Friday, May 25, 2012

Growing old entails not only the usual geriatric ills, but also the possibility of unwanted career news.  Consider the case of psychiatrist Robert Spitzer, who turned 80 on May 22.

He spent most of his career at Columbia University, where he was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research.  Early on he became concerned about the imprecision of the classification (nosology) of psychiatric disorders.  To address this issue he chaired the task force of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) which was released in 1980.  Despite criticisms, in its successive editions the DSM has become widely accepted, and is frequently cited in support of  insurance claims.

Appearing in the 2007 BBC TV series "The Trap," Spitzer acknowledged that the DSM, by operationalizing the definitions of mental disorders while paying little attention to the context in which the symptoms occur, may have medicalized the normal human experiences of a significant number of people.  The controversy continues, even as a new edition of the DSM is being readied for publication.

In 1973, responding to urgent appeals by gay activists. Spitzer spearheaded the APA's 1973 decision to remove homosexuality from its list of mental disorders.  In charge of the revision of the Diagnostic and Statistical Manual, he pondered whether homosexuality should be included in the manual. He decided against inclusion of the category as such, since mental disorders would be identified by the distress an individual felt or an impairment of functioning. Yet he stipulated  that a listing of "ego-dystonic homosexuality" be included; that is, homosexuality that seemingly causes distress to the individual.  Significantly, there was no category of “ego-dystonic heterosexuality,” a sense reported by some feminist women.

In 2001 Spitzer delivered a controversial paper, "Can Some Gay Men and Lesbians Change Their Sexual Orientation?" at the annual APA meeting.  Spitzer maintained that it is possible that some highly motivated individuals could successfully change their sexual orientation from homosexual to heterosexual. A 2001 Washington Post article indicates that Spitzer held 45-minute telephonic interviews with 200 people who claimed that their respective sexual orientations had changed from homosexual to heterosexual. Spitzer said he "began his study as a skeptic," but the study revealed that "66 percent of the men and 44 percent of the women had arrived at what [Spitzer] called good heterosexual functioning," defined as "being in a sustained, loving heterosexual relationship within the past year, getting enough satisfaction from the emotional relationship with their partner to rate at least seven on a 10-point scale, having satisfying heterosexual sex at least monthly and never or rarely thinking of somebody of the same sex during heterosexual sex." Spitzer also found that "89 percent of men and 95 percent of women said they were bothered only slightly, or not at all, by unwanted homosexual feelings," but that "only 11 percent of the men and 37 percent of the women reported a complete absence of homosexual indicators, including same-sex attraction." The Post reported that "[s]ome 43 percent of the individuals in the sample had been referred to Spitzer by 'ex-gay ministries,'" while "an additional 23 percent were referred by the National Association for Research and Therapy of Homosexuality." NARTH is well known for its opposition to homosexuality.

Two years later the paper was peer reviewed and published in the Archives of Sexual Behavior. Two-thirds of the reviews were critical targeting its sampling methods and criteria for success.

Finally, in a 2012 interview, Spitzer said he asked to retract the study, stating that he agreed with its critics:

"In retrospect, I have to admit I think the critiques are largely correct," he said. "The findings can be considered evidence for what those who have undergone ex-gay therapy say about it, but nothing more." He said he spoke with the editor of the Archives of Sexual Behavior about writing a retraction, but the editor declined.

In a letter to Kenneth J. Zucker, editor of Journal of Sexual Behavior, Spitzer wrote:

“Several months ago I told you that because of my revised view of my 2001 study of reparative therapy changing sexual orientation, I was considering writing something that would acknowledge that I now judged the major critiques of the study as largely correct. After discussing my revised view of the study with Gabriel Arana, a reporter for American Prospect,',and with Malcolm Ritter, an Associated Press science writer, I decided that I had to make public my current thinking about the study. Here it is.

Basic Research Question. From the beginning it was: “can some version of reparative therapy enable individuals to change their sexual orientation from homosexual to heterosexual?” Realizing that the study design made it impossible to answer this question, I suggested that the study could be viewed as answering the question, “how do individuals undergoing reparative therapy describe changes in sexual orientation?” – a not very interesting question.

The Fatal Flaw in the Study  There was no way to judge the credibility of subject reports of change in sexual orientation. I offered several (unconvincing) reasons why it was reasonable to assume that the subject’s reports of change were credible and not self-deception or outright lying. But the simple fact is that there was no way to determine if the subject’s accounts of change were valid.

“I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some “highly motivated” individuals.”

I admire Dr. Spitzer for his honesty and integrity in making this avowal.  He could have kept silent, but he did not.  This is a salutary lesson.

[For an earlier account of Robert Spitzer and the DSM, see]


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