Features | Society | East Asia

On the 25th anniversary of the Chinese Classification of Mental Disorders Version 3 (CCMD-3), we revisit the widely repeated claim that China “removed” homosexuality from its list of mental disorders in 2001 – and make the case for retiring it.

For decades, it has been conventional wisdom that homosexuality was “removed” from the Chinese Classification of Mental Disorders Version 3 (CCMD-3) in 2001. Media, scholars, NGOs, and international organizations have regularly cited the “removal” as a milestone in the history of China’s LGBTQ communities. In China, state media and government actors have also held up the “removal” to demonstrate progress on LGBTQ rights and even to deny the presence of the discredited practice of “conversion therapy” in China.

Yet, since 2001, many healthcare providers, educational textbooks, and official actors in China have continued to treat homosexuality as if it were a mental disorder. The “removal” narrative puts the blame for this problem’s persistence squarely on insufficient implementation and public education. Through CCMD-3, the story goes, China achieved depathologization in policy but not in practice.

However, the foundation of this story is a myth. CCMD-3 did not “remove” homosexuality. If one opens up CCMD-3 to the section on “psychosexual disorders” and then flips to the subsection on “sexual orientation disorders,” one will find there disorders simply named “homosexuality” and “bisexuality.”

Now, this is where things get complicated. While CCMD-3 retained these diagnoses, it also described “sexual orientation disorders” as “not necessarily abnormal in terms of sexual behavior itself.” For comparison, its previous 1995 version categorized homosexuality as a “sexual perversion” and explicitly rejected the idea of treating homosexuality as “normal.” That CCMD-3 described homosexuality as “not necessarily abnormal” was a major milestone and would help bolster greater social acceptance.

But why not just remove homosexuality altogether? CCMD-3 explained that the “main reason” for retaining homosexuality was that some individuals “may not wish to be this way or feel hesitant about it, and thus feel anxious, depressed, and distressed. Some people try to seek treatment to change.” The official English version rendered this last line as “change the sexual development and orientation.” CCMD-3’s lead drafter would later confirm that treatment for “homosexuality” indeed included conversion therapy. 

Far from “removing” “homosexuality” along with any rationale for conversion therapy, CCMD-3 retained “homosexuality” as a disorder and legitimized conversion therapy. This scrambled CCMD-3’s message and limited its impact in catalyzing social change. 

China is not alone in having taken an incrementalist approach. Psychiatric classification systems elsewhere also took halfway steps before completely depathologizing homosexuality. For example, in the decades before CCMD-3’s drafting, the American Psychiatric Association (APA) and the World Health Organization (WHO) had replaced “homosexuality” with diagnoses that only applied to people who were distressed by their homosexuality. These diagnoses distinguished between one’s homosexuality and distress about one’s homosexuality, considering the former as normal and the latter as pathological. According to the logic of these diagnoses, treatment could resolve distress either by helping one accept their sexual orientation or by helping one change their sexual orientation – i.e., pursue conversion therapy.

CCMD-3 looked to these other systems as examples. Indeed, it explicitly sought to harmonize with the WHO’s classification system, including its position on homosexuality. However, CCMD-3’s principles stated that it had to balance international harmonization with China’s “national conditions.” Under these circumstances, CCMD-3’s position on homosexuality declined to do three key things that the other systems did.

First, CCMD-3 did not make a firm statement that homosexuality itself is not a disorder. The WHO’s and APA’s classification systems had made such statements. Instead, CCMD-3 landed on the “not necessarily abnormal” language. All claims of homosexuality’s depathologization in CCMD-3 rest on this equivocal clause.

Second, CCMD-3 did not make self-distress a clear diagnostic requirement of the disorder. APA and WHO clearly stated that only individuals distressed by their sexual orientation suffered from a disorder. While these diagnoses were still problematic, maintaining this distinction created a diagnostic threshold and buttressed the idea that one’s sexual orientation itself is not pathological. In CCMD-3, however, self-distress just appears as one justification (the “main reason”) for retaining “homosexuality.” The ambiguity created by not listing self-distress as a clear diagnostic criterion allowed various stakeholders – in clinics, schools, media, and government – to consider homosexuality to be a mental disorder per se, even in the absence of self-distress.

Finally, CCMD-3 did not drop “homosexuality” as a diagnosis name. When APA and WHO took their halfway steps, they also changed the diagnoses’ names to reflect the idea that homosexuality itself was not a disorder and to highlight the diagnoses’ self-distress component. In the 1970s and 1980s, APA chose “sexual orientation disturbance” and then “ego-dystonic homosexuality.” In 1990, WHO endorsed adopting the disorder “egodystonic sexual orientation,” which ostensibly could apply to self-distress about any sexual orientation, including heterosexuality.

CCMD-3, on the other hand, simply kept the diagnosis name as “homosexuality” – this, obviously, did not highlight either that homosexuality itself was not a disorder nor that self-distress was a prerequisite of the diagnosis. This naming convention wasn’t just a drafting error. CCMD-3’s preface explained that “in China, it is necessary to retain or add some mental disorders or subtypes, such as neurosis, recurrent mania, [and] homosexuality.”

CCMD-3’s ambivalent position led to a lot of confusion. Supporters of depathologization took CCMD-3 to mean that homosexuality itself was no longer a disorder, and, over time, began claiming that homosexuality had been “removed” altogether from the list of mental disorders. Opponents of depathologization focused on CCMD-3’s listing “homosexuality” as a disorder and its seeming endorsement of conversion therapy. This has led to an ongoing paradox in which, for example, media reports can claim that CCMD-3 “removed” homosexuality even as official statements assert that “CCMD-3 very clearly classifies homosexuality as a psychosexual disorder.”

CCMD-3’s ambivalence has had real impacts on the ground. While progress has been made, surveys of mental health providers, textbooks, and the public show the stubborn staying power of pathologizing views and practices. In 2015, the Beijing LGBT Center surveyed nearly 1,000 psychiatrists, counselors, and psychologists. About one-third of respondents still believed homosexuality was a disorder, and one-third expressed support for offering “conversion therapy.” In direct contrast to the CCMD-3 “removal” narrative, of the 73 respondents who had conducted conversion therapy, about two-thirds had used CCMD-3 as the diagnostic standard. A 2019 national mental-health-literacy survey found that only one-third of respondents disagreed with the statement “homosexuality is a mental illness.” Generations are changing though. A 2023 survey of roughly 1,000 college students asked them if homosexuality was pathological. Seventy-eight percent responded that it was not.
 
Looking ahead, the “removal” narrative should be replaced with more accurate descriptions such as: “CCMD-3 took a first step toward depathologizing homosexuality by redefining it as ‘not necessarily abnormal,’” or, more concisely, that “CCMD-3 partially normalized homosexuality.”

As for policy change, China has been moving toward adopting the WHO system instead of creating a new version of CCMD. The newest version of the WHO’s classification system, published in 2019, removed “egodystonic sexual orientation” and contains no diagnostic categories based on sexual orientation. Once China officially retires CCMD-3 and fully adopts the newest WHO classification system, China will have fully depathologized homosexuality at the policy level.

This would smooth the way for full depathologization on the ground. For instance, professional ethics codes and educational materials across the whole healthcare sector – including in China’s vast and largely unregulated psychological counseling industry – could then make clear that homosexuality is neither a mental disorder nor a “suboptimal” condition and that conversion therapy lacks a clinical rationale. Only these combined multilevel reforms can give sexual minority people seeking healthcare confidence that they will not be treated as if they need a “cure” for who they are.

This commentary is based on a longer article by the co-authors.