BMJ  2004;328:E287-E288 (17 April), doi:10.1136/bmj.328.7445.E287

BMJ USA: Editorial

Editorial

The pseudoscience of sexual orientation change therapy

An "old" problem with relevance today

In the United States, as in Britain, homosexuality was medicalized and then pathologized in the early part of the last century. The diagnosis of homosexuality as a disease was based on untested and unproven theoretical psychoanalytic concepts that evolved in the Victorian era and were supported by religious doctrine. This led to the application of the physically and emotionally painful, and ultimately, harmful treatments described in the two articles published in this issue of BMJ USA (pp 155, 158). That such intrusive, dehumanizing treatments were even tolerated in the medical profession is testimony to the powerful social stigma and moral indignation surrounding homosexuality.

In the absence of equal rights for gay and lesbian people, social customs and religious institutions will continue to create unhealthy social conditions for people who come to accept their sexual orientation.

In 1957, American psychologist Evelyn Hooker, using validated and reliable psychological testing methods, demonstrated that reputable psychologists blinded to the sexual orientation of the participants could not distinguish homosexual men from those who were heterosexual.¹ This evidence, refuting the psychoanalytic view that homosexual men were either psychotic or arrested at very primitive stages of psychological development, led to more studies that examined whether homosexuality met scientific criteria for anything other than a variant of normal human behavior. Animal and anthropological studies lent further credence to the growing awareness that homosexuality exists across species, cultures, and time. The Kinsey Institute, in a study comparing thousands of homosexual and heterosexual people, debunked the myth that any particular family constellation could account for the presence of a homosexual child.² Whether homosexual orientation is mediated more by nature or nurture, no evidence to date suggests that from a social or psychological perspective homosexuality is anything more than a minority variant in the development of the human species.

In 1973, the American Psychiatric Association removed homosexuality from their Diagnostic and Statistical Manual as psychopathology, for lack of any replicable scientific evidence that same-sex orientation, as such, met criteria for a mental disorder.³ Despite this reclassification, clinicians invested in unproven theories continued to offer treatments to anxious and frightened homosexuals who had internalized self-loathing and fears of divine retribution for feeling and sometimes acting on their same-sex attractions. While the American Psychiatric Association, the American Psychological Association, the National Association of Social Workers, and the American Medical Association all adopted non-pathological views of homosexuality, the American Psychoanalytic Association was relatively late in depathologizing homosexuality.⁴

As the non-patient population of same-sex oriented people became more visible, mental health professionals were able to see that many of the difficulties gay and lesbian people had were a product of social stigmatization and a lack of equal protection under the law, rather than from some intrinsic quality of being homosexual. In spite of every mental health and medical association in the US stating unequivocally that there is no scientific evidence that homosexuality is a disorder, many religious organizations continue to declare homosexuality or homosexual behavior as sinful and immoral. This creates spiritual crises for many people who have grown up within anti-homosexual religious families and communities.

Homosexuals are ostracized by society, often abandoned by their families after "coming out," and omitted from civil rights protection under the US Constitution. It is thus not surprising that some gay and lesbian people flock to therapists who hold out promise of being able to "re-orient" the homosexual person. These practices and the ethical violations accompanying them have been well documented.^5,6

Gay-affirmative therapies have been developed to help people adjust to their internal awareness of being same-sex oriented. As more gay and lesbian people have come out, however, reaction by intolerant people has contributed to the alarmingly high rates of violence towards gay and lesbian people that persist today in many areas of the US, as manifested in the murder of Matthew Shepard and others. The suicide rate among same-sex oriented teens in the US continues to be more than three times that of heterosexual teens.⁷

The present legal and social discourse on same-sex marriage in the US demonstrates how deeply held religious beliefs conflict with the ethical principles affirming equal rights for all Americans. In the absence of equal rights for gay and lesbian people, social customs and religious institutions will continue to create unhealthy social conditions for people who come to accept their sexual orientation. Mental health and physical health are inextricably interwoven with civil rights and internalized beliefs of equality with others. Society must not be allowed to use pseudoscience to justify controls on the behavior and interpersonal relationships of those who are same-sex oriented.

The Cambridge Health Alliance
Assistant Professor of Psychiatry
Harvard Medical School
Cambridge, MA mforstein{at}challiance.org

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Papers pp 155, 158

Competing interests: MF was president of the Association of Gay and Lesbian Psychiatrists from 1990 to 1992.

References

1. Hooker E. The adjustment of the overt male homosexual. J Proj Tech 1957;21: 18-31.
2. Bell AP, Weinberg MS, Hammersmith SK. Sexual preference: its development in men and women. Bloomington, IN: Indiana University Press, 1981.
3. Bayer R. Homosexuality and American psychiatry: the politics of diagnosis. Princeton, NJ: Princeton University Press, 1987.
4. Domenici T, Lesser RC, eds. Disorienting sexuality: psychoanalytic reappraisals of sexual identities. New York, NY: Routledge, 1995.
5. Haldeman DC. The practice and ethics of sexual orientation conversion therapy. J Consult Clin Psychol 1994;62: 221-227.[CrossRef][ISI][Medline]
6. Forstein M. Overview of ethical and research issues in sexual orientation therapy. J Gay Lesbian Psychother 2001;5: 167-179.
7. Remafedi G, Farrow JA, Deisher RW. Risk factors for attempted suicide in gay and bisexual youth. Pediatrics 1991;87: 869-875.[Abstract/Free Full Text]

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