Robert L Spitzer is one of the giants of modern Psychiatry, a scientific philosopher as much as a hands-on medical man. He’s been a fearless opponent of too-easily-accepted givens, notably challenging some of David Rosenhan’s conclusions in his 1973 study, On Being Sane in Insane Places. However, Spitzer really made his mark by leading the campaign to have homosexuality removed from the Diagnostic & Statistical Manual (DSM) as a psychiatric disorder – which it was in 1973.
So the news last week that Spitzer had ‘recanted’ a study he had carried out in 2000-2001 and had published in 2003 caught my eye – especially as I had referenced that same study in a lengthy letter I had published in Therapy Today, the journal of the British Association of Counselling & Psychotherapy, in 2009. My letter, titled ‘An Imposed Etic’, was published as ‘An Imposed Ethic’ – presumably the editor thought ‘etic’ was a spelling mistake and didn’t get the sense I was trying to convey through the use of the term ‘imposed etic’. My point was that particular, localised values and norms were being applied as though they were universals, without empirical justification.
I had been somewhat concerned by John Daniels’ article, ‘The Gay Cure?’, in the previous issue of Therapy Today, and had written ‘An Imposed Etic’ in response. Daniels’ article was based almost entirely on an interview with Michael King of University College London. On the back of a research project he had been involved with – Annie Bartlett, Glenn Smith & Michael King (2009) – King was expressing concern and dismay at the number of therapists in the UK – 17% of the sample surveyed – who had been involved in helping at least one gay man or lesbian reduce their homosexual feelings. 4% of the respondees had said they would try to cure homosexuals of their homosexuality if asked.
As a therapist, I fell into the 17%. At the time I was supporting a bisexual man on the verge of returning to his native country where homosexual practices were not only not accepted by the majority of the population but could potentially carry the death penalty. He had begged me to help him – though I had stressed there was no known ‘cure’ for homosexuality and that all I could do – perhaps? - was help him reduce his homosexual tendencies and increase his heterosexual ones…if he wanted that badly enough.
The Spitzer Study
Unsurprisingly, then, I took a keen interest in Daniels’ article. What really concerned me was King’s dismissal of the claims of NARTH (National Association for Research & Treatment of Homosexuality) to help around 66% of gay men and 44% of lesbians achieve ‘good heterosexual functioning’ (Spitzer, 2003).
NARTH had actually been founded by Charles Socarides, one of Spitzer’s leading opponents in the 1973 debate on whether homosexuality should still be classified as a mental illness. 25 years later Spitzer’s penchant for controversial positioning led him to investigate whether gay men and lesbians could be ‘cured’ of their homosexuality through ‘reparative therapy’. This was a time when the trend in the Western psychological research communities increasingly was to state that, not only was there no validated cure for homosexuality but also that there was no need for a cure as homosexuality was perfectly natural and normal for those who were homosexual. (The spread of the ‘homosexuality is OK’ meme throughout the West in the second half of the 20th Century is a remarkable example of memetic viral infection.)
Spitzer recruited 200 men and women from centres involved in reparative therapy, including NARTH and Florida-based Exodus International. He interviewed each in depth over the phone, asking about their sexual urges, feelings and behaviours before and after having the therapy, rating the answers on a scale. He then compared the scores on this questionnaire, before and after therapy. “The majority of participants gave reports of change from a predominantly or exclusively homosexual orientation before therapy to a predominantly or exclusively heterosexual orientation in the past year,” Spitzer concluded.
Spitzer’s study was certainly vulnerable to a number of methodological criticisms. Firstly, his sample was not a random sampling of gay and lesbian individuals or even a random sampling of gay and lesbian individuals who had experienced reparative therapy. The ‘volunteers’ were put forward by Exodus International and NARTH and included some ‘ex-gay’ advocates who were politically active. Secondly, some of the answers to Spitzer’s questions were based on what people remembered feeling years before – a notoriously unreliable method of investigation. Finally, Spitzer’s investigation did not test any particular therapy; only half of the participants engaged with a therapist at all, while the others worked with pastoral counsellors or in independent Bible study.
Such were the problems with the study that it took Spitzer 2 years to find a journal which would publish it: Archives of Sexual Behaviour. Even then, at the editor’s insistence, criticisms were published alongside the study as a commentary on it.
