship between psychiatry and sexuality; the scientific theories of sexuality that helped shape modern ideas about the relations between gender, genitals, desire, and identity; and the consequences of the medicalization of sexuality.

I’m Averill Earls

And I’m Elizabeth Garner Masarik

And we are your historians for this episode of Dig.

Elizabeth: We are so thankful for all of our Patreon supporters – especially our Auger and Excavator level patrons: Judy, Lisa, Karl, Karen, Jessy, Maria, Denise, Edward, Lauren, Colin, Susan, and Alissa! We can’t thank you enough. Listener, if you enjoy what we do here but aren’t yet a patron of this show, it’s easy: just go to patreon.com/digpodcast to learn more.

Averill: Even though there are obvious connections to our current political moment and this episode, that wasn’t the primary reason I picked this topic. I mean, it’s not not a reason I wanted to do this episode, but it wasn’t the primary. I’m actually working on a new research project with some records that I was able to pull in January from the Grangegorman Mental Hospital in Dublin. I’ve been operating for a while under the assumption that Ireland did not really follow the lead of the US or Germany or the UK in terms of the medicalization of same-sex desire, for better or worse. There were some specific circles of Irish intellectuals who took sexology seriously. Examples are few and far between, like the lesbians who produced the Sapphic journal Urania in the 1920s (which had a limited print run) or the small social circle that engaged with Edward Carpenter’s writings, uncovered by historian Maurice Casey in a recent journal article.^[1] Neither of these examples offer a broader discourse with sexological literature in psychiatric facilities, for example, and so I’ve set out to try and determine if my assumptions are correct – and Ireland did not adopt the medicalization of sexuality until the 1970s, decades behind her peers; or if those conversations and practices were happening behind the formidable walls of places like Grangegorman. This is very much a work in progress, but for 1930-1955, I’ve found very few individuals who were institutionalized in asylums for sexual conditions, and even less evidence of treatment plans or psychiatric care philosophies that engaged with these earlier sexological discourses. That doesn’t mean they weren’t there – only that I haven’t found them yet. But to be able to put my new project into a broader context, I wanted to do a deep dive on the history of psychiatry and sexuality, which brings us to this episode! I’m beholden to the work of Harry Oosterhuis [Awsterhouse], who was one of the first historians to document this history in English – his 2000 book Stepchildren of Nature is the standard in the field. Pieter Adrieans and Andreas de Block’s more recent synthesis helped me bring that conversation up to date. Oostershuis is mostly talking about sexology and psychology in Europe, so to think about the consequences of the pathologization of sexuality globally, I’ve also turned to the excellent works of scholars like John Stuart Miller, Mian Chen, Lamia Mognieh, James Bennett, and Chris Bricknell. As always, you can find a full bibliography and notes for this episode on our website, digpodcast.org.

Elizabeth: Early 19th-century European psychiatry concerned itself only with the disordered mind – which, at first, did not include sexuality. But in France throughout the 19th century, police often called on physicians for how to deal with sex offenders. The Italian criminologist and eugenicist Cesare Lombroso “claimed that sexual abnormalities in women were always associated with what he described as “traces of masculinity,” such as a low jawline, hard facial features, and a low voice.”^[2] Independent of (but also reliant on) the medical establishment, then, the police were linking sexual crimes to a kind of disorder that required medical intervention; maybe this is a chicken and an egg situation, but we think it’s important note that, doctors were not the only (or even the first) ones thinking about sexual deviance as illness. According to Pieter Adrieans and Andreas de Block, it wasn’t until the 1860s that European psychiatrists expanded their definition of “madness” to include “disorders of will, desires, and emotions.”^[3] Once that idea took hold, though, physicians and psychiatrists across Europe embraced it.

Averill: Richard von Krafft-Ebing was born in Baden, part of the German Confederacy, in 1840. He studied medicine at the University of Heidelberg, and spent a period of his early career as a medical assistant at the Illenau mental hospital in the 1860s. After the 1870 Franco-Prussian War–during which he served as a field doctor and then treated wounded soldiers with electrotherapy for neurological conditions–he set up his own psychiatric clinic in Strasbourg. He also taught as a professor of psychiatry, until 1880, when he was able to step down from his practice and dedicate his time to his professorial position. He published several major works on psychiatry, including Textbook of Forensic Pathology (1875) and, of course, Psycopathia Sexualis (1886). In the emerging and rapidly professionalizing field of psychiatry, particularly in Germany, Krafft-Ebing was certainly a leader.

Elizabeth: In their book on the history of homosexuality, Adrieans and de Block go so far as to claim that Richard von Krafft-Ebing created the modern “homosexual identity” with Psychopathia Sexualis and its impact on queer intellectual elites. To say that he created the homosexual identity might be an oversimplification, and certainly historian Harry Oosterhuis resisted flattening the history completely in his book in 2000. But it is true that Krafft-Ebing’s intellectual conversations and letter exchanges with both other philosophers of sexuality and individuals who saw themselves in Psychopathia Sexualis shaped the conversation about the medicalization of same-sex desire for the next century, and influenced individuals like Havelock Ellis in England, Magnus Hirschfeld in Germany, and Sigmund Freud in Austria.

