Last week, the Guardian reported a controversy regarding an iPhone and iPad app for Exodus International. Exodus is an ex-gay ministry promising "freedom from homosexuality through the power of Jesus". The Exodus website homepage displayed a "4+" consumer rating from Apple, signifying "no objectionable material" in the app.
According to other news reports, almost 150,000 person petitioned Apple to remove the app in a public action led by an organisation called Truth Wins Out (TWO). As part of its work, TWO checks the facts about homosexuality in published materials; and it notifies scientists of possible misrepresentations of research findings. Through TWO, I learned of erroneous references to my work in an article by Jeff Buchanan, a senior director at Exodus, accessible through the Exodus app.
The work in question (Remafedi et al, 1992) was a report of research done with about 36,000 Minnesota secondary school students. It is one of the largest studies of adolescent sexual orientation done to date; and it was published in a high impact peer-reviewed journal, Pediatrics. This was one of several reports of mine that have been repeatedly misrepresented in recent years.
Although each episode had its unique features, some recurring themes, issues and errors (for example, a characteristic misspelling of my surname and a consistent error in a citation date) have emerged from the muck. I have responded consistently and specifically to the misrepresentations that have come to my attention. Addressing each incident has been, frankly, a time-consuming nuisance – especially since some of the references to my work have been so far afield from the original writings that there was reason to doubt they were even read.
In this most recent case, I wrote to Apple CEOs Jobs and Cook on 21 March about the misrepresentation of our work in an article accessible via the Exodus app. Retraction of the 4+ rating and deletion of the app were requested as relief. The complaint was directed to Apple, instead of Exodus, because of the risk of spreading and perpetuating misinformation to iPhone users via the app.
A spokesperson for Apple, quoted in the Minneapolis Star Tribune, explained the final decision:
"We removed the Exodus International app from the App Store because it violates our developer guidelines by being offensive to large groups of people."
Although the conclusion was welcomed, the statement opened the door to new criticisms that Apple had caved in to a public rabble and washed its hands of the matter. According to WebProNews, Exodus International President Chambers tweeted the reaction: "Incredibly disappointing. Watch out, it could happen to you."
In the aftermath of the decision, there were lingering questions about: the app's original approval and 4+ rating, the decision to remove it, Exodus's interest in my research, and lessons to be learned from the incident. Tackling these issues requires some basic information about US law and scientific knowledge of homosexuality.
The first amendment of the United States Constitution provides freedom of religion and freedom of expression from governmental interference. It states:
"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances."
Under the first amendment, corporations like Apple have no obligation to publish every app that comes their way. On the contrary, it permits businesses to conduct their affairs without legislative interference, unless a compelling public interest is at stake. According to Thomas Jefferson, one of the framers, the first amendment also puts a "wall of separation" between church and state; and subsequent laws have bolstered it by prohibiting discrimination in the workplace based on religion or lack thereof. Thus, there is no reason to factor religious considerations into commercial decisions like Apple's as a matter of law.
The freedoms afforded by the first amendment are core values, precious to the American people. Still, there are limits to the expression of speech and religion. For example, the first amendment does not protect the expression of ideas that incite crime, violence or reckless public endangerment. There are other limits on the exercise of religious beliefs. The American Academy of Pediatrics has asserted:
"Constitutional guarantees of freedom of religion do not permit children to be harmed through religious practices, nor do they allow religion to be a valid legal defense when an individual harms or neglects a child." (See American Academy of Pediatrics, Policy Statement "Religious Objections to Medical Care".)
In my opinion, efforts to promote and provide so-called reparative therapy cross the boundaries of protected speech under the first amendment at this time in history, especially when it comes to children and minors. From a medical and scientific perspective, homosexuality is not a medical or mental health condition. Based on the findings of multiple investigators from various disciples over decades of research, a powerful case can be made that claims to cure or change sexual orientation are patently false. The American Medical Association, the American Psychiatric Association, the American Academic of Pediatrics, the American Counseling Association and other professional organisations have found such practices to be unwarranted, ineffective, unethical and harmful, and have opposed them in no uncertain terms.
According to the Roman axiom, caveat emptor (aka "buyer beware"), adopted into British-based common law, competent adults who seek unorthodox treatments to repair "broken sexual identities" may do so at their own risk. However, where children and vulnerable adults are involved, caveat emptor does not apply; and the burden of proving that treatments are safe and effective shifts to adults who should know better.
This may explain why groups like Exodus International have kept my work in their sights. Without scientific grounds for their stand on the treatment issues, such groups have either taken pot shots at seminal research that is incompatible with their practices or have twisted the findings to suit their own purposes.
Adolescent sexuality and its health implications have been the central themes of my research in pediatrics and adolescent medicine. When the work began some 25 years ago, "homosexuality" and other versions of the diagnosis (for example, "ego dystonic homosexuality") had recently been removed from the Diagnostic and Statistical Manual of Psychiatry. The existence of homosexual children and youth was barely recognised; and homosexuality was widely believed to be an adult phenomenon. Children and youth who said they were gay were considered misguided, delusional and in need of psychiatric attention.
Early studies done with colleagues in pediatrics and public health were among the first to involve youth with well-established gay identities. They chronicled the normal processes of sexual orientation development in childhood and adolescence. They described the impact of isolation and stigma on the occurrence of medical and psychosocial problems. Based on what was learned about adolescent sexual behavior, the spread of HIV/Aids to adolescents was anticipated at a time when the illness was known only as an adult "gay-related immune deficiency". The research led to the establishment of the Youth and Aids Projects, one of the first HIV/Aids service organisations for young people. Beyond HIV/Aids, the research has uncovered evidence of other significant healthcare disparities related to sexual orientation and suicide, substance use, tobacco use, eating disorders and other problems of public health significance.
At the risk of sounding self-congratulatory, these works are mentioned as the basis of actions taken to stop distortions of research and harm to vulnerable children and youth. I wrote to Apple asking that the corporation remove an app from the iPhone because it misrepresented our findings and used them in support of erroneous claims that adolescents are confused about sexual orientation and that they can be changed. As I wrote then, and still believe now, associating my work with these claims was "professionally injurious and grievous".
There are many lessons to be learned from the incident. Controversy around Exodus's app was predictable and preventable. By definition, an app that could be expected to draw complaints from thousands of people did not meet Apple's established criteria for a 4+ rating. To my knowledge, there has been no explanation of the rating, acknowledgment of responsibility, expression of appreciation for the gravity of the incident, or any amends made on behalf of consumers who were hurt. Any and all of such remedies would help allay dissatisfaction at the way the matter was handled.
In the future, it would be appropriate for IT corporations to screen the contents of smartphones apps carefully. In the interest of fairness, corporate quality control review processes and rating standards should be objective, fair and transparent. It would be reasonable to ask vendors to describe their organisations and target audiences, provide up-to-date inventories of online contents, and anticipate the potential risks for consumers and sponsors.
Under the guise of the first amendment, groups like Exodus International can be expected to promote so-called reparative therapy and misconstrue research that exposes its fallacious premises. This is not likely to stop until injured parties come forward to claim relief for the harms they have incurred. Until then, this investigator will continue doing what he can to assure that scientific finding are translated to general audiences with fidelity and integrity.
