The case against reorientation treatment
A reply to Dr Avshalom Elitzur
Ronete Cohen MA, Psychologist*
Several months ago, The Israeli Association of Sex Therapists (ETAM) invited Dr. Avshalom Elitzur to lecture at a symposium. The lecture focused on support for re-orientation treatment for homosexuals, and generated a wave of reactions. The event was first reported in a poorly researched and inaccurate article in the popular press. As a result, some homosexuals (and parents of young homosexuals) sought therapists who would “turn them straight” while others warned that his views were biased, dangerous and based on bad science. The press story was discussed in many online communities and effectuated a lot of feedback, mostly emotional. This paper, in contrast, analyses Elitzur’s claims and syllogisms using scientific and analytic criticism and shows they are without merit.
Elitzur has since strongly defended his viewpoint and claims the campaign against him is both unjustified and personal. He insists that he wants the best for those who are dissatisfied with their sexuality, and that denying him the right to promote reorientation is actually causing them harm. What Elitzur perceives as a personal attack is a legitimate attempt to determine whether or not he has the relevant professional and scientific know-how. This paper shows that what he claims to be the best option is not only ineffective, but can also be harmful. He tries to prove that the opposite is true, but does so based on the misinterpretation of bona fide scientific sources and a large amount of biased information from invalid sources. Providing reorientation treatment on such a basis goes against the ethics of the professional bodies concerned: it is an uncontrolled experiment that could cause the participants serious damage.
After providing some background information about reorientation treatment and its origins, I will specifically address the points raised by Elitzur in support of reorientation treatment. I will refute his arguments by showing that the outcome of scientific research contradicts Elitzur’s claims, and by exposing instances of unscientific and unreliable sources, poor methodology and selective and misleading citations. I will finally show that Elitzur’s case is invalid, that he is not qualified to pass judgement on such issues, that reorientation treatment is ineffective and that ETAM were wrong to give him a platform that lent his words an undeserved cachet.
What is reorientation treatment?
Sexual reorientation treatment is a relic from the time when homosexuality was thought to be an illness, and it continues despite the declassification of homosexuality as a mental illness[i]. Nowadays, an unholy alliance between conservative Christians, conservative Jews and old style psychoanalysts is united behind this phenomenon. In an attempt to deflect accusations of homophobia, the term “reorientation” is more commonly used, but fundamentalist Christians whose agenda is less veiled, prefer “reparative therapy” (a term that suggests the presence of a clinical syndrome, despite the American Psychiatric Association’s (APA) removal of homosexuality from its register of illnesses). It is interesting to note that both terms are used interchangeably in the sources Elitzur uses to back his argument.
Non-religious people can easily dismiss the inherent homophobia of the Jewish and Christian religions. Psychoanalysis, on the other hand, is more implicitly embedded in our lives. Its basic tenets have come to form an integral part of our culture, and, in common parlance, it is often used as a synonym for psychotherapy. Until recently, psychoanalysis considered homosexuality to be a deviation from “normal” development and was primarily concerned with searching for its causes. Organised psychoanalysis has long been excluded from mainstream psychiatry in the US. The American Psychoanalytic Association virtually abandoned scientific method, making psychoanalysis the only medical specialty whose therapeutic endeavours were not rooted in science. In rejecting the scientific method, psychoanalysis turned its back on what has been the accepted route to the accumulation of knowledge since the Renaissance, becoming isolated on the periphery of medicine. The belief that psychoanalysis could reorganise personality and repair damaged mental structures has been generally proven to be untrue – not just in the case of reorientation treatment[ii]. So, to sum up, the rationalisation for the existence of reorientation treatment stems from the conservative religious bodies’ view of homosexuality and a non-scientific, outdated and largely rejected set of ideas.
Reorientation therapy is founded on a disease definition that originates from the interplay of scientific and social perspectives. Psychological reorientation programs are based on two basic hypotheses:
- that homosexuality results from an arrest in normal development or from pathological attachment patterns in early life (a psychoanalytic theory) and
- that homosexuality stems from faulty learning[iii].
Christian reorientation programs are based on the view of homosexuality as sinful. Supporters of reorientation try to present it as a valuable service for distressed lesbians and gay men who freely seek their services, but the therapists’ implicit acceptance of sexual orientation as the cause of distress, and the associated agreement to attempt sexual orientation change as a cure, exacerbates distress and reinforces and confirms the internalised homophobia that is in fact the root of the problem[iv].
Reorientation treatment is provided by a small number of psychologists, social workers, mental health counsellors and pastoral ministers[v]. There are also religious “ex-gay” ministries that offer either individual or group treatment and a few 12-step programs like Sex Addicts Anonymous.
All the leading mental health and medical associations[vi] support the APA’s stand on homosexuality and its recommendation “that ethical practitioners refrain from attempts to change individuals’ sexual orientation, keeping in mind the medical dictum to ‘First, do no harm’.”[vii] They – quite rightly, as you will see – consider reorientation therapy to be a pseudo-science[viii]. It causes the kind of damage that it claims to prevent: low self-esteem, depression and suicide; flashbacks and sexual dysfunction; impairment in intimate and non-intimate relationships; and even spiritual harm to religious participants[ix]. What the treatment actually does is lay the blame for the client’s problems with his or her homosexuality (electing to “remove the cause”), instead of dealing with the negative attitudes of the client’s environment and helping him or her to deal with it. If all the people who claim to have the best interest of homosexuals in mind had invested their efforts in developing the most effective gay affirmative therapy, instead of wasting resources on something as dubious and harmful as reorientation, patients would have had a much better chance of happiness. The fact that they do not even attempt to do so is indicative of a hidden agenda.
Elitzur seems to have embarked on a crusade to make reorientation treatment available to as many people as possible, a step in the direction of a mass, uncontrolled and unsupervised experiment that contravenes the ethical requirements of psychological research. After obtaining access to the PowerPoint presentation file of his lecture, I decided to analyse his sources and his interpretation of these sources in order to find out whether he is right to claim what he claims, and whether ETAM’s invitation to him to speak was justified. I was anticipating a standard scientific analysis of the validity of research results in order to accept or refute claims made in the lecture. But I found much more than claims based on methodologically poor research – I found selective and subjective reporting of research results, often based on partial information that is presented in a misleading way. Furthermore, I found a strange agenda that I couldn’t place in a serious scientific analysis and review.
Elitzur presented the topic of his lecture as “Homosexuality, mental health and political correctness”, introducing three main points of discussion:
- Distress among homosexuals – external or inherent?
- Aetiology: biological versus environmental models
- Changing sexual orientation: possible? Advisable?
Elitzur’s claims in favour of reorientation vs. the findings of scientific research
Many of the claims made in the lecture are contradicted by the outcome of valid research. Elitzur tries to portray reorientation as a humane solution to terrible suffering. This also serves to present opponents of the treatment as lacking in compassion. He tries to convince his audience of the bleakness of the homosexual life and he dismisses the APA’s position by suggesting the existence of a hidden agenda. He also tries to disprove the (unproven) theory of the biological origins of homosexuality in order to show that it is not inherent and is therefore reversible.
Elitzur’s main argument in favour of reorientation – the picture he paints of what the life of homosexuals is really like – is outdated, inaccurate or plain wrong. It seems to be based on superficial and biased knowledge. Elitzur starts off by introducing to his audience the “distressing reality” of the homosexual life. He highlights the risk of suicide among gay men, listing the causes as the break-up of relationships and the inability to accept oneself. Yet research on the subject indicates that the main reason for suicide among homosexuals is homophobic persecution, i.e. the cause is external rather than internal. It is ironic that reorientation treatment is considered to be an appropriate solution to such misery, when, in fact, it helps to reinforce the message of rejection of the true self by society. Contrary to Elitzur’s claims, independent studies with diverse designs have failed to find any increased frequency of various forms of psychopathology among homosexual people as compared with heterosexual people[x].
Under the heading “Unstable relationships – a myth?”, he quotes a single (1984) source: “The Male Couple: How Relationships Develop” by D.P. McWhirter & A.M. Mattison. According to it, out of 156 couples none retained sexual fidelity for more than 5 years. A single outdated source based on the experiences of 156 couples is used to show us “the futility of the gay lifestyle” (in the absence of methodological information I will generously assume the article to be scientifically valid). More recent articles present a completely different picture. A review of research on same-gender couple relationships, parent-child relationships, and other family relationships from 2000[xi] shows gay relationships as adjusting positively, even in the face of stressful conditions. Research carried out in 2004[xii] longitudinally compared gay and lesbian couples with heterosexual couples. 50% of the couples showed no differences between the two groups. In 78% of the remainder homosexuals functioned better than their heterosexual counterparts. It was concluded that the processes that regulate relationship functioning generalise across gay, lesbian, and heterosexual couples
The world has come a long way in the last two decades. Many homosexual men and lesbian women do have children – it is not impossible. There are other types of families besides the traditional nuclear family. There is also a growing body of scientific research on the subject. The outcome of a longitudinal study (from 2004) that compared adolescents brought up by same sex couples with those brought up by opposite sex couples indicated no differences between the two groups on measures of psychosocial adjustment, school outcomes, romantic relationships, sexual behaviour, relationship with parents and school adjustment[xiii]. Another article from the same year finds lesbian parents to be equally competent to heterosexual parents[xiv]. This not only puts in doubt Elitzur’s knowledge of the subject, but also further diminishes the basis from which he tries to derive conclusions.
Next, under the heading “Risk”, Elitzur reproduces a piece from a local Israeli news journal about the rise in the prevalence of AIDS among gay men. Associating AIDS exclusively with gay men and presenting the fear of contracting it as a valid reason for seeking reorientation treatment is ignorant and prejudiced. AIDS presents a risk to all people regardless of their sexual orientation, and the way to avoid it is safe sex, a practice not unique to gay men. Even abstinence is a more viable way of avoiding AIDS than reorientation. Since reorientation has not been proven to be effective (this will be discussed in great detail further on in this article), it can have the adverse effect of increasing people’s vulnerability to the risk of AIDS: it can push people deeper into the closet where they are more likely to be uninformed about safe sex practices and more likely to engage in high risk sexual behaviour. It is worth mentioning that “Associating gay men with AIDS is a prejudice exploited by anti-gay individuals” and that “educating men on safe sex is a less invasive and easier option” than reorientation treatment[xv].
