One thing that may get easily overlooked in the recent SCOTUS decision to shoot down DOMA is the fact that, for first time ever, the federal government’s view of gay couples is finally in line with that of the vast majority of the word’s mental health experts. The American Psychiatric Association, for example, isn’t without its own shameful flaws in its historical treatment of gays and lesbians, but eventually, they got it right, declassifying homosexuality as a mental illness in 1973. That was a long time ago. For decades now, the APA’s position has been this:

“Whereas homosexuality per se implies no impairment in judgment, stability, reliability, or general social or vocational capabilities, the American Psychiatric Association (APA) calls on all international health organizations, psychiatric organizations, and individual psychiatrists in other countries to urge the repeal in their own countries of legislation that penalizes homosexual acts by consenting adults in private. Further, APA calls on these organizations and individuals to do all that is possible to decrease the stigma that is related to homosexuality wherever and whenever it may occur.” —APA Position Statement on Homosexuality, December, 1992/Reaffirmed July, 2011

Perhaps the most shocking thing about the high court’s decision, then, is that it took such an embarrassingly long time for SCOTUS to get on the same page with this obviously humane, expert advice from psychiatric professionals in its own country. And indeed gays and lesbians have been “penalized” through exclusion. It’s rather shameful that the wagging fingers of religious fundamentalists had led lawmakers in circles for so long. But at least we’re here now. And it’s indeed reason to celebrate.

Yet, and seldom do I say this, the ultraconservatives do have at least one point. By “redefining” marriage in this way, a precedent has been set. It will be easier now—at least in principle—to change the definition of marriage again in the future to encompass even more “nontraditional” relationships. As morality changes, so too do our perceptions of social justice. Even the morality of us atheistic scientists, despite popular opinion, isn’t willy-nilly, though. It’s unlikely, mercifully, that any generation will undergo such a complete revamp that it finds itself throwing rice at a farmhand and his favorite goat as they amble off into the sunset. Contrary to the social conservative’s fears, the SCOTUS decision doesn’t mean that the country has gone insane. Instead, it’s a direct measure of our nation’s increasing sanity concerning human sexuality, our willingness to use our heads to think about such personal issues, not our guts.

By deferring to psychiatric opinions about what’s “normal” and “abnormal” concerning our erotic tastes, however, the whole matter can admittedly get quite tricky. Only a few months ago, the National Institute of Mental Health stated that it wouldn’t be adopting the APA’s revised Diagnostic and Statistical Manual of Mental Disorders (the beleaguered DSM-5), a move that reflects the deep ideological fissures that continue to divide those in charge of defining “mental illness.” One can look at the whole enterprise of psychiatric nosology as being philosophically dubious, as Thomas Szasz did, but few would take such an extreme position. Rather, debates center on what is properly viewed as a mental illness. And when it comes to the debacle that is—or was—the DSM-5, the proposed new sexual disorders were especially controversial.

For this latest revision, the fates of three proposed big new additions were decided. These included hypersexuality (essentially, sex addiction), hebephilia (attraction to pubescent children), and biastophilia (a rape paraphilia). In the end, all were rejected by the APA, and although the reasons why were complex and many, those who lobbied to include them were pointedly accused of underhandedly infusing morality into medicine.

The proposed disorders have changed, but morality’s unwelcome presence is nothing new in psychiatry. Today’s practitioners cringe at the insinuation that homosexuality is even remotely like those items in the list above. But it wasn’t always like this. In 1897, William Noyes, a psychiatrist at the Boston Insane Hospital, penned a scathing review of the British sexologist Havelock Ellis’s book, Sexual Inversion. Unique in its portrayal of homosexuality as a natural occurrence found in many other species and in most human societies, Ellis’s pioneering work strikes most of us today as commendable—even heroic. But Noyes didn’t see it that way. “Apart from its influence on the perverts themselves no healthy person can read this [book] without a lower opinion of human nature,” he wrote.

What makes one sexual orientation a “true” mental illness and another just an expression of human sexual diversity? I use the term “orientation” in the amoral, nonpolitical sense: One’s sexual orientation is simply what one’s genitals consistently orient toward most strongly, reflecting a lifelong pattern of arousal. This definition encompasses not only the gay/bi/straight dimension, but also the 500+ paraphilias. Sexual orientation is orthogonal to sexual behavior in that it refers to desires, not actions. Just as a person can be a “normal heterosexual” while also being a virgin, so too can a person be a paraphiliac without acting on his or her desires. (Similarly, I use the statistical term “sexual deviants” in a way that translates roughly to “erotic outliers.”)

