Shutting the Door on “Reparative Therapy”

David M. Keepnews, PhD, JD, RN, FAAN, a CHMP Senior Fellow, is an Associate Professor at the Hunter-Bellevue School of Nursing and the City University of New York (CUNY) Graduate Center. He is Editor of Policy, Politics & Nursing Practice, a journal focusing on nursing and health policy.

The April 11, 2012 issue of The American Prospect includes a compelling article, “My So-Called Ex-Gay Life,” written by Gabriel Arana, who also serves as the publication’s Web editor. Arana reflects on his experiences of being sent by his parents—starting at age 14—for “reparative therapy” to derail him from his homosexuality, while providing important discussion of the broader political and policy context of such “therapy.”

The small band of “reparative therapists,” together with the “ex-gay” movement—individuals who claim to have been converted from homosexuality to heterosexuality—have served as a source of ammunition for right-wing religious groups in opposing equality for Lesbian, gay, bisexual and transgender (LGBT) people. As Arana explains, “Instead of fire-and-brimstone denunciations from the pulpit, the ex-gay movement allowed the Christian right to couch its condemnation of homosexuality in a way that seemed compassionate.”

The claim that Lesbians and gay men can be “reoriented” into heterosexuality relies on discredited beliefs that homosexuality is an illness to be cured, a sin to be eradicated, and/or a lifestyle choice to be changed. “Reparative therapy” is itself often harmful to those who undergo it—a source of psychological trauma, frustration and guilt as they “fail” to be cured of a non-existent illness.

There is a dearth of evidence to support the notion that sexual orientation can be changed. However, for the past decade, the “ex-gay” movement has relied on a study by psychiatrist Robert L. Spitzer, in which he interviewed 200 people who had undergone “reparative therapy.” The study was presented at a 2001 American Psychiatric Association (APA) meeting and published in 2003 in the Archives of Sexual Behavior.

Spitzer’s subjects were self-selected. Most had been recruited through “ex-gay” religious ministries or through a national association dedicated to promoting “reparative therapy.” Spitzer concluded that some Lesbians and gay men are able to convert to heterosexuality through some forms of “reparative therapy” and called for further research on the matter. Along with Spitzer’s article, the Archives published 26 commentaries on his study, some of which criticized his methods and charged that his article could prove harmful.

Proponents of “reparative therapy” seized on Spitzer’s study as proof of its legitimacy. The study attracted widespread attention in part due to the author’s own history: Spitzer had played a central role in the APA’s 1973 decision to remove homosexuality from its Diagnostic and Statistical Manual of Mental Disorders (DSM). His study was spun—perhaps unfairly, but not certainly not surprisingly—into a vindication of claims that homosexuality was “treatable.”

For his American Prospect article, Arana interviewed Spitzer, who expressed regret over how the study was received. He quoted Spitzer: “In retrospect, I have to admit I think the critiques [of the study] are largely correct . . . The findings can be considered evidence for what those who have undergone ex-gay therapy say about it, but nothing more.” Spitzer says he had contacted the editor of Archives of Sexual Behavior about writing a retraction, but says the editor had declined. Spitzer wearily asked Arana if he would print a retraction “so I don’t have to worry about it anymore.”

Much of the buzz about Spitzer’s comments so far has focused whether the Archives of Sexual Behavior should publish a retraction. (On the blog of the International Academy of Nursing Editors [INANE], Leslie Nicoll provides some thoughtful discussion of this matter). And many people have commented on the seeming contradiction presented by Spitzer’s study—that the person credited with removing homosexuality from the DSM later, intentionally or not, provided fodder for professional homophobes.

Actually, that brings me to one small concern with Arana’s excellent and thoughtful article. Introducing his interview with Spitzer, he writes that “Spitzer led the 1973 effort to declassify homosexuality as a mental illness.” By all accounts, Spitzer was instrumental in the APA’s decision to eliminate homosexuality from the DSM. But that decision followed ongoing protest by Lesbian and gay activists who had targeted this issue, most visibly starting with a demonstration at the APA’s 1970 convention in San Francisco. This was a priority for gay rights advocates because they recognized that labeling homosexuality as a mental disorder was not only wrong; it played major role in oppression of and discrimination against Lesbians and gay men.

It might be more accurate to say that Spitzer led the APA’s decision to remove homosexuality as a mental disorder from the DSM—but that it was the gay rights movement that had truly “led the effort to declassify homosexuality as a mental illness.” This may seem like a matter of nuance, but I believe it is more a matter of context. And there is more to this context than the removal of homosexuality as a mental disorder.

Spitzer engineered the removal of homosexuality per se from the DSM, but it was replaced in the revised DSM (known as the DSM-II) by a new diagnosis, “sexual orientation disturbance,” and then in the next revision (the DSM-III) in 1980 by “ego-dystonic homosexuality” (which was later removed in the next revision, the DSM-III-R, in 1987).  These new diagnoses referred to people who were actively distressed by their homosexuality.

Of course, there are two ways of viewing such a disorder (and its “treatment.”) One is to focus on the ego-dystonic part–helping someone adjust to his or her sexual orientation. But the other is to focus on the homosexuality part–offering to “treat” an individual’s distress by changing his/her sexual orientation. Explanatory text in both the DSM-II and the DSM-III made clear that such “treatment” was an option for mental health professionals working with individuals distressed by their homosexuality.

Indeed, some clinicians (who at that time—unlike today—included some respected, reputable ones among their ranks) offered “treatment” to convert Lesbians and gay men. And the DSM-II and DSM-III  continued to lend legitimacy to such “treatment.”

Removing homosexuality from the DSM in 1973 should be viewed for what it was: a compromise. It was unquestionably a major step forward —rejecting the notion that homosexuality is invariably a mental disorder and that all gay people are ill. But replacing it with these new diagnoses still left the door open for those who promised to “cure” homosexuality to claim legitimacy. It took another 14 years to close that door. Unfortunately, Spitzer’s study 7 years after that helped reopen it at least a crack.

From all that I have read about Spitzer’s role in 1973, he was sensitive to the harm caused by listing homosexuality as a mental disorder and acutely aware of the changing social and political context that drove the APA’s decision to remove it.

Spitzer’s recent repudiation of his 2001 study similarly reflects sensitivity to the harm caused by “reparative therapy” as well as, I believe, its changing context. In 2012, this “therapy” stands as marginalized, rejected by major mental health professional groups, and exposed for what it is: homophobia cynically masquerading as treatment and compassion.

So, was his study some kind of lapse? A popular version of Spitzer’s record with regard to homosexuality and psychiatry paints him as a hero who somehow later strayed. But I don’t see it that way. I think his study was consistent with his record of trying to find “balance” or compromise—an approach that may have seemed daring in 1973 but frustratingly conservative (and yes, harmful) in 2001.

But I also think this is precisely what makes his repudiation of that study so significant: In 2012, there really is no middle ground left regarding “reparative therapy.” Its proponents have nothing left to grasp in their claim for legitimacy.

It seems that Spitzer has finally shut that door.

— David M. Keepnews, PhD, JD, RN, FAAN