Averill: Oosterhuis argues that Krafft-Ebing’s sexual pathology played a key role in the historical construction of the modern concept of sexuality.^[4] Krafft-Ebing’s ideas weren’t necessarily ground-breaking. Rather, he synthesized the existing body of scholarship on the psychology of sexuality.^[5] He drew on, for example, Heinrich Kaan’s 1844 Psychopathia Sexualis. Kaan was one of the first Europeans to posit that sexual behaviors that Christians categorized as sins were diseases of the mind. But Kaan’s book, despite being translated into English and German, was not nearly as influential as Krafft-Ebing’s–except in how it informed the 1886 Psychopathia Sexualis. What made Krafft-Ebing’s book stand out, and have such a lasting influence, was his use of case studies to illustrate the range of sexual “conditions”. He offered detailed discussions of various episodes of “sexual deviance.” To some, his work bordered on the pornographic, but anticipating the scandalous nature of the case studies, Krafft-Ebing put the details of the case studies in Latin, so only those trained in the language–primarily physicians–would be able to decipher it.

Elizabeth: And decipher it they did. A surprising number of intellectuals wrote to Krafft-Ebing, explicitly identifying with the case studies he showcased in his book. Among them was a young Latvian nobleman, Von R, who wrote:

“I fear to annoy you, Sir, with my letter–after all, in the preface of your “Psychopathia sexualis,” you mention the “innumerable letters by stepchildren of nature”–I still trustingly turn to you, hoping that a layman might report something to the scholar that is not entirely without interest: even the most inconspicuous thing may gain importance in the right place and may be worthy of scholarly attention.”^[6]

For the queer and trans individuals who gained access to the 1886 edition of Psychopathia Sexualis – or one of its multiple reprintings in the decades after – Krafft-Ebing offered language that was more than just deviant behavior. But the extent to which that language helped individuals better understand themselves, or helped society reconceive of individuals like them, is not as clear cut.

Averill: Among historians of sexuality there is an on-going debate about the true impact of psychological and sexological debates, and how much they actually influenced the way people thought about queer and trans people, or how much they influenced how queer and trans people thought about themselves.^[7] Harry Oosterhuis suggests that the experience of sexuality wasn’t shaped so much by sexological discourse as the expansion of the middle class and their ideal of romantic love; as well as the autobiographical analysis of the bourgeoisie, who wrote about themselves and their relation to society; and the growth of economic independence and social/geographical mobility.^[8] By that logic, rather than psychiatry or sexology reshaping the experience of sexuality, then, the 19th century experience of sexuality shaped the development of psychiatry.

Elizabeth: According to Oosterhuis, many scholars have defined “sexual modernism mainly as a reaction against Victorian prohibitions.” Sexual modernism “is not only an ideology of sexual liberation, but even more an epistemological transformation of individualization and psychologization of sexuality.”^[9] This means, essentially, that sexual modernism wasn’t just about sexual freedom. It represented a fundamental shift in how people understood sexuality: “Individualization” means sexuality became viewed as a personal matter rather than just a societal or moral issue. People began to see sexual identity as part of their individual self rather than solely defined by social rules. “Psychologization” refers to understanding sexuality as connected to psychology and personal experience. This shift brought sexuality into the realm of mental health and personal well-being rather than just reproduction or moral behavior. So in essence, sexual modernism completely transformed how people thought about sexuality, viewing it as integral to individual identity and psychological health rather than just a behavior governed by social norms. It wasn’t explicitly in response to Victorian prudishness, but did emerge as an experience and element of identity-making in the Victorian era.

Averill: But the wheels of change were put in motion much earlier. The nation-state became increasingly concerned with depopulation, and the ways sexual “crime” weakened the state and disrupted public order.^[10] In effect, the ideas of the Enlightenment – and their application to governance and society – wrested control of sexuality away from Christianity. Morality and sin were still important social factors, but in places like France, Britain, the young American Republic, the Nordic countries, and later Germany and Russia, the state supplanted the Church in sexual authority.^[11] At the same time, the Scientific Revolution invited closer scrutiny of bodies and difference, birthing sexual science, in which scientists defined women as distinct and complementary to men in new and biologically-determined ways.^[12] Sexual science was baked into the debates of Enlightenment thinkers like Rousseau and Wollstonecraft, who each bought into the idea that men and women were fundamentally different, even if they disagreed about what that should mean.

Elizabeth: Among the earliest scientists to think about the sexual as connected to the mind was the naturalist Georges-Louis Leclerc de Buffon. According to historian of science Ross Brooks, Buffon separated sex from morality by framing it as a biological propagative function of every species (asexual or sexual). Thus, engaging in non-procreative sex was evidence of a dysfunction or abnormality, rather than a moral failing.^[13] The emergence of sexual science paved the way for explicit study of sexuality.