To address which of the sexual orientations are “true” mental illnesses, the APA has long relied on the following four factors. And all, I believe, are conceptually flawed.

Harmfulness. Sexual harm may seem straightforward, but due to its inherent subjectivity, it’s deceptively complex. Any masochist can tell you that one person’s horror story is another’s erotica. To affix the stigmatizing label of mental illness to a given sexual orientation on the grounds of its universal harmfulness to others is to assume, usually without evidence and often in spite of it, that all people would be equally harmed by it. It also implies that anyone who fails to be harmed must therefore be disordered too.

Personal distress. Even if the question of harm to others is moot—say, in the case of a foot fetishist who prefers sex with shoes instead of people—the crippling emotions of shame and anxiety plaguing sexual deviants are often used to diagnose them with a mental illness. Yet such personal distress doesn’t arise in a cultural vacuum. We gays and lesbians might not like being lumped together with more deviant deviants (and the paraphilias are, indeed, meaningfully different from homosexuality), but the principle here is the same. Even after homosexuality was removed from the DSM in 1973, “ego-dystonic homosexuality” (those who were gay but who really didn’t want to be) lingered for a while, being excised from the DSM only in 1986. The APA eventually realized that these people’s “personal distress” wasn’t a symptom of their homosexuality, but of living in a society that rejected a core part of their unalterable natures.

Naturalness. The sexual nature of the individual, however, may be at odds with that of natural selection. In other fields of medicine, biological dysfunction—for example, an organ failing to work in the manner it evolved—is the hallmark of disease. The APA’s declassification of homosexuality as a mental illness was not only a watershed gay rights victory, it also, unintentionally, set an important medical precedent. There are plenty of evolutionary hypotheses for homosexuality, most unconfirmed. All, however, speak only to its possible fringe genetic benefits.

It is silly to debate the obvious fact that heterosexuality is a more effective reproductive strategy than is an exclusive attraction to the same sex. With homosexuality reconceptualized by the APA as “a normal form of human sexuality,” the clinical use of “normal” as it’s applied to human sexuality could never again be perfectly synonymous with “biologically adaptive.” The unspoken effects of this decision still reverberated, some forty years later, in the debates over the recently proposed (and rejected) DSM-5 additions. “Biological dysfunction” is an uncomfortable guide for our mental-illness classifications given that, morality aside, hebephilia, biasotophilia and hypersexuality are arguably more “functional” than exclusive homosexuality. Religious fundamentalists and social conservatives might want to think twice before using their favored rhetoric of emphasizing the “unnaturalness” of gay sex in reproductive terms; in doing so, they’re insinuating the “naturalness” of some unconscionably cruel sex acts.

Consent. It’s important to tease apart the legal and psychiatric uses of the word “consent.” Even if it’s “consensual” in the sense of the other party’s willingness, having sex with a 16-year-old is still illegal in most states given that the individual is “below the legal age of consent.” In psychiatric terms, by contrast, the emphasis rests not on culturally variable factors (such as arbitrary age cutoffs) but on coercion, which includes physical force and psychological manipulation. As with harm, sexual consent may appear straightforward, but in fact it’s anything but. Those at the far end of the BDSM community, for instance, may consent to physical force resulting in great bodily injury. And some “zoophiles” (who are attracted more to other species than to human beings) have begun putting a “Z” at the end of the “LGBT” community acronym. They’re well aware of the retort that animals cannot give verbal consent, but they strive to distinguish themselves from “zoosadists” (who derive gratification from sexually abusing animals) and stress that consent can be gauged through the animal’s body language. Getting explicitly verbal “yes or no” consent is rare with human-human sex too, they point out.

Psychiatry’s ongoing efforts to cull the “true” mental illnesses from the radiant spectrum of human sexual diversity is questionable business, since it simply cannot be done without somehow imposing morality onto medicine. Rather than asking what is or isn’t a psychological disorder when it comes to the sexual orientations, perhaps it’s time we ask ourselves what, exactly, we so fear lies at the bottom of the slippery slope.

We’ve been focusing as a society so much on what’s “natural” and “unnatural” when it comes to sex that we’ve completely lost sight of a more important question: “Is it harmful?” Resolving that libertarian question is where we should be concentrating our moral efforts.

[The above post was originally published at 06.27.13]