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American Sex and American Psychiatry

"Excessive time" thinking about sex considered a sign of Hypersexual Disorder.

Two weeks ago, on her show on MSNBC, Rachel Maddow included a segment about former DSM editor Robert Spitzer’s strange connection to the Ex-Gay Movement that raised fresh and troubling questions about a controversial article the influential psychiatrist published in 2001. Twenty-eight years after spearheading the American Psychiatric Association’s move to declassify homosexuality as a mental illness, one that conservative psychiatrists angrily opposed at the time, Spitzer published an article in Archives of Sexual Behavior claiming that, for highly motivated individuals, ex-gay therapy worked.

When the article appeared, the Associated Press (noting Spitzer’s earlier influence in declassifying homosexuality) called it “explosive.” In the years that followed, during which the Ex-Gay Movement seized on its “findings,” the article was likened to “throwing a grenade into the gay community.” Since branded as truth countless times over the past decade, its influence has become incalculable.

The only problem with the article? It just came to light that it relied exclusively on the testimony of patients whom Spitzer had personally "recruited," who were already identified with prominent ex-gay groups such as Exodus and NARTH (short for the National Association for Research and Therapy of Homosexuality) and thus far from an unbiased or representative sample. Consequently, the position that Spitzer presented as neutral, even scientifically sound, in the article was in truth a great deal closer to the propaganda that Ex-Gay Ministries still like to distribute, including to supportive politicians and religious leaders, insisting that one can “pray away the gay”—that sexuality can more or less take the form that an individual wants it to.

Spitzer's awkward professional disclosure, more than a decade after the essay appeared, is itself newsworthy and came to light in a recent article in American Prospect, “My So-Called Ex-Gay Life,” in which reporter Gabriel Arana movingly describes the repeated failure of Ex-Gay Ministries to change his own orientation, despite his fervent wish at the time to not be gay—and despite Spitzer's representing him in the article as a success story for orientation conversion. The article also features a brief interview with Spitzer, also filmed, in which the former DSM editor at last took the opportunity to recant the article and publicly acknowledge its egregious flaws:

“I actually had great difficulty finding participants,” Spitzer recalls in recollection of the study on which he reported in 2001. “In all the years of doing ex-gay therapy," Spitzer continues, "you’d think [Dr. Joseph] Nicolosi would have been able to provide more success stories. He only sent me nine patients.” (The article claims that its argument came from telephone interviews with "200 self-selected individuals.") Even more troubling, it seems Spitzer had welcomed such findings because of the "controversy" they would cause.

The following three paragraphs appear verbatim in the essay by Arana (who has since married another man), and are worth reproducing in full given their broader implications:

Spitzer was drawn to the topic of ex-gay therapy because it was controversial—“I was always attracted to controversy”—but was troubled by how the study was received. He did not want to suggest that gay people should pursue ex-gay therapy. His goal was to determine whether the counterfactual—the claim that no one had ever changed his or her sexual orientation through therapy—was true.

I asked about the criticisms leveled at him. “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. (Repeated attempts to contact the journal went unanswered.)

Spitzer said that he was proud of having been instrumental in removing homosexuality from the list of mental disorders. Now 80 and retired, he was afraid that the 2001 study would tarnish his legacy and perhaps hurt others. He said that failed attempts to rid oneself of homosexual attractions “can be quite harmful.” He has, though, no doubts about the 1973 fight over the classification of homosexuality.


I was thinking about the American Prospect article as I read an eloquent Open Letter to the APA from psychiatrists and forensic psychologists deeply concerned about the current bid to expand the list of paraphilias in the DSM to include “hypersexual disorder,” “pedohebephilia,” and “paraphilic coercive disorder.” Drafted by Richard Wollert and reported on by fellow PT blogger Karen Franklin, the Letter declares: “The expansions would be a major mistake, due to poor reliability, unproven validity and—most of all—the potential for vast and harmful unintended consequences.”