Around the same time and with a similar sample size (202), Michael Schroeder & Ariel Shidlo (2002) found 14% of their participants did manage long-term to either greatly reduce or completely stop homosexual practices. Of these, 5% were ‘struggling’. Another 5% reported being reasonably happy (almost all of this group were celibate). Only 4% (ie: 8 participants) reported a shift in sexual orientation from 5 or more to 3 or less on a 1-7 scale of hetero/homosexual balance. Of these, the only ones who could perhaps be classified as ‘ex-gays’, 7 out of 8 put down as occupation that they were ‘ex-gay’ counsellors and so could be accused of having a vested interest in the ‘success’ of reparative therapy.
In spite of the heated controversy around Spitzer’s study and the quite different findings reported by Schroeder & Shidlo, Spitzer’s findings were seized on by the ‘religious right’ as ‘proof’ that homosexuality could be cured and, therefore, it could not be defended as ‘natural’ or ‘God’s will’. Since the publication of the study, critics (some professional researchers but mostly gay political activists) have consistently and loudly scorned it. Spitzer himself has repeatedly bemoaned his findings being taken out of context and/or wilfully misinterpreted. Thousands – perhaps, tens of thousands – of people have been ‘treated’. Many indeed claim to have been cured; but others have spoken of the treatment failing, some of having their lives ruined and some that it had driven them to a suicide attempt.
So Spitzer’s ‘recanting’ and apologising for the misery his 2003 study had contributed to is news indeed. Now 80, retired and suffering from Parkinsons’ Disease, Spitzer was struck by guilt one night lying in bed recently and got up to write his letter of recantation. (Spitzer’s disquiet with his study had been building for several years; and thing finally came to a head following a meeing with Gabriel Arana, a gay journalist who had suffered significantly as a result of failed reparative therapy.) His letter, to be published in Archives of Sexual Behaviour where the study had been published 9 years earlier, is one of the most sincere and heartfelt apologies ever offered by a major figure in the world of Psychiatry or Psychology.
Unfortunately, while Spitzer’s apology might help assuage whatever sense of guilt is being produced by his BLUE and GREEN vMEMES working as a vMEME harmonic, it does nothing to help us resolve the issue of whether reparative therapy might work for some.
Is Spitzer’s Study really that bad?
For sure, Spitzer’s 2003 study has serious weaknesses. For one thing, it’s a relatively small sample size which makes it dangerous to generalise from. Schroeder & Shidlo’s sample group was no bigger yet gay political activists use it with abandon to bash Spitzer.
Secondly, Spitzer’s findings were based on self-reporting. King dismisses them, saying: “There’s no collateral evidence that they’ve changed.” So, is he calling the volunteers who talked with Spitzer liars? Anyone who’s been involved in analysing self-report work will know just how untrustworthy it can be. But how do King and similar critics know Spitzer’s volunteers were lying? Are they now the arbiters of people’s private experience – ie: they can tell people what they think and feel?
Unfortunately, Spitzer seems to have been infected with a similar meme to King. A key point in his letter of apology is that he believed the self-reporting of people who may have been motivated to deceive him. They indeed may have had such motivations; but how does Spitzer know they actually did lie to him?
Thousands of psychological studies have used self-reporting - the famous and much-cited Love Quiz is just one – and most researchers regard self-reporting as especially dubious when people are asked to recall things from the past. But, while it’s highly advisable to be cautious about the findings from self-reporting, if that’s the only data collection method employed, then that’s all the researcher can go on. It’s a serious design flaw in Spitzer’s study that he only had the one method and it’s another serious flaw that he didn’t control for sample bias – but neither of those criticisms automatically invalidates Spitzer’s findings. They do mean that his findings need to be treated with caution.
As for the much-vaunted Schroeder & Shidlo invesitagation…er, hang on: didn’t they use self-reporting?!?
A good many key pieces of research in the history of Psychology have contained similar flaws to those of Spitzer. Indeed, if we take the view of Karl Popper (1969), then it is impossible to be free of bias as soon as you decide what the issue is, theorise or choose the variables to study.
It can’t be anything other than highly creditable that Spitzer is finally and openly acknowledging the weaknesses in his study; but perhaps he’s going further than he really needs to in recanting it…?
Religion, Homosexuality and Bias
Religion and homosexuality are two topics that, when put together, seem to predicate bias. As most of the major religions – at least in their fundamentalist versions – declare homosexuality to be a ‘sin’, it’s hardly surprising that gay political activists and liberal sympathisers campaign against religious organisations that take such a view. Nor is it surprising that some of that campaigning is vociferous and sometimes even violent. Homosexual activity in some countries can lead to imprisonment and even the death penalty, so it’s no wonder that gay men and lesbians (and their heterosexual sympathisers) feel strongly about these things. Wellbeing, the freedom to be who you are and sometimes even your life are at stake.