Averill: Sexologists of the 19th and 20th centuries were biologists, like Georges-Louis Leclerc de Buffon, as well as entomologists, philosophers, poets, physicians, and, by mid-century, psychiatrists. A fair number from the early 20th century were eugenicists. Their fields of expertise and pseudoscience influenced their methodologies for studying and theses about sexuality. But the collective body of sexological literature – from Krafft-Ebing’s Psychopathia Sexualis to Havelock Ellis’s Studies in the Psychology of Sex to Alfred Kinsey’s Sexual Behavior in the Human Male and Female – were in conversation, and shaped how those in the medical fields understood sexuality.

Elizabeth: Krafft-Ebing, like several scholars before him, endeavored to differentiate between perverse acts and the pathology of perversity. He wrote: “In order to differentiate between disease (perversion) and vice (perversity), one must investigate the whole personality of the individual and the original impulse leading to the perverse act. Therein will be found the key of diagnosis.”^[14] And so what he called the perversity of sexual desire could range widely. Among other “disorders,” Krafft-Ebing notably coined “sadism” and “masochism” as examples of “perversity of sexual desire.”^[15] He offered anonymous case studies like that of “Case 44” to illustrate these esoteric concepts of sexual experience. Case 44, notably, told his own story of his sexual development and experiences:

“My imagination has always been very lively, and was very early directed to sexual matters. As far as I can remember, I was much given to onanism long before puberty. Even at that time my thoughts were, for hours at a time, directed to intercourse with females. But the relations in which I placed myself with the opposite sex were entirely peculiar. I fancied that I was a prisoner and absolutely in a woman’s power, and that this woman used her power to hurt and abuse me in every way possible. In this, whipping and blows played an important part in my fancy… The more severely I was humiliated and abused, the more I indulged in these thoughts.”^[16]

Averill: And so this is a really interesting case, because most of Krafft-Ebing’s case studies are in the third person – his clinical report, rather than the subject’s experiences in their own words. In this case, the autobiographical nature of Case 44’s confession to Krafft-Ebing is striking. He is self-assessing his inclinations and preferences, demonstrating a remarkable self-awareness about his sexual preferences. As Harry Oosterhuis argues, this reflectivity among the Victorian bourgeoisie was essential to the development of modern sexuality. Not Krafft-Ebing’s analysis of the text, but of this bourgeoisie man’s self-reflection on his sexuality and his inclinations and his desires. In that way, Krafft-Ebing was not inventing, but rather synthesizing that emerging sense of modern sexual identities.

Elizabeth: All of Krafft-Ebing’s case studies–particularly the ones where he is summarizing interviews he had with individuals, rather than quoting them directly–follow a similar formula. If there’s a family history of any mental illness, he remarks on that, and also spends considerable time describing physiological details that he deems important: whether the genitals are “normal,” whether a woman has menstruated “normally”. These markers of “normal” physicality seem to be important both to differentiate his case studies from individuals who suffer from physical issues that cause sexual deviance, versus those whose sexual impulses are shaped by their mental degeneracy or deviance.

Averill: There are over 190 case studies in the 1894 edition of Psychopathia Sexualis. While we’re mostly talking today about the long-term impact of the medicalization of sexuality on queer people, I wanted to share some specifics from Krafft-Ebing’s reporting on asexuality. I had a student work on a research project about asexuality in Northern Ireland–and he didn’t find a ton of good sources–so it is interesting to see this 19th century psychiatrist offer an extensive section on the absence of sexual desire in a number of individuals. The first of these cases, Case 3, was a young man. Krafft-Ebing draws attention to his family’s mental illness history–because, of course, Krafft-Ebing is keen on tying sexuality to his mental pathology. He says

“As early as his thirteenth year, D. was troubled with the thought of becoming insane. At fourteen he attempted suicide. Later, vagabondage, and, as a soldier, repeated insubordination and crazy pranks. His intelligence was very limited; no sign of degeneration, genitals normal. At seventeen or eighteen he had emissions of semen, had never masturbated or had sexual feeling, and never had sought intercourse with women.”^[17]

Most of Krafft-Ebing’s case studies identify as men, but one 35-year-old woman, “Mrs. O,” was not “averse to coitus, and sometimes seemed to experience pleasure in it, but she never had a wish for repetition of cohabitation.”^[18] In his description of her, he emphasized that she menstruated normally and married, though she never experienced erotic excitement with her husband of 15 years. Like most of the case studies throughout the book, Krafft-Ebing offers the case details that he finds the most relevant, and they aren’t nearly as compelling or revealing as the quotes from his patients, but the documentation of asexual people in such clear and specific terms is fascinating.

Elizabeth: Krafft-Ebing’s cataloging of sexual “disorders” ends with three that he addresses only briefly: lesbianism, necrophilia, and incest. We don’t think their location in the volume is in any way affiliating them, but rather, they seem to be the “disorders” that he gathered the least data about. According to Krafft-Ebing, “Lesbian love does not seem to approach urningism in frequency [in comparison with male same-sex desire].”^[19] Krafft-Ebing, like many before him and after him, attributed lesbian love not to “real” or “innate” sexual desire, but to circumstantial and close friendships. Most of his data seems to have come from prison studies of female prisoners. Kraussold reports: ” The female prisoners often have such friendships, which, when possible, extend to mutual masturbation. But temporary manual gratification is not the only purpose of such friendships. They are made to be enduring, — entered into systematically, so to speak, — and intense jealousy and a passion for love are developed which could scarcely be surpassed between persons of opposite sex.”^[20] Like the criminologist Lombroso, Krafft-Ebing and the source he quotes presume that this kind of relationship could only flourish in situations where there were no suitable men, even as Kraussold reports that their love is more intense than that between the opposite sexes. This seems more evidence of the male sexologists’ lack of imagination or understanding of women than the “infrequency” of innate lesbian sexual desire.

