In 1973, when Columbia University psychiatry professor Robert Spitzer, M.D., chaired the committee that oversaw the revision of the first edition of APA’s Diagnostic and Statistical Manual (DSM), he brought to the APA Board of Trustees the controversial proposal that homosexuality should be dropped as a psychiatric diagnosis.
Spitzer stressed that there were no valid data linking sexual orientation to mental illness and that studies showed that homosexuals functioned just as well as heterosexuals.
The Board overwhelmingly agreed with Spitzer, and when DSM-II appeared, only the concept of ego-dystonic homosexuality remained as a way to categorize those who were unhappy with their sexual orientation. That diagnosis, whose inclusion was also proposed by Spitzer, was deleted from the next edition of the diagnostic manual.
Now 28 years later, Spitzer has ignited a controversy involving the same topic, and it has become the focus of media attention throughout the country.
Speaking at APA’s 2001 annual meeting in New Orleans in May, Spitzer maintained that so-called reparative psychotherapies can and have successfully changed homosexuals into heterosexuals and that he has the data to prove it.
Spitzer’s position runs counter to that of APA and other major medical and mental health organizations, which are on record rejecting the notion that "reparative" therapies do what they claim. To date there have been no rigorous scientific studies that validate the notion that sexual orientation is mutable, even after psychotherapy. The only "evidence" is from anecdotal reports of "cures" or of being harmed by such attempts at therapy.
His contention, which was reported in major print and broadcast news media within a day of the May 9 annual meeting presentation, has provoked heated responses from psychiatrists, mental health professionals, gay and lesbian activists, and others.
Spitzer based his conclusions on a telephone survey he conducted of 153 men and 47 women who sought to change their sexual orientation through conversion therapy or an "ex-gay ministry." Subjects, who were identified by reparative therapists, an ex-gay ministry called Exodus, and radio and print notices, were given a structured interview asking about their sexual orientation before and after therapy. The interview consisted of 112 closed-ended and nine open-ended questions. Spitzer is submitting the study to various journals for publication.
He reported that the survey results showed that "some" of these individuals were able to alter their sexual behaviors and fantasies as a result of their participation in these reorientation programs and that they had maintained that shift for at least five years. He indicated that about 66 percent of the men respondents and 44 percent of the women were able to function as heterosexuals after the therapy. Almost all of them, he acknowledged, were extremely religious individuals who were "highly motivated" to change their sexual orientation.
About 90 percent of the respondents indicated that they were only slightly or not at all troubled by the intrusion of homosexual thoughts or feelings, though 89 percent of the men and 37 percent of the women said they still had some degree of same-sex attraction.
The therapist these subjects turned to most often was a psychologist (23 percent); only 3 percent said their therapy was provided by a psychiatrist.
Spitzer explained in a summary of his presentation that "the subjects’ self-reports of change appear to be, by and large, valid, rather than gross exaggerations, brain washing, or wishful thinking." He added that his survey "provides no information as to how frequently such changes are possible," and cautioned that his conclusions should not be "misused to justify coercive treatment". He noted that his subjects did not constitute a study population representative of the gay and lesbian population in the U.S.
Jack Drescher, M.D., a psychiatrist and psychoanalyst in New York City who was also on the annual meeting panel, took strong exception to Spitzer’s position.
"The question of whether some people can change their sexual behavior has never been in doubt, and it is a misrepresentation to claim there is ‘another side’ saying that no one can change," he said in an interview with Psychiatric News. "Spitzer has set up a straw man with whom he’s now arguing."
In addition, Spitzer’s "focus on people who claim to have changed their sexual orientation does not address the larger issue, which is how to distinguish patients who may be able to change their sexuality from those who cannot and are often harmed" by their "treatment," said Drescher, who was one of the authors of APA’s 2000 position statement on therapies to change sexual orientation (see box).
Drescher is concerned about the harm that patients can suffer after going through some of the conversion therapies, an issue not addressed in Spitzer’s selective patient sample.
"Religious reparative therapies, like the faith healing from which they are derived, are a treatment modality that purports to provide definitive answers regarding human nature and sexuality. They always define homosexuality as wrong and require that individuals trying to change their sexual orientation submit to the therapist’s authority as a condition of treatment," he said in his annual meeting presentation.
In the type of interventions Spitzer assessed, "it is the client’s compliance with the therapist’s authority, rather than the therapist’s interpretations, that will determine the outcome of treatment," Drescher suggested. "This is a clinical stance with troubling ethical implications."
Spitzer’s report was startling enough that at least 30 newspapers and news magazines, 14 television programs, and 26 radio shows reported on the annual meeting presentation. Major wire services and Internet health sites also covered the session. Almost all of them emphasized the controversy his report sparked in light of his involvement in the DSM depathologizing of homosexuality and how conservative religious groups are leaping to his defense, while the medical community, as well as gay and lesbian advocates, are condemning it for being shoddy science and an attempt to further stigmatize people who are not heterosexual.
Spitzer told Psychiatric News that while he was not surprised that the media were intrigued by his paper, he was "flabbergasted" by how extensive the coverage turned out to be.
"I am happy that people were taking note of the presentation," he said. "It confirms what I’ve said, namely, that there is a lot of media interest in the idea that once a homosexual, always a homosexual."
He was disappointed, however, that many reports overlooked his statements explaining that his sample was limited and that he was not maintaining that a substantial number of gays and lesbians could become straight if they sought reparative therapy. "For the vast majority it is not possible for them to change their sexual orientation," he said.
Spitzer also acknowledged that "a lot of people will misuse" his findings, which could cause pain for many individuals. "It may help 5,000 people, but harm 500,000," he said. He is concerned, he added, that "the Christian right," with its intolerance of and opposition to homosexuality, will use his findings in its campaign to prevent gays and lesbians from gaining civil rights protections.
His goal, he pointed out, is "to open a dialogue between the people who do [conversion] therapies and the gay and scientific communities" who do not believe these therapies are of any value. "That dialogue is not likely to happen," he acknowledged.
APA issued a press release at the annual meeting in which Medical Director Steven Mirin, M.D., emphasized that "APA maintains there is no published scientific evidence supporting the efficacy of reparative therapy as a treatment to change one’s sexual orientation."
The press release points out that APA does not endorse annual meeting presentations and that many papers presented at the meeting "have not been subject to traditional peer review, nor have they been published in the scientific literature."
More information about APA’s position on therapies that attempt to change sexual orientation is available on the Web at www.psych.org/pract_of_psych/copptherapyaddendum83100.cfm. ▪