Reliable information about AIDS can be obtained from UNAIDS, The Joint United Nations Programme on HIV/AIDS. This is the information they provide: “Does HIV only affect homosexuals and drug users? No. Anyone who has unprotected sex, shares injecting equipment, or has a transfusion with contaminated blood can become infected with HIV. Infants can be infected with HIV from their mothers during pregnancy, during labour or after delivery through breastfeeding. Ninety per cent of HIV cases are the result of sexual transmission and 60–70% of HIV cases occur among heterosexuals.” As for the prevention of AIDS, the following options are suggested: “abstinence, monogamous relations between uninfected partners, non-penetrative sex, consistent and correct use of male or female condoms.” Furthermore, it states that “When used properly, condoms are a proven and effective means of preventing HIV infection in women and men”. The UNAIDS is “the main advocate for global action on the epidemic” whose main aim is “preventing transmission of HIV, providing care and support, reducing the vulnerability of individuals and communities to HIV/AIDS, and alleviating the impact of the epidemic” to promote a viable and effective means of prevention. It never mentions reorientation as an option or a solution. Finally, if it really is the desire to protect people from the risks of AIDS which makes Elitzur promote reorientation, then he should follow the same line of logic and recommend reorienting heterosexual women to lesbianism, since the incidence of infection among women who have sex exclusively with women is practically negligible.
Elitzur casts aspersions on the professionalism and expertise of the APA and hints that many organisations blindly followed its recommendations. This is a recurring theme throughout the lecture and a view that is perpetuated by the pro-reorientation lobby. Just for the record, the APA is a medical speciality society with world-wide recognition. It has a large international membership and is the voice and conscience of modern psychiatry working to ensure humane care and effective treatment. It publishes DSM – the most widely used psychiatric reference and diagnostic tool in the world. The APA promotes:
- best standards of clinical practice
- highest ethical standards of professional conduct
- prevention, access, care and sensitivity for patients and compassion for their families
- patient-focused treatment decisions
- scientifically established principles of treatment
- advocacy for patients
- respect for diverse views and pluralism within the field and the association
- respect for other health professionals
The APA clearly states: “To date , there are no scientifically rigorous outcome studies to determine either the actual efficacy or harm of “reparative” treatments”. This statement is based on carefully researched reviews of available data on the subject, published in reputable scientific journals. The APA criticises reorientation treatment for viewing homosexuality as a disorder, and adds that “In recent years, noted practitioners of “reparative” therapy have openly integrated older psychoanalytic theories that pathologise homosexuality with traditional religious beliefs condemning homosexuality”.
Biological theories on homosexuality (categorised as genetic, constitutional, endocrinological, and ethological) were historically used in the struggle for homosexual rights and also in an attempt to “cure” homosexuals, where every theory led to a specific therapy[xvi]. There is no general consensus on the cause of homosexuality and Elitzur produces evidence to that effect quite early on in his argument. Despite that, he then goes on to dissect numerous pieces of research in order to show that, to date, no one has found irrefutable evidence that homosexuality has a biological origin. By showing the fallacy of the (so-called) widespread belief that homosexuality is genetic (he fails to substantiate his claim of a consensus), he concludes that it is not unchangeable. This too is an elementary logical error: even if X were untrue (or, more accurately, in this case: X has not been proven to be true) it does not follow from that that the opposite of X is true. Of course, the fact that there is currently no established proof that homosexuality is genetic, does not mean that such a connection may not be ascertained in the future. It most definitely does not mean that homosexuality is not inherent and can therefore be changed through behaviour modification treatment. In his argument against the innateness of homosexuality, Elitzur skims over important distinctions (such as that between correlation and causality) and generally fails to follow the basic rules of research methodology of the social sciences.
Elitzur fails to establish a viable foundation for reorientation treatment. The findings of valid scientific research contradict his claims (that homosexuals’ lives are distressing, that the APA’s opposition is invalid and that homosexuality is caused by environmental factors and is therefore changeable) and remove his basic justification for the treatment. But there are many additional problems with his material.
The use of pseudo- and non-scientific sources
The lion’s share of Elitzur’s lecture relies heavily on some very dubious sources: a closed circuit of organisations with a preset (anti-homosexual) agenda. They peddle the same pseudo-science and cite each other in an endless chain, in an attempt to lend an air of scientific respectability to what is unfounded propaganda. Elitzur initially adheres to the predetermined structure of his lecture, starting with suicide in homosexuals and its alleged causes. But it very quickly becomes noticeable that the lecture is replete with unexplained diversions:
- doubts about Kinsey’s claim that homosexuals make up 10% of the population
- an internet news source alerting us to the rise in AIDS in the gay community
- the “conspiracy” of the American Psychiatric Association (APA) and its stand against viewing homosexuality as an illness and the implication that it “forced” many other organisation to comply with that standpoint
- “an aside about paedophilia”
- allegations of a “pro-homosexual bias” in research
- an attempt to present homosexuality as the result of sexual abuse in childhood
- yet more paedophilia references under the heading “The sensitive subject of paedophilia”
Elitzur claims to be acting solely because of a desire to relieve the suffering of those individuals who are unable to live with their homosexuality. Yet it is impossible to ignore the strong undercurrent of a greater purpose: a tirade against the “pro-homosexual lobby” and its stranglehold on the world, and an attempt to unmask “the real and ugly face of homosexuality”. These issues do not sit comfortably with Elitzur’s declared concern for the welfare of particular individuals in distress, so much so, in fact, that it is possible to feel as if one has walked into the wrong lecture hall. These seemingly irrelevant diversions become clear upon identification of the sources on which Elitzur bases much of his case.
I sometimes found it impossible to trace certain articles that Elitzur cites to any reputable scientific database. A search in Google, however, eventually bore fruit. This was my introduction to a collection of Christian anti-homosexual pro-reorientation therapy websites. There are many such sites, some more offensive than others, but they all deal with the same range of subjects. Here is a selection of quotes from an article on homosexuality by The Christian Medical Fellowship: “it has become ‘politically correct’ to view homosexual orientation as a normal variant”, “There has also been a concerted effort to present homosexual orientation as one of many normal biological variants”, “This change of opinion makes it difficult to evaluate the facts objectively, and many people are afraid to contradict it for fear of the wrath of the ‘new’ establishment” – recurring themes throughout Elitzur’s lecture. And then the mystery topics that didn’t fit into his pre-stated summary materialised: “Incidence of homosexuality” (the 10% “myth”), “High-risk sex”, “Mental illness” – leading to the natural solution of “Changing orientation”, saving them from a non-Christian life and the danger of AIDS.
Elitzur tries to argue that it is the truth that is being rejected by those on a mission to promote homosexuality. He reiterates his view that there is a grand conspiracy and that his goal is to voice all available alternatives for homosexuals in suffering. What we have here is someone who who chooses the subjective and inexpert judgement of fundamentalist Christians over the objectivity of empirical science and professional societies.
I searched for another article Elitzur quoted under the heading “The sensitive subject of paedophilia”: “Child molestation and the homosexual movement” written by S. Baldwin in 2002, and published by Regent University Law Review. When unable to find it in academic databases, I looked up Regent University School of Law. I discovered that Regent University defines itself as “The nation’s academic center for Christian thought and action” and that the Regent University Law Review is “a forum for Christian perspective on law in a traditional legal periodical”. Sample articles one can download from their site include:
- “Fairness, Accuracy and Honesty in Discussing Homosexuality and Marriage”
- “Studies of Homosexual Parenting: A Critical Review” (a study that claims to illuminate “the flaws of the leading social science studies on homosexual parenting and child development that are relied upon by courts, legislators, and lawyers in advocating homosexual adoption of children”)
- “Child Molestation and the Homosexual Movement” (“From the international campaign to lower or remove age of consent laws, to the recent assault on the Boy Scouts of America, homosexuals are waging an all out campaign to normalize homosexuality”)
- “Crafting Bi/Homosexual Youth” (“exposes fraudulent sex scientists and sex education; and discusses the power and effect the media and gay rights organizations have on “turning” children gay. This article presents undeniable proof that homosexuals are after the hearts and minds of the nation’s children.”)
- “Selling Homosexuality to America” (“explores how gay rights activists use rhetoric, psychology, social psychology, and the media–all the elements of modern marketing–to position homosexuality in order to frame what is discussed in the public arena and how it is discussed”)
- “Homosexuality: Innate and Immutable?”, “Why NARTH? The American Psychiatric Association’s Destructive and Blind Pursuit of Political Correctness” (“exposes the political influence of gay rights activists in the APA’s decision to redefine homosexuality from a disorder, and the way this unscientific decision is used as propaganda to further gay rights objectives”).
Evidently, this is not the most neutral of institutions or publications. Specifically, Steve Baldwin (who authored the article quoted by Elitzur) is a graduate of Pepperdine University who “was elected to the California State Assembly in 1994, where he chaired the Assembly Education Committee and fought the homosexual community’s efforts to insert pro-gay curriculum into California’s public schools.” It is clear that Mr. Baldwin is strongly biased against gay people; here is a selection of quotes from his article (the one that Elitzur quotes in his lecture):
- “Lately, the gay movement seems to be making large gains in its war on America’s Judeo-Christian culture”
- “And yet the destructive impact homosexuality has upon Western Civilization is rarely discussed”
- “A vast amount of data demonstrating the deviant nature of the gay lifestyle is ignored by the media as well as the leadership of the psychological, psychiatric, and medical professions.”
- “Research confirms that homosexuals molest children at a rate vastly higher than heterosexuals, and the mainstream homosexual culture commonly promotes sex with children.”
- “Homosexual leaders repeatedly argue for the freedom to engage in consensual sex with children, and blind surveys reveal a shockingly high number of homosexuals admit to sexual contact with minors.”