Averill: Significantly, most scholars agree that Krafft-Ebing didn’t want to create a world in which queer and trans people were tortured with experimental therapies and drugs. The language and framework that he employs–though, in large part a synthesis of pre-existing language and frameworks–is certainly problematic. But in his career of working with and trying to create a better understanding of queer and trans people, he became convinced that these sexual desires emerged by no fault of the individual. He tried to help the state see that punishing people for something that they simply cannot help is wrong. Late in his life he advocated for the decriminalization of homosexuality, and even signed Magnus Hirschfeld’s petition to abolish Paragraph 175 of the German legal code, which criminalized homosexuality. As evidenced by the many who wrote to him following the publication of Psychopathia Sexualis, its message found its audience.

Elizabeth: Though many 19th and early 20th century sexologists are often remembered primarily for the harmful applications of their theories, they represent pivotal inquiries in the evolving understanding of human sexuality. While Krafft-Ebing ultimately advocated for the decriminalization of homosexuality, recognizing it as an inherent rather than chosen condition, Sigmund Freud approached the subject through his developing psychoanalytic framework. Both men’s work, despite their intentions, became weaponized in ways that caused tremendous suffering. Their theories, however flawed or dated by modern standards, nonetheless marked important steps in the intellectual transition from purely moral or religious frameworks toward medical and psychological understandings of sexuality—a shift that would have profound implications for how society conceptualized and responded to sexual diversity in the decades to follow.

Averill: Like Krafft-Ebing, Sigmund Freud’s views on homosexuality were complex and evolved throughout his career, and were also used as justification for the (mis)treatment of queer and trans people in psychiatric facilities. He did not present a single unified theory about the causes of homosexuality, but rather offered several hypotheses. For men, Freud generally proposed that homosexuality could result from an unusually strong attachment to the mother and distant or hostile relationship with the father during the Oedipal phase, arrested psychosexual development, narcissistic object choice (selecting partners who resemble oneself), or fixation during specific developmental stages. For women, Freud suggested homosexuality might stem, ridiculously, from penis envy and resulting disappointment with the mother for not providing her with a penis, or failure to transfer attachment from the mother to the father during development, or fixation in pre-Oedipal attachment to the mother. So really, it’s all about mama.

Elizabeth: Importantly, Freud did not consider homosexuality to be an illness or pathology in the same way many of his contemporaries and followers did. In his famous “Letter to an American Mother” (1935), he wrote that homosexuality “is nothing to be ashamed of, no vice, no degradation; it cannot be classified as an illness.” He viewed it as a variation in sexual development rather than a disorder requiring treatment. Though his ideas were, ultimately, instrumental for “diagnosing” homosexuality. Psychoanalysis and talk therapy were also used as treatment. For some, therapy offered a means to work through personal struggles with sexuality or gender identity.

Averill: For others the results could be just as harmful as some of the experimental “treatments” tested in psychiatric facilities throughout the twentieth century. This depended largely on the individual doctor they were working with, how and why they were in a psychiatrists’ care, and their level of agency in the choice to receive “care”. The medicalization of sexuality had far-reaching consequences. Like Oosterhuis, we won’t go so far as to say that medicalization changed the way queer and trans people thought about themselves. The forging of a modern sexual identity between the nineteenth and twentieth centuries was far more complex than that, and to attribute these developments to doctors rather than the queer and trans individuals and communities that found themselves and each other would be dismissive and untrue. It’s true that for some people, having scientific language to understand their difference in a world demanding conformity was helpful. For some, having a medical establishment that would eventually provide things like gender affirming care was literally life saving. But for many others, the opposite was true.

Elizabeth: In this crucial moment when sexology was devising a new lexicon for sexual desire and its innateness was the same moment of the eugenics movement. Eugenicists believed they could socially engineer a “better” world, and in that “better world” with people who were “fit” to reproduce, sexual deviance, now categorized as disordered, was something to breed out of humanity. Governments, despite their secularization, were still concerned with same-sex sex, and couching it in the language of “depopulization” and “degredation” instead of sin and morality wasn’t really changing anything. If anything, the industrialized state with its bigger and more powerful tools for controlling the population became more dangerous for anyone deemed “unfit”. People with disabilities, which, in the early 20th century, ranged from alcoholism to neurodiversity to physical limitations to same-sex desire, were institutionalized, sterilized, experimented on, and in the most extreme and awful cases, murdered under the guise of “euthanasia.” Some eugenicists drew the line at just encouraging the “right” people to procreate and discouraging the “wrong” people from procreating. But plenty of eugenicists believed in removing the “wrong” people from the population entirely to prevent any chance of them passing on their “defects.” We’ve talked about these processes and the specific places that carried them out – the United States, including in Puerto Rico; Britain, through private birth control advocates like Marie Stopes; and of course in Nazi Germany.

