during the 1970s, the anti-psychiatry movement was involved in promoting restraint from many practices seen as psychiatric abuses. the gay rights movement continued to challenge the classification of homosexuality as a mental illness and in 1974, in a climate of controversy and activism, the american psychiatric association membership (following a unanimous vote by the trustees in 1973) voted by a small majority (58%) to remove it as an illness category from the dsm, replacing it with a category of "sexual orientation disturbance" and then "ego-dystonic homosexuality," which was deleted in 1986, although a wide variety of "paraphilias" remain. it has been noted that gay activists in the 1970s and 1980s adopted many of szasz's arguments against the psychiatric system, but also that szasz had written in 1965 that: "i believe it is very likely that homosexuality is, indeed, a disease in the second sense and perhaps sometimes even in the stricter sense . nevertheless, if we believe that by categorising homosexuality as a disease we have succeeded in removing it from the realm of moral judgement, we are in error." the diagnostic label gender identity disorder (gid) was used by the dsm until its reclassification as gender dysphoria in 2013, with the release of the dsm-5. the diagnosis was reclassified to better align it with medical understanding of the condition and to remove the stigma associated with the term disorder. the american psychiatric association, publisher of the dsm-5, stated that gender nonconformity is not the same thing as gender dysphoria, and that "gender nonconformity is not in itself a mental disorder. the critical element of gender dysphoria is the presence of clinically significant distress associated with the condition." some transgender people and researchers support declassification of the condition because they say the diagnosis pathologizes gender variance and reinforces the binary model of gender. szasz also publicly endorsed the transmisogynist work of janice raymond. in a 1979 new york times book review of raymond's the transsexual empire, szasz drew connections between his ongoing critique of psychiatric diagnosis and raymond's feminist critique of trans women. increased legal and professional protections, and a merging with human rights and disability rights movements, added to anti-psychiatry theory and action. anti-psychiatry came to challenge a "biomedical" focus of psychiatry (defined to mean genetics, neurochemicals and pharmaceutic drugs). there was also opposition to the increasing links between psychiatry and pharmaceutical companies, which were becoming more powerful and were increasingly claimed to have excessive, unjustified and underhand influence on psychiatric research and practice. there was also opposition to the codification of, and alleged misuse of, psychiatric diagnoses into manuals, in particular the american psychiatric association, which publishes the diagnostic and statistical manual of mental disorders. anti-psychiatry increasingly challenged alleged psychiatric pessimism and institutionalized alienation regarding those categorized as mentally ill. an emerging consumer/survivor movement often argues for full recovery, empowerment, self-management and even full liberation. schemes were developed to challenge stigma and discrimination, often based on a social model of disability; to assist or encourage people with mental health issues to engage more fully in work and society (for example through social firms), and to involve service users in the delivery and evaluation of mental health services. however, those actively and openly challenging the fundamental ethics and efficacy of mainstream psychiatric practice remained marginalized within psychiatry, and to a lesser extent within the wider mental health community. three authors came to personify the movement against psychiatry, and two of these were practising psychiatrists. the initial and most influential of these was thomas szasz who rose to fame with his book the myth of mental illness, although szasz himself did not identify as an anti-psychiatrist. the well-respected r d laing wrote a series of best-selling books, including the divided self. intellectual philosopher michel foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. the term "anti-psychiatry" was coined by david cooper in 1967. in parallel with the theoretical production of the mentioned authors, the italian physician giorgio antonucci questioned the basis themselves of psychiatry through the dismantling of the psychiatric hospitals osservanza and luigi lolli and the liberation – and restitution to life – of the people there secluded. challenges to psychiatry civilization as a cause of distress in recent years, psychotherapists david smail and bruce e. levine, considered part of the anti-psychiatry movement, have written widely on how society, culture, politics and psychology intersect. they have written extensively of the "embodied nature" of the individual in society, and the unwillingness of even therapists to acknowledge the obvious part played by power and financial interest in modern western society. they argue that feelings and emotions are not, as is commonly supposed, features of the individual, but rather responses of the individual to their situation in society. even psychotherapy, they suggest, can only change feelings in as much as it helps a person to change the "proximal" and "distal" influences on their life, which range from family and friends, to the workplace, socio-economics, politics and culture. r. d. laing emphasized family nexus as a mechanism by which individuals become victimized by those around them, and spoke about a dysfunctional society. inadequacy of clinical interviews used to diagnose 'diseases' psychiatrists have been trying to differentiate mental disorders based on clinical interviews since the era of kraepelin, but now realize that their diagnostic criteria are imperfect. tadafumi kato writes, "we psychiatrists should be aware that we cannot identify 'diseases' only by interviews. what we are doing now is just like trying to diagnose diabetes mellitus without measuring blood sugar." normality and illness judgments a madness of civilization: the american physician samuel a. cartwright identified what he called drapetomania, an ailment that caused slaves to be possessed by a desire for freedom and a want to escape. in 2013, psychiatrist allen frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests". reasons have been put forward to doubt the ontic status of mental disorders.: 13 mental disorders engender ontological skepticism on three levels: mental disorders are abstract entities that cannot be directly appreciated with the human