In its statement on “Therapies Focused on Attempts to Change Sexual Orientation (Reparative or Conversion Therapies)”, the APA states: “The “reparative” therapy literature uses theories that make it difficult to formulate scientific selection criteria for their treatment modality. This literature not only ignores the impact of social stigma in motivating efforts to cure homosexuality, it is a literature that actively stigmatizes homosexuality as well. “Reparative” therapy literature also tends to overstate the treatment’s accomplishments while neglecting any potential risks to patients.” Baldwin’s paper fits this pattern perfectly, as does much of the other literature quoted by Elitzur.
Elitzur continues with the subject of the origins of homosexuality. Under the heading “The most wide-ranging surveys” Elitzur classifies research as being biased either “for” or “against” the claim that genetics plays a role in sexual orientation. He is justifiably thorough in pointing out methodological shortcomings of research he disapproves of, but research that he uses to support his argument for reorientation treatment escapes all scrutiny. This is doubly surprising in light of the fact that much of this material comes from Christian pro-reorientation organizations websites and not from recognised scientific sources. The one “biased against” source that Elitzur quotes is in fact an easy target to dismiss: “My Genes Made Me Do It: A Scientific Look at Sexual Orientation” by Neil and Briar Whitehead. Practically impossible to obtain from sources other than the Christian pro-orientation websites that stock all the other non-scientific works referred to in this article, this book was written by a New Zealand based husband and wife team. The wife, Briar, is the writer of the book “Craving for love: relationship addiction, homosexuality and the God who heals”. Her husband is responsible for works such as “Science and Sexuality” (a submission to the Anglican Commission on Sex and Gender Issues from 1995) and “Do genes cause homosexual behaviour?” (one of many “resource papers on homosexuality” offered by “Festival of Light: A Christian ministry to our nation promoting true family values in the light of the wisdom of God”). These – and the book – are not included in any scientific database.
A slide titled “the pre-homosexual child” announces “Daddy didn’t love me” and, underneath, two questions: “a reason?”, “a consequence?” Research has long ago invalidated the once popular psychoanalytic idea that castrating mothers and detached or hostile fathers are necessary or sufficient causes of male homosexuality[xvii]. Elitzur provided no source for his assertion. The only other place where I could find similar ideas being voiced was on the website of “The National Association for Research and Therapy of Homosexuality” (NARTH: a non-scientific source – “a non-profit, educational organization dedicated to affirming a complementary, male-female model of gender and sexuality.”[xviii]). It carries an article by Joseph Nicolosi Ph.D, titled “Fathers of male homosexuals: a collective clinical profile” and quoting psychoanalytic and Christian sources. Joseph Nicolosi is also the author of works on reparative therapy (note the term “reparative”, which implies a defect and is used mainly in a Christian anti-homosexual context), and a particular gem titled “A parent’s guide to preventing homosexuality”. Together with A. Dean Byrd and Richard Potts he has carried out research for NARTH on sexual orientation change. This research was privately published.
After reviewing the speculated causes of homosexuality, Elitzur turns to look at the success rates of re-orientation treatments. He reproduces tables of data underneath an attribution to “Homosexuality and the Politics of Truth” by J Satinover, an article unpublished by scientific journals, but available for perusal on sites such as Bridges-Across the Divide (“provides models and resources for building respectful relationships among those who disagree about moral issues surrounding homosexuality, bisexuality and gender variance”). The actual source of the tables is slightly unclear: the Bridges-Across website describes them as “a comparison of statistics that Dr. Jeffrey Satinover presented in his DOMA testimony with the analysis of research papers which was done by Rob Goetze, the director of New Direction for Life, a reorientation ministry in Canada.” This is by no stretch of the imagination a scientific source.
On his website, Satinover describes his own work (“Homosexuality and the Politics of Truth”): “A stunning book. Originally trained as a Jungian analyst, Satinover presents a scientific perspective on homosexuality interpreted through a traditional Judeo-Christian viewpoint. This book is both scholarly and philosophical, and is written in a clear style that is at once erudite and passionate.” Others share his elevated view of himself: Dr Laura Schlessinger (and here’s a selection of infamous quotes from her: “If you’re gay or a lesbian, it’s a biological error that inhibits you from relating normally to the opposite sex.”[xix]; “When we have the word homosexual, we are clarifying the dysfunction, the deviancy, the reality. We change it to the word gay, it makes it more difficult to pinpoint the truth.”[xx]; “…a huge portion of the male homosexual populace is predatory on young boys.”[xxi]), “Women for faith and family” (they describe the book as “a superb handbook for countering politically correct “facts”.”), and the “Catholic Education” website.
Satinover (also the author of “Cracking the Bible Code” – a controversial work that attempts to lend scientific respectability to the claim that hidden codes are contained within the text of the Bible), whose writing features prominently in websites of religious and conservative anti-gay groups, has views that parallel many themes raised by Elitzur. His article “The gay gene?” appears in “The Journal of Human Sexuality”, a publication from Leadership University (a resource sponsored by Christian Leadership Ministries, the journal “is a publication of Christian Leadership Ministries exploring the many issues surrounding homosexuality.”).
An interview with him published in World Magazine (“written from a Christian perspective” and “a perspective committed to the Bible as the inerrant Word of God”) provides the following quotes: “…we should remember that homosexuality has risen to the top of the social-policy agenda because of the utter wreck we all have made of family life over the past 50 years. This horror cannot be blamed on anyone but us.” and “We now know that in the majority of both men and women, “homosexuality,” as defined by any scientifically rigorous criteria, spontaneously tends to “mutate” into heterosexuality over the course of a lifetime. The proportion of people who adopt a homosexual identity and the length of time they persist in holding on to it are affected primarily by environmental factors clearly identifiable in these epidemiologic studies. These factors—deemed “cultural” or “demographic”—include effects such as social networks, education, early sexual experiences, childhood sexual abuse, and cultural beliefs.”
“Homosexuality and the Politics of Truth” describes the “homosexual agenda to protect homosexuality “as a perfectly acceptable, normal, and safe way of life”. It informs us that “gay activists allied themselves with the mental health community. Together, the goal was and is to persuade the rest of us that homosexuality is 1) genetically determined, 2) irreversible and 3) normal.” and draws parallel between that and feminism where “the end justifies the means”. Satinover grapples with issues such as “sin, guilt and reconciliation with others and with God”, something which earns him the respect of Rabbi Daniel Lapin (he called the book “a beacon of light to anyone struggling to emerge from homosexuality or struggling with the homosexual debate”).
Like his articles, Satinover’s book is a standard for religious and conservative anti-gay groups. His book is favourably reviewed by family.org (whose mission it is “To cooperate with the Holy Spirit in disseminating the Gospel of Jesus Christ to as many people as possible, and, specifically, to accomplish that objective by helping to preserve traditional values and the institution of the family.”), Women for Faith and Family (promotes fidelity to the teachings of the Catholic Church), Evergreen International (“The most complete resource for Latter-Day Saints struggling with Same-Sex Attraction” – its “mission statement” is “Evergreen attests that individuals can overcome homosexual behavior and diminish same-sex attraction and is committed to assisting individuals who wish to do so.”), First Things (“The Journal of Religion, Culture and Public Life” published by “The Institute on Religion and Public Life, an interreligious, nonpartisan research and education institute” in order to “advance a religiously informed public philosophy for the ordering of society.”), NARTH, Convention of Atlantic Baptist Churches, Regeneration Books (“a Biblically based, Christ-centered ministry helping men and women seeking to overcome homosexuality.” that refers to homosexuality as a “form of sexual brokenness”), Eagles’ Wings Ministry (“exists to minister to all who desire freedom from homosexuality”), and many more.
Satinover’s motivation comes from an association of homosexuality with AIDS, and a strong pro-reorientation agenda. His book is a hugely biased source of information full of hatred and prejudice against homosexuals. He presents information selectively, confusing prejudice and fact. It is a subjective piece of propaganda. In support of his pro-orientation agenda, he relies on a variety of (non-scientific) resources, one of which, “New Direction for Life Ministries of Canada”, defines its mission as “Offering Christian support to men and women choosing to leave homosexuality, and equipping the church to minister effectively and compassionately.” It tries to lend credibility to assertions that go against the grain of good science by redefining scientific methodology and validity, and dismissing valid concerns about the quality of research that invalidate the results. Against all logical principles, it shifts the arguments and redefines issues in order to try and prove each point. This may be permissible in religious thinking, but not in science.
Without exception, the statistics quoted by Elitzur as proof of the success of reorientation therapy are widely accepted to be wrong, outdated, subjective and resulting from extremely poor research. Remember that the data he bases his judgement on derives from data obtained by Satinover from “research” done by Rob Goetze, the director of New Direction for Life, a reorientation ministry in Canada, i.e. not a scientist who is capable of determining the validity of such data. There is scant information available about him. At the New Direction’s website, several members are referred to only by their first name and the initial of their surname. We can only assume that the line “July 1998: Rob G. became Executive Director” refers to the same person.
In an interview carried by the website www.christianity.ca (“Canada’s Christian Community Online”) Goetze says: “According to New Direction, homosexual attractions and behaviour are symptoms of deeper emotional hurt and needs. Unless the underlying causes are dealt with, the problem will remain. Fear, rejection and past sexual abuse all play a part in choosing to live a same-sex lifestyle. So do lack of warmth, acceptance or affirmation from a father (or mother), insecurity in gender identity and exposure to pornography.”
Other sources that Elitzur quotes in defence of reorientation are equally dubious. E James wrote “Treatment of Homosexuality: A Reanalysis and Synthesis of Outcome Studies” as her 1978 PhD dissertation. It was presented to the Department of Psychology at (Mormon) Brigham Young University, but was never published in a scientific journal. James’ dissertation is cited only by Christian pro-reorientation sites (Meridian – “the place where Latter-Day Saints gather”, lds-mormon.com – “Mormonism and the LDS Church”, Fathers for Life – a site that promotes old-fashioned “family values” and sees feminism and modern culture as elements of a “planned destruction of the family”, NARTH – the ubiquitous anti-homosexual organisation, and others).