Averill: Like eugenics, and wrapped up in eugenic thought, sexology–and this medicalization of sexuality–paved the way for queer and trans people to be “treated” by doctors. Again, for some people, “treatment” could be helpful, when it provided things like gender-affirming care or helped individuals deal with the traumas inflicted on them by a society that refused to accept them. But for too many, “treatment” was trauma.

Elizabeth: Also like eugenics, psychiatry in the twentieth century was, unsurprisingly, transnational. Scholars and doctors attended international conferences, did residencies abroad–many in Vienna, where these ideas were coalescing–and books like the 1886 Psychopathia Sexualis were translated into multiple languages. By the mid-20th century, these European psychiatric models had spread globally, crossing ideological divides of the Cold War and adapting to local contexts in ways that reveal a troubling global pattern of medical control over sexual and gender diversity. The consequences cannot be understated. The medicalization of sexuality, and same-sex desire in particular, was built on by subsequent generations of European sexologists, like Havelock Ellis and John Addington Symonds in England, Sigmund Freud in Austria, and Magnus Hirschfeld in Germany. But that narrow framework for conceiving of sexuality was exported to and adopted in a wide range of national contexts, often interacting with local prejudices and perspectives on non-normative sexualities in harmful ways.

Averill: We can see this in a wide range of case studies, from the United States and Lebanon at mid-century, to New Zealand in the 1960s, to China in the 1970s. While medicalization may have offered some queer and trans people a new lexicon for self-discovery and assertion, for others, it was a tool for the state, family, or community to punish the sexually non-normative.

Elizabeth: Medicalization naturally led to a push to “treat” or “cure” sexual “disorders.” “Treatments” for homosexuality were developed around the world, with some of the more experimental efforts coming out of Britain, the United States, and Canada. From the 1950s through the early 1970s, psychiatrists administered LSD to gay patients in an attempt to “cure” their homosexuality. At Hollywood Hospital in British Columbia, at least twelve men were treated for homosexuality using LSD between 1955 and 1973. Similarly, at Marlborough Day Hospital in London, psychiatrist A. Joyce Martin gave LSD to twelve gay men in 1962, claiming success in converting seven of them to heterosexuality after “three to six years” of treatment. These therapists believed that LSD’s ability to enhance memory recall and dissolve ego boundaries would allow patients to revisit childhood traumas that supposedly caused their homosexuality. Based on Freudian theories that had originated in Europe, they connected homosexuality to problematic parent-child dynamics that could be “fixed” during LSD-enhanced psychotherapy sessions.

Averill: In 1957, a 36-year-old woman named Hala in Lebanon was brought to the Lebanon Hospital for Mental and Nervous Disorders under false pretenses by her sister.The hospital, founded as a missionary project at the turn of the twentieth century, represented a complex blend of European and American medical expertise and local healthcare practices. Hala was diagnosed with both schizophrenia and “nymphomania” – a European psychiatric category dating back to the 19th century that pathologized female sexual desire as a medical disorder. Hala received a combination of drug therapy and electroconvulsive therapy (ECT). The hospital records meticulously documented her “outspoken sexual behaviors,” treating her sexuality as a symptom to be observed, recorded, and treated. What makes Hala’s case particularly illuminating are two unsent letters found in her patient file. In these letters, she negotiates with her family for release, promising to control her sexuality and conform to acceptable gender roles – revealing how deeply she had internalized the medical model of her sexuality as pathological.^[21]

Elizabeth: In 1964, 20-year-old Ralph Knowles, a theological student in New Zealand who identified as homosexual, was pressured by his religious confessor to seek psychiatric help.He was referred to Dr. Basil James, a clinician at the University of Otago who had trained in the United Kingdom and imported British psychiatric methods to New Zealand. Dr. James prescribed aversion therapy – a behavioral treatment technique developed in Europe that was widely used throughout the Western world during this period. The “treatment” was brutal: five days of injections with apomorphine, a drug that induces violent nausea, combined with whisky.

Averill: As Knowles listened to recordings of his own homoerotic fantasies, he would vomit uncontrollably. When that initial treatment failed, he received hormone injections supposedly to boost heterosexual desire, followed by electric shocks to his hand during outpatient visits. Unsurprisingly the treatment was a complete failure, except in one perverse sense: Knowles developed a permanent aversion to whisky. More importantly, the experience transformed him into a vocal opponent of such treatments, which he later described as “psychiatrically crude and physically barbaric – not to mention medically ineffective, morally wrong, and socially outrageous.”^[22]