senses or indirectly, as one might with macro- or microscopic objects. mental disorders are not clearly natural processes whose detection is untarnished by the imposition of values, or human interpretation. it is unclear whether they should be conceived as abstractions that exist in the world apart from the individual persons who experience them, and thus instantiate them.: 13 in the scientific and academic literature on the definition or classification of mental disorder, one extreme argues that it is entirely a matter of value judgements (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms). common hybrid views argue that the concept of mental disorder is objective but a "fuzzy prototype" that can never be precisely defined, or alternatively that it inevitably involves a mix of scientific facts and subjective value judgments. one remarkable example of psychiatric diagnosis being used to reinforce cultural bias and oppress dissidence is the diagnosis of drapetomania. in the us prior to the american civil war, physicians such as samuel a. cartwright diagnosed some slaves with drapetomania, a mental illness in which the slave possessed an irrational desire for freedom and a tendency to try to escape. by classifying such a dissident mental trait as abnormal and a disease, psychiatry promoted cultural bias about normality, abnormality, health, and unhealth. this example indicates the probability for not only cultural bias but also confirmation bias and bias blind spot in psychiatric diagnosis and psychiatric beliefs. it has been argued by philosophers like foucault that characterizations of "mental illness" are indeterminate and reflect the hierarchical structures of the societies from which they emerge rather than any precisely defined qualities that distinguish a "healthy" mind from a "sick" one. furthermore, if a tendency toward self-harm is taken as an elementary symptom of mental illness, then humans, as a species, are arguably insane in that they have tended throughout recorded history to destroy their own environments, to make war with one another, etc. psychiatric labeling "psychiater europas! wahret eure heiligsten diagnosen!" ("psychiatrists of europe! protect your sanctified diagnoses!"), says the inscription on the cartoon by emil kraepelin, who introduced the schizophrenia concept, "bierzeitung", heidelberg, 1896 mental disorders were first included in the sixth revision of the international classification of diseases (icd-6) in 1949. three years later, the american psychiatric association created its own classification system, dsm-i. the definitions of most psychiatric diagnoses consist of combinations of phenomenological criteria, such as symptoms and signs and their course over time. expert committees combined them in variable ways into categories of mental disorders, defined and redefined them again and again over the last half century. the majority of these diagnostic categories are called disorders and are not validated by biological criteria, as most medical diseases are; although they purport to represent medical diseases and take the form of medical diagnoses. these diagnostic categories are actually embedded in top-down classifications, similar to the early botanic classifications of plants in the 17th and 18th centuries, when experts decided a priori about which classification criterion to use, for instance, whether the shape of leaves or fruiting bodies were the main criterion for classifying plants. since the era of kraepelin, psychiatrists have been trying to differentiate mental disorders by using clinical interviews. experiments admitting "healthy" individuals into psychiatric care in 1972, psychologist david rosenhan published the rosenhan experiment, a study questioning the validity of psychiatric diagnoses. the study arranged for eight individuals with no history of psychopathology to attempt admission into psychiatric hospitals. the individuals included a graduate student, psychologists, an artist, a housewife, and two physicians, including one psychiatrist. all eight individuals were admitted with a diagnosis of schizophrenia or bipolar disorder. psychiatrists then attempted to treat the individuals using psychiatric medication. all eight were discharged within 7 to 52 days. in a later part of the study, psychiatric staff were warned that pseudo-patients might be sent to their institutions, but none were actually sent. nevertheless, a total of 83 patients out of 193 were believed by at least one staff member to be actors. the study concluded that individuals without mental disorders were indistinguishable from those with mental disorders. critics such as robert spitzer cast doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement. the challenge of the validity versus the reliability of diagnostic categories continues to plague diagnostic systems. neuroscientist tadafumi kato advocates for a new classification of diseases based on the neurobiological features of each mental disorder. while austrian psychiatrist heinz katsching advises psychiatrists to replace the term "mental illness" by "brain illness." there are recognized problems regarding the diagnostic reliability and validity of mainstream psychiatric diagnoses, both in ideal and controlled circumstances and even more so in routine clinical practice (mcgorry et al.. 1995). criteria in the principal diagnostic manuals, the dsm and icd, are not consistent between the two manuals. some psychiatrists in critiquing diagnostic criteria point out that comorbidity, when an individual meets criteria for two or more disorders, is the rule rather than the exception, casting doubt on the distinctness of the categories, with overlap and vaguely defined or changeable boundaries between what are asserted to be distinct disorders. other concerns raised include using standard diagnostic criteria in different countries, cultures, genders or ethnic groups. critics contend that westernized, white, male-dominated psychiatric practices and diagnoses disadvantage and misunderstand those from other groups. for example, several studies have shown that african americans are more often diagnosed with schizophrenia than white people, and men more than women. some within the anti-psychiatry movement are critical of the use of diagnosis at all as it conforms with the biomedical model, seen as illegitimate. tool of social control whitchurch hospital. according to franco basaglia, giorgio antonucci, and bruce e. levine, whose approach pointed out the role of psychiatric institutions in the control and medicalization of deviant behaviors and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups.: 70 according to mike fitzpatrick, resistance to medicalization was a common