The history of how this paper came about is very revealing[xxii]. In the 1970s, Brigham Young University had forced gay and lesbian campus members into undergoing aversion therapy (involving electric shocks and vomiting) in order to change their orientation. The university and Mormon church officials grew so alarmed at the presence of a homosexual “ring” on campus that in 1976 they established the Institute for Studies in Values and Human Behavior and charged it with producing a manuscript that would produce empirical (“secular”) evidence in support of the church’s position on homosexuality. Other goals would be to review how homosexuals are trying to “indoctrinate” people, explain the “developmental pattern of sexual deviance”, and prepare “anti-Gay papers and rebuttals”. Elizabeth C. James’ 1976 PhD dissertation, cited by Elitzur, is one of the resulting papers. It was conducted, sponsored and supported by the Values Institute.
And, finally, a really audacious instance of the use an unscientific source. Under the heading “It’s been proven to be genetic”, Elitzur quotes a slogan allegedly displayed on a t-shirt of a San Francisco gay man: “Xq28 – Thanks for the genes, Mum”. It was immediately obvious to me that a US-origin t-shirt wouldn’t carry the British spelling of the word “mum” (US spelling: “mom”). Google finds this exact quote in a single website – a UK university site that carries information about Chandler Burr, a journalist with a BA in Political Studies, who used to be a reporter for “Christian Scientist”. In his 1996 book “A Separate Creation: How Biology Makes Us Gay” Burr states his belief “not only in the overriding power of the Xq28 region, but that homosexuality is a ‘genetic/bacterial condition’ that might be ‘cured’ with antibiotics”. The alleged t-shirt quote is lifted verbatim from a review of the book by Robin McKie, from The Observer Review (a British publication), 14 July, 1996. It is patently obvious that this second hand “t-shirt quotes” is in no way scientific evidence of any statistical value. Yet Elitzur states unequivocally: “The t-shirt worn by the San Francisco gay made it clear: A single piece of DNA – from the q28 region of his X-chromosome, inherited from his mother – was the sole cause of his sexual orientation”.
When so much of the material that forms the backbone of Elitzur’s lecture is shown to be highly dubious and scientifically worthless, his whole case for reorientation treatment crumbles. It is evident that this is area is clearly outside his expertise. And yet there is still so much more wrong with the material.
Poor methodology: research that has failed to prove what it claims
A surprisingly large number of scientific articles used by Elitzur to prove his case do not stand up to scrutiny. They are methodologically flawed to an extent that invalidates their results and conclusions. Some have long been rejected by the scientific community, but Elitzur is either unaware of that, or chooses to ignore it and present their findings as valid proof.
In his discussion of the origins of homosexuality, Elitzur discussed the relation of sexual orientation to physical brain structure. The first article mentioned[xxiii] has serious methodological flaws, the main one being the assignment of people to the three experimental groups: homosexual men, heterosexual men and heterosexual women. In the absence of any information that indicated that a person was homosexual, that person was assumed to be heterosexual. This makes the results insignificant, as (at least some of the) presumed-heterosexual brains could have been closet-homosexual brains. It is unclear what Elitzur is trying to prove with a piece of research that has long been widely discredited in the scientific world.
Elitzur then quotes from another article[xxiv], in which the sampled population consisted of 675 “graduate or undergraduate students currently enrolled and attending classes in colleges and universities in central California”: “The vast majority of the students who received questionnaires completed and returned them, but the exact percentage is not known.” This sentence is sufficient to invalidate any results drawn from this research; the “drop-out factor” here is significant, because it could be connected to the factors that are being researched.
Next, “Two hundred sixty-seven additional participants with fully completed questionnaires were obtained at the homosexual pride events in the central California area. The principal investigator rented a booth at the event and asked individuals who approached the booth to participate in the research.” The article ends with the words: “It must also be borne in mind that the present homosexual participants may not be representative of homosexual persons. The overwhelming preponderance of homosexual participants was in the gay pride group. There were only three homosexual men and seven homosexual women in the college group. On the other hand, the gay pride participants certainly seem to be a nonclinical group. It is most unlikely that all the present findings apply only to homosexual persons who go to homosexual fairs and volunteer to participate in questionnaire research.” Let’s examine what the researchers are saying: “the gay pride participants certainly seem to be a nonclinical group”. On what basis do they determine that? The questionnaire they were given contains not a single question regarding mental health, so this is pure guesswork not backed by any scientific findings. They also say that “it is most unlikely that all the present findings apply only to homosexual persons who go to homosexual fairs and volunteer to participate in questionnaire research”, but there is no basis in scientific reasoning to back that assertion and give this group statistical significance.
The items that are used to determine childhood sexual abuse (CSA) in the questionnaire are too inclusive and the researchers end up with a definition that encompasses a very wide range of behaviours. Some of these behaviours, it can be argued, fall outside what one would normally perceive of as sexual abuse. CSA is detected by a positive answer to the question “Before you were 16 years old, did you ever have sexual contact with a woman[/man] or girl[/boy] 5 or more years older than yourself and at least 16 years of age?” There is no mention of whether that sex was consensual or non-consensual. At the higher end of the age-scale this would differentiate between the grey areas that exist around sexual relations with those just under the age of consent. Heterosexual youngsters are surrounded by other heterosexual youngsters and can easily find a sexual partner (at school, for instance) who is nearer their age. Homosexual youngsters, on the other hand, are in a minority and are more likely to be secretive about their sexuality in front of their peers due to its unacceptability in many school environments. This could drive them to seek partners elsewhere, where they are more likely to meet older partners. It has been pointed out with regard to research on CSA that more care should be taken when the term “sexual abuse” is operationalised. This is one example of a definition that groups together too many behaviours without sifting out non-abusive situations from true abuse. When all the methodological errors detected in this piece of research are added up, it is easy to see that any conclusions based on the data obtained from it are invalid.
And then Elitzur turns to the subject of the “pre-homosexual child”. He quotes from “The Science of Desire[xxv]”: “Most sissies will grow up to be homosexuals, and most gay men were sissies as children.” There has been some research on the subject of effeminate behaviour in boys. A review of such research[xxvi] identifies both longitudinal and retrospective research designs (the first concentrating on boys who have been identified as effeminate and following them to adulthood, the second questioning adult homosexuals about childhood behaviours) and concludes that male homosexuals were effeminate in childhood. There is no denying that there some gay men are effeminate, and that it is quite likely that they were also effeminate when they were young, but such certainty seems slightly odd in light of what we already know, not just regarding methodological concerns. Where are the “non-sissy” boys? How can they be sure that the “non-sissy” boys who grew up to be “non-sissy” men are not in reality undetectable to them as gay for various reasons that have been mentioned several times already in this paper?
The belief in the effeminacy of gay men is deeply rooted in the collective consciousness. It is true that some male homosexuals do display effeminate behaviour, but it is also true that many others do not. It is perhaps interesting to realise how deeply entrenched this image of the “sissy” homosexual is. A quote from Andre Gide’s 1924 book Corydon[xxvii] is a good illustration of that: “On entering his apartment, I admit I received none of the unfortunate impressions I had feared. Nor did Corydon afford any such impression by the way he dressed, which was quite conventional, even a touch austere perhaps. I glanced around the room in vain for signs of that effeminacy which experts manage to discover in everything connected with inverts* and by which they claim they are never deceived.”
A later article by the author who carried out the review of research on “sissiness”[xxviii] paints a more nuanced picture: there is a suggestion that we are not dealing here with “the pre-homosexual child”, but with early manifestations of homosexuality that are already present in the young child. This has implications for Elitzur’s argument, because he actually uses that term in a way that is strongly suggestive of a non-homosexual or “neutral” child who is then made homosexual by factors in his environment.
When it comes to proving that reorientation treatment does work, Elitzur resorts to some truly bad science: it is a mixture of flawed methodology and citations from non-scientific and biased sources. It is interesting to note that Robert L. Spitzer’s 2003 article, “Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation” (which is examined further on in this article), the one source for which pro-reorientation activists claim a thorough scientific pedigree, cites Goetze’s (see previous section on pseudo- and non-scientific sources) research[xxix].
Even Goetze and New Direction cannot ignore the fatal errors of research claiming success of reorientation treatment:
- According to Satinover, the study by van den Aardweg showed a success rate of 65%. Goetze admits that the reliability of the data on which the conclusions are based is extremely doubtful. Critical information is either omitted or disregarded and the methodology concerned with the measurement of change is so poor as to immediately invalidate the results. The study is vague and undetailed about clients’ sexual histories. It mentions radically changed clients who have “occasional and weak homosexual ‘flashes’ at most” but does not state what these constitute or how many clients this applies to. “Information was based only on interviewing clients. The information given was not corroborated, nor were other measures used.”;
- According to Satinover, the Bieber study showed a success rate of 27%. Here too, Goetze admits that the reliability of the data on which the conclusions are based is extremely doubtful. Critical behaviours on which the conclusions were based have been very poorly defined and operationalised and the methods to measure change are extremely subjective. “The questionnaires were filled out by the psychoanalysts who had seen the patients. The patient was not asked these questions directly, nor were outside sources used to confirm the answers. The questionnaire asked general questions about fantasies and dreams. It did not ask about changes in these, nor whether at the time of the study they were directed to the same sex and/or the opposite sex. To determine change, the questionnaire only asked about the patient’s sexual status at last contact, using the categories of exclusively homosexual, bisexual, exclusively heterosexual, and inactive (p. 347). The questionnaire itself did not provide definitions of these terms. Bieber sometimes groups patients who initially were bisexual, together with those who initially were exclusively homosexual.”;
- According to Satinover, the Mayerson study showed a success rate of 47%. Goetze admits that there are serious shortcomings in the classification of people regarding sexuality. Classes of sexuality are very poorly defined: “there [are] significant differences in the definitions of Class 4 and Class 5, [but] the authors grouped them together under the heading “heterosexual””, “At least four (and possibly more) of the “exclusively homosexual” (class 1) patients had had heterosexual intercourse before starting therapy. No explanation is given as to why patients who have had heterosexual intercourse are classified “exclusively homosexual.” No information is supplied on the nature of these heterosexual experiences (i.e.., were they the result of family and cultural pressures? or an attempt to try to fit in?) Note, however, that the definition for class 1 clearly excludes those who are bisexual in behaviour.”, “The psychiatrists who did the follow-up interviews accepted what the patients reported. No other evidence was sought to confirm or deny the patients’ statements (Green, 1988). In other words, the patients could have been giving the answers which they thought the interviewers wanted to hear.”.