Let’s consider a few of those unintended consequences, since the APA task force seems intent on putting hypersexual disorder in the Appendix to the DSM-5, more or less regardless of the outcry, some of which stems from the proposal’s questionable rationale and extraordinarily open-ended language:

The first listed criterion for hypersexual disorder is as follows: "Excessive time is consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior."

“Excessive time”? What exactly does that mean, and according to whose standards? That's not a small or trivial matter to settle when the APA is talking in vague generalities about the nation’s libido—how much sex it wants and how much sex the APA thinks it should think about wanting. The APA is talking about how much time Americans can devote to sexual fantasy before it suggests that we’re mentally ill if our preoccupations are stronger than those set by the relevant task force.

Does that initiative seem to overreach a bit, even to the point of sounding almost Orwellian? It does so to me. If we're to have criteria, are quotas next, including for fantasy? It’s as if the East Coast offices of the APA had morphed into those of the Thought Police in Orwell's 1984, warning citizens that they’d overstepped their "sexual thought quota" for the week and must be rationed—or punished accordingly.

“Even if you were in favor of creating such a disorder,” I tried to explain in a recent interview in The Sun Magazine, voicing doubt about the APA's blanket claims, “would the parameters for young adults really be the same as for retirees with, most likely, much lower sex drives? Would the standard for ‘excessive’ sexual activity be identical for a newly formed relationship and for one that’s lasted decades? Why should we see a man’s cheating on his wife as a result of brain chemistry rather than, say, marital unhappiness or personal recklessness?… We need broader public discussion of th[ese] complex issue[s] rather than the kind of psychiatric judgment and ritualized shaming that goes on right now for those who prefer to remain nonmonogamous. Good for them if that’s what they want."

As for the move to call Hebephilia a paraphilia, and thus a mental disorder? The word designates an attraction to adolescents, even to those quite able to give their legal consent. It's an archaism, a throwback literally to 19th-century psychiatry, but refers to practices that were as central to the Classical age—and thus to Western democracy—as were Socrates, Plato, and especially Plato’s Symposium, one of the foundational books in the West on eros and love. Yet as one scholar noted recently in an article on the DSM proposal published in Behavior Sciences and the Law, “Prior to the advent of contemporary sexually violent predator laws, the term [Hebephilia] was not found in any dictionary or formal diagnostic system. Overnight, it is on the fast track toward recognition as a psychiatric condition meriting inclusion in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.” The abstract is quoted in Franklin’s excellent piece “Hebephilia Controversy,” which elaborates further on the DSM proposal and the controversy it’s igniting.

As Dr. Wollert puts it in his letter, a “large number of industrialized countries [put] the age of sexual consent [at] 14 (Green, 2010).” The APA may be working in an American context, but the influence and reach of the DSM extends to a significant number of other industrialized countries, which presumably will be asked to import the APA’s spurious and ambiguous criteria. Next thing we’ll know, entire countries will be asking the APA to define how many times their citizens can think about sex.

Given the task the APA has set itself, is it any surprise, as Franklin reports, that “the British Psychological Society, the American Counseling Association, and the Society for Humanistic Psychology and many other divisions of the American Psychological Association have all submitted petitions or letters of concern to the American Psychiatric Association regarding revisions proposed for the DSM-5”? “These documents,” she writes, “express concerns about the lack of empirical support for many DSM-5 proposals, the likelihood of ‘false-positive epidemics’ flowing from decreased diagnostic thresholds, and the negative effects of "over-medicalizing" human behavior. They also point out that the prevention of false-positive epidemics should take precedence over ‘nomenclatural exploration’ and that the temptation to adopt new diagnoses should be tempered by the recognition that diagnostic labels tend to be confounded with normative social expectations.”

The APA is already trying to determine how long normal grief should last before it’s thought pathological. Its brisk, jaw-dropping answer: two weeks. Do we really want the same organization dictating how often we can think about sex? These kind of proposals can only end badly.

The Open Letter appears here. Updates on Spitzer's recanting and apology: New York Times, The Guardian.  Follow me on Twitter: @christophlane