Elizabeth: There were similar patterns of medicalization in socialist countries, revealing how European psychiatric models transcended Cold War ideological divides. In China during the Mao era, psychiatrists categorized homosexuality as a form of “psychopathic personality,”
drawing on both Soviet psychiatric knowledge and translated Western medical texts.In May 1973, for example, a 38-year-old engineer was sent to Shashi Psychiatric Hospital in Hubei Province after being “diagnosed” as homosexual. Much like Ralph Knowles in New Zealand, he received aversion therapy and was administered chlorpromazine and chlordiazepoxide – psychiatric medications first developed in Europe. The Chinese psychiatric establishment continued this medicalization into the Deng era. By the early 1980s, psychiatrists were collaborating with police to identify homosexual individuals, and a 1984 psychiatric textbook explicitly framed homosexual people as criminally-inclined beings who “often try all means to fornicate or seduce children and commit a crime.” Chinese psychiatrists, despite operating in a supposedly isolated socialist system, were actively engaging with and adapting European psychiatric models. Medical texts from Mao’s China cite both Soviet sources and translated British psychiatric works like Mayer-Gross and Roth’s “Clinical Psychiatry,” which introduced concepts from Freud and Kinsey to Chinese practitioners.^[23]

Averill: The pathologization of sexuality, and especially homosexuality, is not coincidental. The psychiatrists themselves were often internationally connected. Dr. Basil James in New Zealand had trained in the UK, where he had previously used aversion therapy while working as a registrar at a hospital in Bristol. Chinese psychiatrists translated and studied Soviet and British psychiatric texts. The Lebanon Hospital for Mental and Nervous Disorders was founded by a Quaker missionary and maintained connections with European and American medical institutions. This global circulation of knowledge reveals how the pathologization of sexuality was not just a series of parallel developments, but an interconnected system that shared techniques, theories, and rationalities across borders and ideological divides.^[24]

Elizabeth: And, of course, these histories are not merely academic. The legacy of these practices continues to affect LGBTQ+ people around the world today. Conversion therapy remains legal in many countries, and the psychological impact of medicalization persists in contemporary attitudes and policies. The rise of gay liberation in the 1970s began to challenge the medicalization of sexuality, creating what historians James Bennett and Chris Brickell call “a divisive political contest with the psychiatric profession.” But change was slow. Even in more progressive countries like New Zealand, as late as 1977, when gay liberation groups surveyed New Zealand psychiatrists, they found that only about half considered electroconvulsive therapy inappropriate for “treating” homosexuality, and a mere 10% rejected aversion therapy. Homosexuality wasn’t removed from the American DSM until 1978, the result of queer individuals having to fight for the right to not be categorized as “ill” or “disordered” and in need of treatment or cure. And this perspective is still popular in some corners of the world.^[25] China didn’t remove homosexuality from their diagnostic manuals until 2001.^[26] While “conversion therapy” has largely been taken over by evangelical Christians in places like the United States, the fundamental idea that sexuality is something that can be “treated” or “cured” is still persistent and part of the daily lexicon.

Averill: When we understand the historical roots of these modern issues, it puts them into perspective. Krafft-Ebing, Ellis, Carpenter, and the host of other individuals responsible for medicalizing sexuality believed this framework advanced the scientific understanding of the human condition, and they believed–from within that framework–that the existing treatment of queer and trans people was problematic. If, as they asserted, sexuality was not (usually) a behavior that one could control, but was an innate part of one’s being. In their minds, then, those deemed “sexual offenders” didn’t deserve to be punished–because they couldn’t help themselves–but instead to be offered help to “treat” their disorder. They came from a place of empathy, even if the results, in which queer and trans people were violated with institutionalization, experimental drugs, electroshock, and even lobotomies instead of prison sentences and hard labor. Later sexologists advocated for entirely different treatment of queer and trans people. In the 1930s, Magnus Hirschfeld’s Institute for Sexual Science, for example, helped trans people gain papers that insisted “cross-dressing” was the “treatment” for their particular disorder. Today’s wide-ranging gender-affirming care is an outgrowth of Hirschfeldian standards–the idea that “treatment” should be to meet individuals where they are instead of trying to force them back into the box of cis and heteronormativity, to stop punishing and start supporting. While that kind of care was set back decades by fascism and conservative backlash, most of the psychiatric and medical fields across the world have, today, rebuilt those models of care for queer and trans people. It is possible to build something even better, once we defeat the Nazis and clear the rubble and bullshit.

Elizabeth: I have some questions. Um, so talk to me. Then. Let’s circle back a bit to your your own research. So, uh, you are trying to figure out how this medicalization that was happening in much of the Western world, but even all over the globe, as you kind of point out, like what was happening in Ireland and as of now, is the kind of established understanding. Are you still finding it true that Ireland did not really engage in this medicalization of homosexuality until the 1970s