Van den Aardweg speculates in another article of his that parents are the cause of homosexuality in their sons: “the combination of overconcernedness of the mother and detachment and hypercriticism of the father push the boy into avoidance of “masculine” behavior, which in turn is leading to a feeling of inferiority because the boy considers himself as lacking in manliness. The homosexual urge is an expression of an infantile longing for acceptance to counteract the loneliness and self-pity of not belonging and must be seen as a specific neurotic manifestation.[xxx]” These are all theories that have long been discredited, as demonstrated elsewhere in this article. The research by Freud, Ovesey, Ross et al, and Monroe et al, (cited by Elitzur directly from Goetze’s data – the data he provides in his PowerPoint slide is an exact facsimile of the material that appears on the New Directions website, down to the tiniest style details) can be discounted as the number of cases treated is too low to be statistically significant. This invalidates any data obtained and makes an examination of the rest of the methodology superfluous.
Since Elitzur quotes wholesale from Satinover without providing source references for the reorientation research quoted, it was impossible to trace the original Schwartz et al article that gave rise to the claim of a 65% success rate for psychotherapeutic reorientation. Other material published by Schwartz discusses therapy for paraphilia (the need for an unusual sexual stimulation or abnormal stimulus, e.g. a sadistic or masochistic practice, in order to achieve sexual arousal or orgasm). It implicitly equates homosexuality with sexual dysfunction or disorder when it states that “The format of the psychotherapy has components similar to the programs for sexual dysfunction and homosexual dissatisfaction therapy”[xxxi]. In another article[xxxii] he claims that “Certain individuals who want to change their homosexual preference can be helped by a short-term intensive intervention adapted from the Masters and Johnson model for treating heterosexual disorders.”
Another piece of research of doubtful value is H MacIntosh’s “Attitudes and experiences of psychoanalysts” from 1994. Elitzur quotes that “23% of analysts noticed a change of orientation”, which sounds impressive until you check the methods used: the results were obtained by making a survey of psychoanalysts (a potentially biased party because they have a personal interest in the success of the treatment). They didn’t interview the patients themselves. As before, unreliable techniques invalidate any conclusions drawn. The article mentions that the patients “received significant therapeutic benefit” – this, however, is no more than the (fuzzy) opinion of the analyst who treated them and is therefore subjective information.
Next, we are presented with “Retrospective self-reports of changes in homosexual orientation: a consumer survey of conversion therapy clients” by Nicolosi, Byrd & Potts (this is the article mentioned earlier that was written for NARTH, published privately, and subsequently submitted to and published by Psychological Reports – a journal for experimental, theoretical, and speculative articles in the field of general psychology). Once again, Elitzur claims that “67% exclusively homosexual dropped to 12.8% – 54.2% changed”. Let’s examine what really happened: 882 dissatisfied homosexuals were surveyed. This is already problematic: they are dissatisfied, therefore they are eager for change. This is likely to affect their interpretation and assessment of their own situation and make any self-reporting by them potentially subjective. The methods of the survey were flawed: self-report (again) and anonymous questionnaires (impossible to independently or externally verify answers), poor definition (“89.7% viewed themselves as “more homosexual than heterosexual,” “almost exclusively homosexual,” or “exclusively homosexual” in their orientation before receiving conversion therapy or making self-help efforts to change” – even the writers had to admit that many terms were left undefined, including sexual orientation, self-acceptance, etc.), subjective assessment of the efficacy of treatment and the (direction of) causality of change (“the participants reported large and statistically significant reductions in the frequency of their homosexual thoughts and fantasies that they attributed to conversion therapy or self-help”). The abstract of the article clearly states: “[The reports of change] cannot, for several reasons, be generalized beyond the present sample”. This is a very telling sentence: something that cannot be generalised beyond a specific sample is statistically invalid, and therefore completely insignificant. This makes a mockery of the conclusions and stops them being applicable to anything other than the teaching of how not to design research projects.
And then we finally come to Robert L. Spitzer’s 2003 article, “Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation[xxxiii]”. This is an often quoted work that claims a real scientific pedigree. Elitzur presents the following information about it: “Of 247 respondents, 200 (143 males, 57 females) selected for exclusive or predominant homosexuality prior to therapy. Average age: male 42, females 44. 5 years after therapy: 41% were openly gay before therapy, 34% males and 2% females engaged with > 50 partners”.
I have carefully dissected Spitzer’s article. Before I report my findings, I would like to quote an analogy of his research, taken from a published comment on it[xxxiv] that clearly illustrates its shortcomings:
“A pharmaceutical company claims its new dietary supplement can change lefthanded people to right-handers. Medical associations oppose the supplement on the grounds that it harms many people who use it. Noting that there is no reason for left-handed people to try to change, they urge their members not to recommend or administer the product to their patients. To test the drug company’s claim, a researcher conducts brief telephone interviews with self-proclaimed “exlefties.” He recruits respondents mainly through the drug company, which promotes his study to individuals who have given public testimonials about the product’s effectiveness. They say they tried the supplement because they felt miserable as left-handers in a righthanded world. Most claim they now function as right-handers, although many report occasional thoughts about using their left hand and some have had occasional lapses into left-handedness. The researcher’s findings are based entirely on the one-time interviews in which he asked the ex-lefties to rate their handedness prior to taking the supplement (12 years earlier, on average) and during the previous year. Respondents’ ratings of their past and current handedness are significantly different. The researcher concludes that the supplement does indeed change lefthanders to right-handers in some cases. Meanwhile, other researchers and clinicians report anecdotally that the food supplement does not change most left-handers to right-handers, but many who tried the supplement report serious negative side effects.”
As obviously absurd as the above research seems, the only difference between it and Spitzer’s research is the substitution of the words “lefthanded” and “righthanded” for “homosexual” and “heterosexual” respectively. The comment article (by Gregory M. Herek, PhD) finds Spitzer’s research “methodologically flawed and curiously silent about ethical concerns”, but due to space limitations, it elects to highlight just four major criticisms:
- Reliance on self-reporting (some of it relating to behaviour that took place 12 years prior to the interview). “Despite his acknowledgement of its serious methodological inadequacies, Spitzer asks readers to take it on faith that his respondents were both willing and able to report accurately on their past and current thoughts, feelings, and behaviors. This represents a curious abdication of the scientist’s obligation to design his or her study to avoid known sources of bias.”
- Conclusions about causation. Sexual orientation can naturally change over a person’s lifetime. “The question at issue is not whether sexual orientation can change but whether interventions designed to bring about such change can do so. Spitzer’s methodology is incapable of answering this question.” Asking people to attribute the cause of their change of behaviour is extremely subjective: it is subject to personal beliefs, motivation, and other bias. Even if he had managed to show a correlation between treatment and change, correlation does not prove causation, and definitely not its direction.
- Risk and harm. Although concerns about risks and harm have not been scientifically proven and are still largely anecdotal, “the standards for demonstrating harm are different from those for demonstrating efficacy. If harm seems to be at all likely, we have an ethical obligation to investigate the actual risk to patients before offering them an intervention. Indeed, clinical trials are structured to establish a treatment’s safety before testing its efficacy.” This is the reason for the resolutions on reorientation therapy passed by both the American Psychiatric Association and the American Psychological Association.
- Homosexuality isn’t an illness. The paper insensitively fosters an anti-gay stigma by promoting the belief that homosexuals can change their sexual orientation: “a condition is more readily stigmatized to the extent that it is perceived as controllable, that is, the person with the condition has a choice about it.”
Because Spitzer’s research is cherished by the pro-reorientation camp as the one true work of science that supports their views, I have taken the trouble to go through it with a fine tooth comb. In his introduction Spitzer mentions the standard claims of bias against reorientation. He insists that, contrary to common belief, research in support of the efficacy of reparative therapy does exist, and then proceeds to cite all the pseudo-scientific research mentioned earlier in this article. His research doesn’t avoid the usual methodological pitfalls. He tells us of “Announcements aimed at recruiting participants [that] requested individuals who had sustained some change in homosexual orientation for at least 5 years.” So not only were they self-selected, but all those for whom re-orientation had failed had been sifted out in advance. They were poorly defined: they had to be “predominantly homosexual” (self-report, scored on a scale of 0-100) and to have experienced a change (in the direction of heterosexuality) of at least 10 points on the scale.
And a few more interesting facts: “These criteria were designed to identify individuals who reported at least some minimal change in sexual attraction, not merely a change in overt homosexual behavior or self-identity as “gay” or “straight.” It should be noted that individuals who satisfied these criteria were not excluded from the study if they had had homosexual sex during or following therapy.” If the individual is still having homosexual sex then what exactly constitutes “success”? “Forty-three percent of the 200 participants learned about the study from ex-gay religious ministries and 23% from the National Association for Research and Therapy of Homosexuality”. The rest were either recruited by their therapists or by other participants. The type of therapy participants received was not standardised and therefore varied wildly from psychological to pastoral counselling. Major methodological flaws are the recruitment of people who may be motivated towards self-deception (e.g. from ex-gay religious ministries) or even towards giving false information (out of a misguided sense of loyalty towards those who had tried to help them and who were also the ones urging them to participate in the study) and the lack of objective corroboration of the claims that have led to their selection in the first place.
“On all measures, the year prior to the therapy was compared to the year before the interview” – again, we see usage of the unreliable retrospective self-assessment. Spitzer admits that “Reports of complete change were uncommon”. An insightful statement of his encapsulates many of the psychological mechanisms that give rise to the dismissal of the subjective techniques used in such research: “Are the participants’ self-reports of change, by-and large, credible or are they biased because of self-deception, exaggeration, or even lying? This critical issue deserves careful examination in light of the participants’ and their spouses’ high motivation to provide data supporting the value of efforts to change sexual orientation.” This is immediately followed by: “Again, it is impossible to be sure, but comparing the actual results to the results that might be expected if such systematic bias were present suggests (at least to the author) that, by and-large, this is not the case.” This, of course is pure speculation based on nothing more than a hunch. He suggests that the presence of a bias would lead to a much higher reported change of sexual orientation. And why exactly is that? Is bias equally distributed? You can’t determine or even estimate the effect of an unmeasured factor. This is poor logical thinking, as is his assertion that bias would also lead to the female participants reporting a change of equal magnitude to that of the men. There is no examination of the mechanisms in action, and therefore no way of determining whether they have identical influence on men and on women.