In the 2009 Therapy Today article, King, a homosexual, articulates his personal biases very clearly indeed: “My hope is that homosexuals and heterosexuals will become indistinguishable.”
Such a strong bias may well have coloured King’s ability to approach Spitzer’s study impartially. He makes a somewhat convenient distinction between sexual behaviour and sexual orientation. So a Spitzer volunteer could be enjoying heterosexual relations in terms of behaviour but inside they’re still a homosexual? If so, then that is a level of self-deception that could be described in terms of Sigmund Freud’s defence mechanism of reaction formation (Anna Freud, 1936). In other words, you act out the opposite of what you unconsciously are. There are documented examples of repressed homosexuals acting out as heterosexuals – famously in the study by Henry Adams, Lester Wright & Bethany Lohr (1996) in which homophobics were found to be turned on by homosexual pornography. But how does King know for fact such self-deception applies in the case of those of Spitzer’s volunteers who were having heterosexual relationships?
The general consensus among research professionals is that reparative therapies don’t work and, according to a new Pan American Health Organisation report, may even be dangerous. Some American state legislatures, such as California, are proposong banning reparative therapy. It is now illegal in the UK to use certain types of therapy, such as Aversion Therapy, for the purposes of ‘curing’ homosexuals.
Personally I’ve no idea how effective or dangerous reparative therapies are. However, there is a variable that King and other researchers like him seem to miss: the power of faith. (It’s not clear if Spitzer missed that one as well.)
To declare my own bias: in my youth, I was a Bible-bashing fundamentalist Christian who believed I had personal dialogue with Jesus, that miracles really did happen, and that I would be one of the righteous who would be saved at the Second Coming. I’ve long since lost that faith – but the memory of it has stayed with me: the sheer sense that God is with you and you are doing his will can create the most incredible determination.
It’s a personal anecdote, of course; but, if we’re to value Carl Rogers’ (1959) phenomenological approach, it counts. I have no problem understanding why radicalised young Muslims become suicide bombers: they know they are doing God’s will – and that gets them through all the barriers that would stop someone without that determined faith. ‘Altruistic suicide’, in terms of Émile Durkeim’s (1897) classic study of suicide. When you believe to that degree, nothing is more important than doing God’s will.
For the believer, it may work something like this: if, for today I am doing God’s will by using reparative therapy to keep me from a gay lifestyle, well, the most important part of my identity is that I am a faithful person to my God. If I’m actually able to have a heterosexual relationship of some kind, well, how much the better! Of course, there may be inner turmoil and repressed homosexual desires; but, in countries where homosexuality is despised culturally and subject to severe legal punishment, a ‘forced’ heterosexuality, in which I can at least take pride that I am fulfilling my duty to my God, may well be the better option.
Even in this country there are considerable pockets of resistance to the idea that homosexuality is not abnormal. Life for those who find themselves to be gay and lesbian is often very, very difficult. They do need our support and, preferably, our encouragement to accept themselves for who they are – but not all will be able to do so. For a variety of reasons including social and family pressures, some will become desperate to be ‘not gay’. And, in other parts of the world, it is socially (and legally) impossible for them to accept themselves as gay – their culture tells them it’s wrong and their legal system persecutes them for it.
If organisations like Exodus International and NARTH say they can make a difference, then researchers need to investigate but considering it as an emic – a possible phenomenon specific to those people in those contexts – without imposing their own values on what they find. ‘Making a difference’ needs to be seen in terms of what it means for the highly-religious and supposedly-converted homosexual in their society – their take on it – not what ‘difference’ means to openly gay men and lesbians clearly pushing a ‘gay agenda’ in cosmopolitan London or multi-cultural Leeds. If we take the phenomenon outside of its own context and judge it against what is found in different contexts, then it may well be found to lack the magic it has in its own context. By judging it against our own emics, we risk that old cross-cultural demon: the imposed etic.
Before reparative therapy is banned and legislated against, research needs to establish whether it may work for a small number of ‘natural’ homosexuals who develop a areally strong religious faith. If it does, as Spitzer declared in 2003, then maybe some degree of rethink about reparative therapies may be needed. If we ban reparative therapies without knowing whether they may be successful in a small number of extreme circumstances, then we deny some people the possibility of a choice that could make the difference between some kind of acceptable life and no life worth living at all – or even no life (literally!) at all.