Averill: Yes and no. So for the 1930 1955 period, I found eight people who were institutionalized in Grange Gorman, which is like the public mental hospital. So this doesn’t even account for private mental institutions, which is a whole other can of worms, but so for in this public one eight individuals who were institutionalized for sex disorders, basically, now I know for sure that two of those were men who raped women. Three were men who were imprisoned in conjunction with same sex sex crimes, one for sexually assaulting a child, a boy child, and two for sex with other men. One person was in there for having secondary sex characteristics, which, yes, which likely means intersex or some other elements going on there. And the last was a woman, and I know nothing about why. There’s no other details about her, yeah. And so what’s really odd is that, with all of these, like, all I have is their register, registry form where they were signed in, it gave this, like, brief diagnosis that says why they’re in there, which is all sexual deviance or sexual disorder. And then some, like, some little details, like has is a weak character or weak minded or has secondary sex characteristics. Most patients of Grange Gorman have a outtake form, or outtake pages, death and discharge pages in the in the collection, and in those death and discharges papers, there’s like little details from the weekly or daily check ins from physicians that talk about how they’re doing and what the treatment is being prescribed for. There is not an entry for any one of these eight people. And the one that I was able to at least locate that he had a page in this book. It has its name at the top, and then it’s just a blank page. Yes, so either, and I know, like, I know when they were, they were brought in, and when they were they left. Some of them didn’t leave for three years, and this is a place that tried to get rid of people within six months, because they wanted to keep their like stats up that they were curing people and sending them on their way because it was a publicly funded hospital, and that was going to help keep their sort of reputation up, right? So some of these people who had sex disorders were there for three years, but there’s no there’s no file of their treatment in that three years. So yeah, it’s very strange. I don’t know if the materials were destroyed, if they’re kept somewhere else or what, but yeah. And then the other thing about Ireland is that in unlike other places, which have sort of more developed psychiatric fields, Irish psychology is sort of controlled, or psychiatry is sort of controlled by like, one guy for 20 years when he is the head of the department of, you know, like hospitals for the for the nation. So what he says, it goes right, like, whether that’s, hey, we’re going to be using electro therapy as much as possible until we cure everybody, and that’s going to be the standard of care, or if it’s like, we’re going to use talk therapy, and that’s going to be the standard of care. So individuals have, like, too much power, and it’s not really like a conversation as much as it is in other places.

Elizabeth: And do you know what his feelings were on homosexuality?

Averill: Not that I’ve found yet. I haven’t found any of his writings on homosexuality. He published extensively, just not about that.

Elizabeth: And when you say he found eight people out of like, roughly how many are we?

Averilll: 1000s.

Elizabeth: Interesting.

Averill: Grangegorman was cycling through like 40 patients a day.

Elizabeth: Yeah. And just curious, do you have any hypotheses about maybe other words they were using? Like, I’m just thinking of some of your other your other episodes talking about how I think it was prostitution or sex work, and how with with that doesn’t happen in Ireland. Was that it, or was it homosexuality? With Roger Casement, like, there was this idea that, like, we are a Catholic nation, and these bad things do not happen.

Averill: Yes, Irish men don’t have sex with men. There are no prostitutes in this town, even though there are and there are right?

Elizabeth Right. So is that kind of a hypothesis that you have, that this is also something that’s like that?

Averill: Or, yeah, I mean, I, I feel like when that is being said by nationalists who run newspapers right, like they write, they they publish newspapers, so they publish the court records or the court cases that are Irish men being accused of sex with men. So when they say Irish men don’t have sex with men, they’re saying that, knowing that they’re not telling the truth with political ends, right? I want to, I want to believe that that. The psychiatry like the doctors in Ireland, knew better and wouldn’t have pretended otherwise, right? Like that, they there would have been very little to gain for them to pretend otherwise

Elizabeth: So, but if they’re being funded by the state, wouldn’t that they have a lot riding on their reputations.

Averill: I don’t, I don’t know, maybe, maybe. But if they could prove that they were curing people of homosexuality, then that might be right.

Elizabeth: But again, they’re like, back to the chicken and the egg, right? How can you cure somebody of homosexuality if homosexuality doesn’t exist in this Catholic country, right? Yeah, no. It’s fascinating. It’s really, I mean, I love, I love that you’re presenting this, you know, new project that you’re doing. And, you know, you have these questions, right? Like, this is how we do history. We ask these questions and we dig and we dig and we dig and, yeah, see what’s there. See what the sources show you. Yeah.

Averill Earls: And I just think, like, if China was using like China in after the Cultural Revolution, after the Civil War, right? Communist China is using these texts, right? And the Chinese are also saying, oh, there’s no homosexuality here that we’re going to admit to. But they’re also using these texts to “quote, unquote, “treat homosexuality,” then it’s so hard for me to believe that the Irish are disconnected from that conversation. But maybe they are. Maybe they are, I don’t know.

Elizabeth: Yeah, it’s a good question.

Averill: It was actually kind of hard for Irish doctors to get copies of sex logical texts, right? I have, like, there’s records in the census office, records at the National Archives, of doctors writing in me like, Hey, can I please import a copy of Krafft-Ebing’s Psychopathia Sexualis and they’ll be like, what do you need it for? I’m a doctor and I’m doing a sexology study. Well, okay, fine, you can have one set of Psychopathia Sexualis, and then they’re like, Can I also get this one novel that is also about sex? And that’s the only way that I could study it, because, of course, there’s no queerness here in in Ireland. And they’re like, No, you can’t have that. So there’s pretty strict parameters, and anything that mentions homosexuality is banned, yeah.