He concludes: “Thus, there is evidence that change in sexual orientation following some form of reparative therapy does occur in some gay men and lesbians.” It is important to note that “To recruit the 200 participants, it was necessary to repeatedly send notices of the study over a 16-month period to a large number of participants who had undergone some form of reparative therapy. This suggests that the marked change in sexual orientation reported by almost all of the study subjects may be a rare or uncommon outcome of reparative therapy.” And: “The participants in the study all believed that the changes they experienced were due primarily to their therapy. However, the lack of a control group leaves the issue of causality open.”
Because there is no proof of causality, we cannot attribute any of the changes to the treatment. Any change reported could be the result of the strong Christian beliefs of individual participants, or other factors that had not been taken into consideration. Even the most enthusiastic, anxious-to-convert population is likely to return to homosexuality after some time, and only in a small number of cases did participants actually report maintaining heterosexual orientation over time. It is impossible to confirm that even those reporting heterosexuality had in fact changed their orientation or even their behaviour. It is impossible not to wonder why those approached were so reluctant to participate. You would expect someone who had undergone a “cure” of any kind to be enthusiastic about it and to want to “spread the word” through helping with related research.
Spitzer then says: “It probably is the case that reparative therapy rarely, if ever, results in heterosexual arousal that is as intense as a person who never had same sex attractions. However, advocates of reparative therapy do not make that claim. One would not judge a psychosocial treatment for a sexual dysfunction as a failure if it did not result in sexual function indistinguishable from that of individuals who never had experienced such a disorder.” But homosexuality is not a “sexual dysfunction”. This has strong implications for reorientation treatment: what is the ethical justification for trying to destroy someone’s natural (and therefore strong) sexual desire and replacing it with something that is not quite the real thing? Why is it justified for a therapist to cause psychological damage to someone in this context but not in any other context? Homosexuality is not a sexual dysfunction (such as paedophilia or any other form of sexual non-consensual aggression) and as such, there is no justification for it to be treated in a similar way.
Spitzer claims that “The findings of this study have implications for clinical practice. First, it questions the current conventional view that desire for therapy to change sexual orientation is always succumbing to societal pressure and irrational internalized homophobia. For some individuals, changing sexual orientation can be a rational, self-directed goal.” On what evidence does he base that? This is not supported by any facts or valid data gathered in his research. He continues: “Second, it suggests that the mental health professionals should stop moving in the direction of banning therapy that has as a goal a change in sexual orientation. Many patients, provided with informed consent about the possibility that they will be disappointed if the therapy does not succeed, can make a rational choice to work toward developing their heterosexual potential and minimizing their unwanted homosexual attractions.” The APA and the many other bodies that oppose this therapy, do so after careful consideration and in order to protect the public from unethical treatment and likely psychological damage. But above all, it is difficult to comprehend what motivates someone to promote a treatment that has never been proven to be effective.
An article[xxxv] that deals with issues in scientific sexology raises some interesting points that are of great significance for the pro-reorientation camp. It determines that the assessment of arousal based on penile circumference is unreliable and should therefore be replaced with the more sensitive method of measurement of penile volume. Use of the penile circumference method has led to the erroneous acceptance that existing therapy for sexual offenders is successful and that their sexual urges had been redirected. It transpired that, in fact, those who had received treatment had higher re-offending rates than those who hadn’t. It has also been accepted that statistical manipulation of the results gave the impression that such treatment had been effective and that reviews of existing studies had been used uncritically. This has huge ramifications for the existing assessment of the success of re-orientation treatment. If even certain types of physiological measurement can be inaccurate, then what does that say for the quality of research that relies on self-report? It is evident from this that existing research that is used to support the continuation of re-orientation is worthless. And what does this say about the efficacy of treatments that are purported to redirect sexual urges in general? It is now evident that not only is there no valid proof that such a feat is feasible, but that data has been manipulated to give the appearance of success. So, to recap: there is no evidence whatsoever that re-orientation treatment works, and, furthermore, there is no evidence that sexual urges of any kind can be successfully redirected.
Flawed logic and selective and misleading citations from scientific articles
In order to try and prove his point, Elitzur quotes selectively and misleadingly from scientific articles. His arguments sometimes do not comply with the strict rules of logic that have been laid down in the methodology of the social sciences. When it comes to proving that homosexuality is caused by child sexual abuse (CSA) and therefore makes a suitable case for treatment, he is let down by his extremely narrow focus on the subject and lack of understanding of the bigger picture. This is true of his handling of other issues as well.
In his discussion of the origins of homosexuality, Elitzur selectively quotes from an article[xxxvi]: “Amidst the conflicting findings, it seems that, whether operationalised in terms of gender atypicality or as a primary trait, sexual orientation has a substantial genetic component, and that this may be located on the X chromosome.” The underlining is Elitzur’s. The chapter from which it is taken analyses existing research on the subject of the psychobiology of sexual orientation, and the quote refers solely to what the results of that research seem to suggest. At this stage, the article offers no more than a listing of findings. Perhaps a more important quote (from the conclusions section) is “From a scientific viewpoint, the causes of homosexuality are irrelevant to whether it should be considered as a psychopathology. Homosexuality does not inherently cause personal distress (other than that due to society’s reaction to it) or prevent individuals from being productive and fulfilled members of society (Gonsiorek & Weinrich, 1991).” which of course contradicts several of Elitzur’s previous arguments.
Elitzur goes on to quote selectively from another article[xxxvii]: “The available evidence does not support the hypothesis that the brains of male homosexuals are structurally different from those of male heterosexuals.” He fails to quote that “establishing a distinction in the brain structures of homosexuals and heterosexuals is not the same as establishing a cause. The direction of causation may be difficult to establish because behaviour both affects and is affected by brain structure and function. In any case, our current understanding of the brain is inadequate to explain how such quantitative differences could account for such a complex phenomenon as homosexuality. Besides, there need not be a causal connection between sexual orientation and the brain structures in question. The two may be caused by a third variable such as a developmental event during gestation or early life.” The writer explains that neuroscience is not yet developed enough for us to be able to understand something as complex as homosexuality. He even raises the (not disproved) possibility of people being born homosexual. It all looks a bit different when one can see more than an isolated statement outside the main context.
Elitzur quotes from “Sex on the brain”[xxxviii]: “…it is possible that differences in sexual behaviour cause (rather than are caused by) differences in the brain.” It is indeed possible, but he has just told us that there are no differences in the brains of homosexuals and heterosexuals. The article specifically deals with how the frequency of adult sexual experience alters the appearance of rat motor neurons, so its direct relevance to the subject of human male homosexuality is not entirely clear. Next Elitzur mentions sexual abuse[xxxix] and the neurological damage it causes. If he is building a case for sexual behaviour as the cause of (changes in brain structures and resulting) homosexuality, then CSA is too complex a phenomenon to provide an adequate parallel. A review of research on the subject of the neurological effects of CSA [xl] cannot distinguish between the consequences of abuse and those of neglect, and does not rule out physical trauma as an additional cause. Children who are sexually abused are usually subject to the detrimental environmental factors that leave them open to such exploitation; and there is also the matter of the extreme stress that the abuse causes the child to experience. All these factors can have neurological consequences, therefore it is impossible to isolate the effects of sexual abuse.
A review and synthesis of the impact of CSA [xli] suggests that the trauma of sexual abuse leads to effects that are specific to sexual abuse and to the sexual act itself, to interact with the child’s prior vulnerabilities, the health or toxicity of the family environment, and the social response to the discovery of the abuse. But even if it were possible to isolate all the intervening factors and to conclude that CSA leads to neurological changes that lead to homosexuality, then Elitzur’s conclusion on the matter is contradictory for the case he is trying to make: if homosexuality is a product of brain scarring then how exactly is it reversible?
Elitzur claims that CSA is a cause of adult homosexuality. He presents us with research to back his point, but repeatedly fails to notice significant methodological failings. Major reviews of research on the subject[xlii] [xliii] pinpoint the problems that invalidate the results:
- There is a failure to use standardised or appropriate instruments. The assessment of childhood sexual experiences and adult interpersonal functioning is done many years after the fact and via self-report. That makes it highly unreliable.
- There are problems with definition and a failure to measure the severity of the abuse. Nearly all studies have classified participants as having either experienced or not experienced sexual abuse based on a set of criteria established by the investigators. Definitions vary to a degree that leads to inconsistencies in the definitions of “abuse” and “childhood”. This leads to discrepancies in the estimates of prevalence and the consequences, and prohibits us from generalising the conclusions.
- There are problems with validation. Adult retrospective reporting is unreliable: it can lead to non-reporting and to “false memory”. This could lead to adults being assigned to the wrong groups which makes a nonsense of the results.
- As already mentioned in the discussion of the neurological effects of CSA, additional contributory factors are ignored. The negative family functioning that often contributes to sexual abuse, also contributes to its consequences. Victim often experience interpersonal dysfunction, but the relationship between CSA and adult psychopathology diminishes or disappears altogether once other factors have been statistically controlled.
- The sampling in such research is often biased, providing non-representative groups (college students, clinic visitors). Even samples drawn from the community at large seem to be self-selected. There is a failure to use control groups.
I quote the conclusions of one of the reviews24: “In the absence of prospective designs, causal hypotheses about the relationship between CSA and adult interpersonal dysfunction cannot be confirmed.”
Let’s be clear about the facts on CSA and its effects on the victim. Victims are affected in four major areas: emotional/psychological, sexual adjustment, interpersonal relationships, and social functioning[xliv]. CSA is a complex issue with complex effects that go beyond the sexual abuse itself and cause great dysfunction in interpersonal relationships. Because too many factors on both the “causes” and the “effects” side cannot be isolated, there could be adults displaying behaviours that are outwardly indistinguishable from homosexuality but that are driven by completely different motivations; for instance, those driven by trauma to seek further victimisation in abusive relationships that mirror the CSA they experienced in their youth. A review of research on re-victimisation of adults who had experienced CSA[xlv] showed that those who showed re-victimisation behaviour had more symptoms of Post Traumatic Stress Disorder and dissociation. These are two severe psychiatric disorders. Another article[xlvi] finds additional correlation with sexual preoccupation and self-harm. Failing to distinguish between re-victimisation and homosexuality and, as a result, administering reorientation treatment to such damaged people is unprofessional, negligent and downright dangerous.