Elizabeth: Well, I hope, I hope the archive fairies bless you and you can figure out what’s going on with those missing records. That’s very, very interesting.

Averill: Thank you for joining us today. As always, we invite you to follow us on BlueSky, Instagram and Tik Tok at dig_history. If you have a comment or question or want to share some kind words with us, you can always email us at hello@digpodcast.org – we love listener mail! If you’re an educator, we’ve got a compendium of episodes you can use in the classroom – and free teaching resources, including full lesson plans! – on our website, digpodcast.org. We realize that recent changes to curriculum in states like Florida and Texas will complicate being able to use our podcast episodes in the classroom, so please reach out if there’s something we can do to be helpful to you and your classroom. And get a copy of our book, SPIRITUALISM’S PLACE, out now! You’ll also find full bibliographies, the scripts for all of our episodes, resources, and a link to our swag store at digpodcast.org.

BIBLIOGRAPHY

Adriaens, Pieter R., and Block, Andreas De. Of Maybugs and Men : A History and Philosophy of the Sciences of Homosexuality, University of Chicago Press, 2022.

James E. Bennett and Chris Brickell, “Surveilling the Mind and Body: Medicalising and De-medicalising Homosexuality in 1970s New Zealand,” Medical History 62, no. 2 (2018): 199-216.

Ross Brooks, “Transforming Sexuality: The Medical Sources of Karl Heinrich Ulrichs (1825–95) and the Origins of the Theory of Bisexuality,” Journal of the History of Medicine and Allied Sciences, 67 (2010) 177–216.

Maurice Casey, “‘I want to be to Ireland what Walt Whitman was to America’: Esotericism and Queer Sexuality in an Irish Social Circle, 1890s–1920s,” History Workshop Journal, 00 (2025), 1–22.

Mian Chen, “Homo(sexual) socialist: Psychiatry and homosexuality in China in the Mao and early Deng eras,” Gender & History 36 (2024): 657-672.

Richard von Krafft-Ebing, Psychopathia Sexualis (1894)

Harry Oosterhuis, Stepchildren of Nature (2000)

John Stuart Miller, “Trip Away the Gay? LSD’s Journey from Antihomosexual Psychiatry to Gay Liberationist Toy, 1955-1980,” Journal of the History of Sexuality, Vol. 33, no. 2 (May 2024)

Lamia Moghnieh, “The Broken Promise of Institutional Psychiatry: Sexuality, Women and Mental Illness in 1950s Lebanon,” Culture, Medicine, and Psychiatry 47 (2023): 82-98

Notes

^[1] Maurice Casey, “‘I want to be to Ireland what Walt Whitman was to America’: Esotericism and Queer Sexuality in an Irish Social Circle, 1890s–1920s,” History Workshop Journal, 00 (2025), 1–22.

^[2] Pieter R. Adriaens, and Andreas De Block, Of Maybugs and Men: A History and Philosophy of the Sciences of Homosexuality, University of Chicago Press, 2022, 146-172.

^[3] Adriaens and Block, Of Maybugs and Men, 142-176.

^[4] Oosterhuis, Stepchildren of Nature, 9.

^[5] Andreans and Block, Of Maybugs and Men, 140-176.

^[6] Qtd in Oosterhuis, Stepchildren of Nature, 1.

^[7] Oosterhuis, Stepchildren of Nature, 13.

^[8] Oosterhuis, Stepchildren of Nature, 15.

^[9] Oosterhuis, Stepchildren of Nature, 9.

^[10] Andreans and Block, Of Maybugs and Men, 140-176.

^[11] Oosterhuis, Stepchildren of Nature, 23.

^[12] Oosterhuis, Stepchildren of Nature, 25.

^[13] Ross Brooks, “Transforming Sexuality: The Medical Sources of Karl Heinrich Ulrichs (1825–95) and the Origins of the Theory of Bisexuality,” Journal of the History of Medicine and Allied Sciences, 67 (2010) 177–216.

^[14] Krafft-Ebing, Psychopathia Sexualis, 89.

^[15] Krafft-Ebing, Psychopathia Sexualis, 57 & 89.

^[16] Krafft-Ebing, Psychopathia Sexualis, 89.

^[17] Krafft-Ebing, Psychopathia Sexualis, 43.

^[18] Krafft-Ebing, Psychopathia Sexualis, 43.

^[19] Krafft-Ebing, Psychopathia Sexualis, 428.

^[20] Krafft-Ebing, Psychopathia Sexualis, 428

^[21] Lamia Moghnieh, “The Broken Promise of Institutional Psychiatry: Sexuality, Women and Mental Illness in 1950s Lebanon,” Culture, Medicine, and Psychiatry 47 (2023): 82-98.

^[22] James E. Bennett and Chris Brickell, “Surveilling the Mind and Body: Medicalising and De-medicalising Homosexuality in 1970s New Zealand,” Medical History 62, no. 2 (2018): 199-216.

^[23] Mian Chen, “Homo(sexual) socialist: Psychiatry and homosexuality in China in the Mao and early Deng eras,” Gender & History 36 (2024): 657-672.