There is a general correlation between sexual abuse and a wide range of mental health problems and severe psychiatric illness in adulthood. It is unclear whether sexual problems experienced by victims are specifically caused by the sexual abuse in childhood or whether they are more related to the difficulties they experience in forming and maintaining trusting relationships. Sexual abuse survivors are at a greater risk of being re-victimised (either sexually or physically) in the context of couple relationship and sexual maladjustment is a common problem. “Given the broad range of outcome among sexual abuse victims, as well as the methodological weaknesses present in many of the studies reviewed, it is not possible at this time to postulate the existence of a “post-sexual-abuse-syndrome” with a specific course or outcome.[xlvii]” The effects vary enormously: some become hyper-sexualised as a result, others become asexual. Some become eternal victims, others become perpetrators. There is no algebraic formula that determines the outcome of CSA. These facts raise questions about the interpretation of homosexual relationships in this context. What Elitzur is doing is simplifying reality (thereby achieving a distorted reduction) in order to prove his point. He discards too many meaningful data on the way and is therefore left with something quite meaningless.
It is also important to reiterate the methodological shortcomings of seeking a cause for homosexuality in a clinical population. It is important not to forget that the research Elitzur uses is about the effects of CSA and not about the causes of homosexuality. It is Elitzur who chooses to present it in this light. This too has implications for the determination of causality. If you want to prove that homosexuality is a pathology that results directly from CSA, then it is advisable to also try and exclude the possibility of it occurring in any other way. A more robust way of showing that CSA causes homosexuality would be to examine a (statistically significant) cross-section of homosexuals and determine whether they had experienced CSA prior to becoming homosexual. Interestingly enough, no serious scientist has yet undertaken such a project. The most likely reason for that is that serious scientists do not like to waste time on prepositions that they know in advance to be ludicrous.
There are too many contradictions contained in Elitzur’s attempt to prove that homosexuality is caused by CSA. When confronting his critics, he denies that he is homophobic and claims to regard homosexuality as neither an illness nor an abnormality. At the same time, he believes it to be an effect of CSA. If X is the opposite of Y, then X and Y cannot be simultaneously true.
If Elitzur is suggesting that reorientation is the treatment suitable for victims of CSA, then he has no support from the scientific literature on the subject that determines that victims need to address the issues of abuse in treatment. Treating symptoms in isolation and, in doing so, taking actions that go against perceived wisdom, is very dangerous and can lead to a worsening of the situation[xlviii]. Recent reviews on the psychopathology[xlix] and treatment[l] of CSA suggest that it is associated with a number of psychiatric disorders and maladaptive lifestyles in childhood and adulthood. They found that successful treatments involved group therapy, combined individual and group play therapy and cognitive behaviour therapy. They concluded that treatment should be based on an explicit conceptual model of the psychopathology of sexual abuse and that a transactional model of treatment (teaches coping with stressors) is the most comprehensive and encompassing method. This model is the direct opposite of reorientation treatment: it promotes dealing with adversity as opposed to changing your nature in order to avoid it.
Victims of CSA are re-traumatised when they reveal what has happened to them to the outside world. They are often faced with disbelief, blame and rejection from those around them, driving them deeper into self-blame, self-hate, alienation and re-victimisation. One typically faulty coping strategy is denial. An empathic clinician within a supportive treatment network can provide vital credibility and endorsement. A review of the efficacy of treatment for victims of CSA[li] stresses the importance of using empirically validated interventions. It is clear that reorientation is not an option: it reinforces the negative self-image of the victim and it is not supported by valid science.
Elitzur also quotes a 1983 article that supports the idea that homosexuality in males is caused by hormonal changes in the womb. Reviews of existing research conclude that there is no convincing empirical evidence in support of the hormonal theory[lii]. “Sexual orientation and birth order”, are up next. Another selective quote[liii]: “Likelihood increases by 33% with every male elder brother”. The writers conclude, however, that only “roughly 1 gay man in 7 owes his sexual orientation to the fraternal birth order effect.” Elitzur then goes on to quote from a Bogaert article[liv]: “The birth order effect seems to be one of the more robust findings in human sexology.” And “One of the more impressive elements of the birth order effect is its generalisability.” It is unfortunate that he chose to ignore the “1 in 7” information from the other article.
Elitzur cites the article “Fathers of male homosexuals: a collective clinical profile”, in which the psychoanalytic theory of homosexuality and the child-parent relationship is presented as fact. As we have already seen, psychoanalysis is not generally considered a scientific discipline. Even so, the views presented are outdated. I quote from an extensive review undertaken in 2000[lv]: “It was generally held that psychoanalysis could and should convert sexual orientation from homosexual to heterosexual (Socarides, 1978). These ideas are formally viewed as being outdated and invalid by the American Psychoanalytic Association. Psychoanalysis is an international enterprise, however, attitudes towards homosexuality in some European and Latin American countries tend to be those that were in vogue in North America in the 1950s.” Even the main psychoanalytic body has rejected reorientation treatment. The only article (Nicolosi’s) that I did manage to find on the subject has such numerous logical fallacies that it is no wonder that no scientific journal would agree to publish it.
Flawed logic and selective citations result in a failure once again to prove his point. Elitzur shows that he lacks the required deep acquaintance with the subject and the related disciplines.
Is ETAM’s decision to give Dr Elitzur a platform vindicated?
Modern medical practice requires an adequate evidence base for treatments[lvi]. In addition to that, the World Association of Sexology’s Declaration of Sexual Rights[lvii] clearly specifies the right to sexual information based on scientific enquiry. Since homosexuality is not on the list of sexual health problems that qualify for treatment by sexologists (homophobia, however, is[lviii]), ETAM’s decision to provide a platform for the pro-reorientation lecture is difficult to understand.
According to Dr Ronit Aloni of ETAM, Elitzur was invited because he had a valid point to present and, as a scientist, he was qualified to present it. Let us summarise Dr Elitzur’s credentials (this is an excerpt from the CV on his homepage). Elitzur is somewhat of an oddity in the scientific community – he describes himself as an autodidact: he left school at 16 and later obtained a PhD from the Cohn Institute for the Philosophy of Science and the Department of Physics at Tel-Aviv University. Highly unusually he has no other degrees. Elitzur states his fields of research as physics, biology and psychology (specifically: psychoanalysis, humour, religious experience, aetiology of mental diseases, suicide prevention).
Elitzur has no published record in the fields of sexual identity and sexual treatment. Articles specifically relating to research in psychology can be misleading in this context: he has no formal background in the research methodology and the statistical analysis used in social sciences, which is vital if one is to reach the correct conclusions from the use of such techniques (e.g. the relationship between theory and research, the nature of causation, the application of research design, the issue of measurement, and the various research methods). There is no evidence that he has conducted any independent controlled experiments (in the field of psychology, for instance). Rather, he publishes his reflections on a subject, sometimes reviewing existing papers that contain analyses of research performed by others.
Elitzur’s interest in psychology stems from a lifelong fascination with psychoanalysis, but a deep acquaintance with psychoanalysis is no substitute for a thorough knowledge of psychology. It does not qualify one to pass judgement on (or reject) the decisions of those who possess an expertise in the full range of psychological or psychiatric disciplines, especially in the field of psychological research and its correct methodology.
It is difficult to see how ETAM can justify their invitation to Elitzur. He has no formal qualifications or expertise on the subject on which he was asked to speak. Furthermore, what he is promoting goes against the professional and ethical standards of sexology.
Clearly, none of Elitzur’s claims in support of reorientation treatment stands up to scientific scrutiny. Reorientation is a pseudo-science whose origins lie in religion and classic psychoanalysis. A significant proportion of the material Elitzur uses to back his argument is not only non-scientific, but much of it is also highly speculative and even homophobic. He tries to justify his stance by showing the distress experienced by homosexuals, but, if anything, the most significant stressor for many homosexuals is society’s attitude towards them – something that, ironically, reorientation treatment only helps to exacerbate. It is evident that he is very poorly informed about the reality of the life of homosexuals.
Elitzur fails to establish a viable foundation for reorientation treatment. Valid scientific research contradicts his claims (that homosexuals’ lives are distressing, that the APA’s opposition is invalid and that homosexuality is caused by environmental factors and is therefore changeable) and removes his basic justification for the treatment. He relies heavily on some very dubious pseudo-scientific sources with a preset (anti-homosexual) agenda. Almost without fail, the material that forms the backbone of Elitzur’s lecture is shown to be scientifically worthless. As a result, his whole case for reorientation treatment is baseless. It is clear that he is not an expert source. A large number of scientific articles used by him to prove his case are methodologically flawed to an extent that invalidates their results and conclusions. Nevertheless, Elitzur presents their findings as valid proof. There is no evidence that re-orientation treatment works, or that sexual urges of any kind can be successfully redirected. Elitzur resorts to flawed logic and selective citations in order to try and prove his point. He repeatedly shows that he lacks the required deep acquaintance with the subject and the related disciplines.
It is worrying to note that Elitzur’s views have been widely and uncritically reported in various Israeli popular media, allowing people who are not in possession of all the facts to be swayed. It is worrying too that the professional members of ETAM have exercised little control over the quality of material that is presented at their symposia. Homosexuals, their families and the public at large have a right to be adequately informed and warned about the misinformation (and disinformation) peddled by the established pro-reorientation camp and the dangers that this treatment poses. They should be able to rely on the bodies that are supposed to protect them. It is not too much to expect such bodies to act according to international standards of ethics and human respect. They should be able to trust that, when they seek therapy, not only will they receive appropriate help, but – above all – that they will not be harmed.
– – –
I would like to thank Oded Mor for his help and his insightful and constructive comments.
* An accepted term for homosexuals at the time
[i] The Practice and Ethics of Sexual Orientation Conversion Therapy. Douglas C. Haldeman. Journal of Consulting and Clinical Psychology. 1994, Vol. 62, No. 2, 221-227.
[ii] Psychoanalysis and the model of homosexuality. Friedman & Downey. The American Journal of Psychoanalysis. Vol. 58, No. 3, 1998.
[iii] The Practice and Ethics of Sexual Orientation Conversion Therapy. Douglas C. Haldeman. Journal of Consulting and Clinical Psychology. 1994, Vol. 62, No. 2, 221-227.
[iv] Martin, A. (1984). The emperor’s new clothes: Modern attempts to change sexual orientation. In E. S. Hetrick & T. S. Stein (Eds.), Innovations in psychotherapy with homosexuals (pp. 24-57). Washington, DC: American Psychiatric Association.
[v] Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation. Robert L. Spitzer, M.D. Archives of Sexual Behavior, Vol. 32, No. 5, October 2003, pp. 403–417.
[vi] American organisations supporting the APA stand on reorientation treatment: American Academy of Pediatrics, American Federation of Teachers, American Medical Association, American Psychiatric Association, American Psychological Association, The Interfaith Alliance, National Association of School Psychologists, National Association of Social Workers, National Association of Secondary School Principals, National Education Association, New Ways Ministries, People for the American Way
[vii] APA Document Reference No. 200001. Therapies Focused on Attempts to Change Sexual
Orientation (Reparative or Conversion Therapies). COPP Position Statement. Approved by the Board of Trustees, March 2000. Approved by the Assembly, May 2000.
[viii] BMJ USA editorial. BMJ 2004;328:E287-E288, 17 April.
[ix] Changing Sexual Orientation: A Consumers’ Report. Ariel Shidlo & Michael Schroeder. Professional Psychology: Research and Practice. 2002, Vol. 33, No. 3, 249–259.
[x] The empirical basis for the demise of the illness model of homosexuality. JC Gonsiorek. Homosexuality: Research implications for public policy, Sage, 1991.
[xi] Family relationships of lesbian and gay men. Charlotte J. Patterson. Journal of Marriage and Family. Vol. 62, issue 4, page 1052 – November 2000.
[xii] Are Gay and Lesbian cohabiting couples really different from heterosexual married couples? Lawrence A. Kurdek. Journal of Marriage and Family. Volume 66 Issue 4 Page 880 – November 2004.
[xiii] Psychosocial Adjustment, School Outcomes, and Romantic Relationships of
Adolescents With Same-Sex Parents. Jennifer L. Wainright, Stephen T. Russell, and Charlotte J. Patterson. Child Development, November/December 2004, Volume 75, Number 6, Pages 1886 – 1898
[xiv] Experience of parenthood, couple relationship, social support, and child-rearing goals in planned lesbian mother families. Henny M.W. Bos, Frank van Balen, and Dymphna C. van den Boom. Journal of Child Psychology and Psychiatry. Volume 45 Issue 4 Page 755 – May 2004.
[xv] AIDS stigma and sexual prejudice. Gregory M Herek & John P Capitanio. American Behavioral Scientist, 1999, 42, 1126-1143.
[xvi] On the history of biological theories of homosexuality. Herrn R. J Homosex. 1995;28(1-2):31-56.
[xvii] Male homosexuality: a contemporary psychoanalytic perspective Friedman RC. Arch Sex Behav. 1991 Apr;20(2):219-20.
[xviii] Changing Sexual Orientation: A Consumers’ Report. Ariel Shidlo & Michael Schroeder. Professional Psychology: Research and Practice. 2002, Vol. 33, No. 3, 249–259.
[xix] Dr. Laura’s Website, December 8, 1998.
[xx] Dr. Laura’s radio show, August 13, 1999 (quoted by CBSC).
[xxi] Dr. Laura radio show, August 13, 1999 (quoted by the Canadian Broadcast Standards Council (CBSC)).
[xxii] Private Pain, Public Purges: A History of Homosexuality at Brigham Young University, 1940-1980. Connell O’Donovan. Preface to lecture given on April 28, 1997 at University of California, Santa Cruz, on the history of homosexuality at Brigham Young University (BYU).
[xxiii] Neurobiology: Sexual orientation and the size of the anterior commissure in the human brain(homosexuality/sex difference/sexual differentiation). Laura S. Allen & Roger A. Gorski. Proc. Nati. Acad. Sci. USA. Vol. 89, pp. 7199-7202, August 1992.
[xxiv] Comparative Data of Childhood and Adolescence Molestation in Heterosexual and Homosexual Persons. Marie E. Tomeo, Donald I. Templer, Susan Anderson, Debra Kotler. Archives of Sexual Behavior. 30 (5): 535-541, October 2001.
[xxv] The Science of Desire. Hamer DH & Copeland P. Simon and Schuster, New York, 1994.
[xxvi] Early effeminate behavior in boys. Outcome and significance for homosexuality. Zuger B. J Nerv Ment Dis. 1984 Feb;172(2):90-7.
[xxvii] Corydon. André Gide. University of Illinois Press. First Illinois Paperback, 2001. English translation copyright © 1983 by Farrar, Straus and Giroux LLC.
[xxix] Homosexuality and the possibility of change: An ongoing research project. Goetze, R. Retrieved October 16, 2002, from http://www.newdirection.ca/research/index.html. 2001.
[xxx] Parents of homosexuals–not guilty? Interpretation of childhood psychological data. van den Aardweg GJ. Am J Psychother. 1984 Apr;38(2):180-9.
[xxxi] Conceptual factors in the treatment of paraphilias: a preliminary report. Schwartz MF, Masters WH. J Sex Marital Ther. 1983 Spring; 9(1):3-18.
[xxxii] The Masters and Johnson treatment program for dissatisfied homosexual men. MF Schwartz and WH Masters. Am J Psychiatry 1984; 141:173-181.
[xxxiii] Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation. Robert L. Spitzer, M.D. Archives of Sexual Behavior, Vol. 32, No. 5, October 2003, pp. 403–417.
[xxxiv] Evaluating Interventions to Alter Sexual Orientation: Methodological and Ethical Considerations. (Comment on Spitzer, 2003). Gregory M. Herek, Ph.D. Archives of Sexual Behavior, 32(5), 438-439. 2003.
[xxxv] Unresolved Issues in Scientific Sexology. Nathaniel McConaghy. Archives of Sexual Behavior.
28 (4): 285-318, August 1 1999.
[xxxvi] Review: Born gay? The psychobiology of human sexual orientation. Qazi Rahman, Glenn D.Wilson. Personality and Individual Differences 34 (2003) 1337–1382.
[xxxvii] Sexual orientation and brain structures: a critical review of recent research. Mbugua, K. Current Science, 84: 173-178.
[xxxviii] Sex on the brain. S. Marc Breedlove. Nature 389, 801 (23 October 1997).
[xxxix] Scars that won’t heal: the neurobiology of child abuse. Teicher MH. Sci Am. 2002 Mar; 286(3):68-75.
[xl] Child Abuse and Neglect and the Brain—A Review. Danya Glaser. Journal of Child Psychology and Psychiatry (2000), 41:97-116 Cambridge University Press.
[xli] Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Kathleen A. Kendall-Tackett, Linda Meyer Williams, David Finkelhor. Psychological Bulletin. January 1993, vol. 113, no. 1, 164-180.
[xlii] Child sexual abuse: immediate and long-term effects and intervention. Green AH. J Am Acad Child Adolesc Psychiatry. 1993 Sep;32(5):890-902.
[xliii] Interpersonal functioning among women reporting a history of childhood sexual abuse: empirical findings and methodological issues. David DiLillo. Clinical Psychology Review. Vol. 21, No. 4, pp 553-577, 2001.
[xliv] Adult sequelae of child sexual abuse. Sheldrick C. Br J Psychiatry Suppl. 1991 May;(10):55-62.
[xlv] Child Sexual Abuse and Sexual Revictimization. Catalina M. Arata. Clinical Psychology: Science and Practice V9 N2, 2002.
[xlvi] Revictimization and Self-Harm in Females Who Experienced Childhood Sexual Abuse. Jennie G. Noll, Lisa A. Horowitz, George A. Bonanno, Penelope K. Trickett, Frank W. Putnam. Journal of Interpersonal Violence, Vol. 18, No. 12, 1452-1471 (2003).
[xlvii] A review of the short-term effects of child sexual abuse. Beitchman JH, Zucker KJ, Hood JE, daCosta GA, Akman D. Child Abuse Negl. 1991;15(4):537-56.
[xlviii] The child sexual abuse accommodation syndrome. Summit RC. Child Abuse Negl. 1983;7(2):177-93.
[xlix] Child sexual abuse I: psychopathology. Barry Nurcombe. Australian and New Zealand Journal of Psychiatry. Volume 34 Issue 1 Page 85 – February 2000.
[l] Child sexual abuse II: treatment. Barry Nurcombe, Sally Wooding, Peter Marrington, Leonard Bickman, Gwenneth Roberts. Australian and New Zealand Journal of Psychiatry. Volume 34 Issue 1 Page 92 – February 2000.
[li] Efficacy of treatment for victims of child sexual abuse. Beutler LE, Williams RE, Zetzer HA. Future Child. 1994 Summer-Fall;4(2):156-75.
[lii] Biological Research on Women’s Sexual Orientations: Evaluating the Scientific Evidence. Rosemary C. Veniegas & Terri D. Conley. Journal of Social Issues. Volume 56, Issue 2, Page 267 – Summer 2000.
[liii] How Many Gay Men Owe Their Sexual Orientation to Fraternal Birth Order? James M. Cantor, Ray Blanchard, Andrew D. Paterson, Anthony F. Bogaert. Archives of Sexual Behavior. 31 (1): 63-71, February 2002
[liv] Birth order and sexual orientation in a national probability sample. Bogaert (2000). Journal of Sex Research.
[lv] Psychoanalysis and sexual fantasies. Richard C. Friedman & Jennifer I. Downey. Archives of Sexual Behavior. 29 (6): 567-586, December 2000.
[lvii] Adopted in Hong Kong at the 14th World Congress of Sexology, August 26, 1999.
[lviii] Promotion of Sexual Health – Recommendations for Action. Pan American Health Organization, World Health Organization, in collaboration with the World Association for Sexology. May 19-22, 2000