A Closer Look at Dr. James Holsinger’s “Pathophysiology of Male Homosexuality”
June 11th, 2007
President Bush’s nomination of Dr. James Holsinger to be the next Surgeon General continues to raise concerns among several leading gay rights advocates. Alarms first went up when we learned that Holsinger co-founded a church which sponsors an ex-gay ministry. That discovery reinforced other well-known facts about his tenure on the United Methodist Judicial Council, where he opposed the 2004 decision to allow Rev. Karen Dammann, a lesbian, to continue serving as a minister. He also backed the defrocking of Rev. Beth Stroud, another lesbian minister, and he supported a Virginia pastor who barred an openly gay man from church membership.
Most of those concerns, by themselves, have little direct bearing on his future role as Surgeon General. We should remember that Dr. C. Everett Koop was also an evangelical Christian, and he was able to aside whatever qualms he may have had to become a outspoken advocate for sanity during the AIDS crisis. Not only that, but Dr. Koop battled powerful forces within the Reagan administration to do this, and he created many enemies among his fellow social conservatives. Dr. Koop showed considerable medical integrity and moral bravery in standing firm against the pervasive stigma which gay men were experiencing at the time.
But there is troubling evidence which suggests that Dr. Holsinger is no C. Everett Koop. Holsinger wrote a 1991 white paper for the United Methodist Church’s Committee to Study Homosexuality titled, “Pathophysiology of Male Homosexuality,” (PDF: 752 KB/8 pages) where he tries to give a scientific opinion that gay male relationships are inherently inferior because “when the complementarity of the sexes is breached, injuries and diseases may occur.”
That paper, dressed up as a considered medical opinion backed by a bibliography drawn from professional sources, would likely appear to be rather impressive to the lay reader (as most members of the committee were). But a closer examination of that paper reveals very little of scientific value. Worse, it shows a startling eagerness to pull evidence out of context to provide damning evidence against gay men, while willfully ignoring counter evidence in the same literature which essentially destroys the core of his arguments.
Holsinger’s Scientific Evidence
Holsinger began his “scientific” examination by recounting the reproductive role of male and female genitalia. He then went on to observe that the rectum doesn’t perform such a role, and is, in his estimation, unsuitable for intercourse. He cited Agnew (1986)1 to say:
The rectum is incapable of mechanical protection against abrasion and severe damage to the colonic mucosa can result if objects that are large, sharp or pointed are inserted into the rectum (Agnew 1986.)
As you can surmise from the quoted text, Agnew’s paper deals largely with foreign objects, not intercourse. But before the reader can notice this discrepancy, Holsinger quickly dropped the subject of foreign objects (he will return to it later) to begin a broader outline of conditions “found in homosexually active men.” Holsinger quoted Owen (1985, although the paper is missing from Holsinger’s bibliography):2
Four general groups of conditions may be found in homosexually active men: classical sexually transmitted diseases… enteric diseases… trauma… and the acquired immunodeficiency syndrome (AIDS).
This much is true. These conditions may be found among some homosexually active men. They may also be found in heterosexually active men and women. But to justify his singling out of gay men, Holsinger cited another study to say that STD’s are “strongly correlated to sexual lifestyle,” and presents a large number of statistics for an impressive list of diseases. Unfortunately, the statistics were given without context, leaving the impression that they are representative of all gay men.
But what is that context? It turns out that these statistics came from one lone study consisting of a convenience sample of 365 male patients, all of whom attended a single urban STD clinic in Copenhagen over a seven month period in 1983.3
This is not a representative study at all. It’s not even a representative study of gay men in downtown Copenhagen. It tells us nothing about rural or suburban Danish men. More importantly, it doesn’t tell us anything about gay men who don’t need the services of an STD clinic. It doesn’t even tell us anything about gay or straight men who attend other STD clinics besides the single clinic that performed this study. It is, at best, a snapshot of a small population from one urban center over a short period of time, taken eight years before Holsinger’s paper was written.
This of course means that if you study people with STDs, whether they are gay or straight, you will find people with STDs. Holsinger uses the behavior of one particular sample of men who expose themselves to the risk of STDs to denigrate all gay men (and lesbians!). This study says nothing of those whose “lifestyle” choices do not lead to contracting STDs. And of course, Holsinger’s arguments don’t address whatever responsibility heterosexuals overall have for the 64% of this particular Copenhagen sample who were exclusively straight and were treated for STDs.
After dealing briefly with sexually transmitted diseases, Holsinger introduced the squeamish subject of anorectal trauma, again implying that it is a common condition among gay men. He opened this line of argument by repeating this statement from Bush (1986):4
Consensual penile-anal intercourse can be performed safely. Few anorectal problems and no evidence of anal-sphincter dysfunction are found in heterosexual women who have anal-receptive intercourse. However, forceful anal penetration without lubrication against a resistant sphincter will result in abrasive trauma, causing fissures, contusions, thrombosed hemorrhoids, lacerations with bleeding, pain, and psychic trauma.
Notice what’s going on here. If intercourse is consensual, then everything’s okay. After all, they see few problems among straight women. But if it’s not consensual then damage can occur. This statement seems to preclude the possibility that gay men can have consensual sex, doesn’t it?
Holsinger seems to agree. The entire premise of his “scientific” evidence is not based on the ordinary bonds of affection that arise between committed gay and lesbian couples. Nor is it even based on the ordinary physical expressions of that love that occur in a mutually supportive and consensual basis. Instead, all three sources that Holsinger quoted from in this section (Bush, 1986; Geist, 1988; and Agnew, 1986)5 describe conditions that were found among men and women treated in emergency room settings. And much of the evidence provided in the Bush and Geist papers were the result of sexual assault, not consensual sex. It’s no wonder Holsinger is able to find so many alarming medical problems. But what does his evidence have to do with gay and lesbian couples in love? Well, the answer is simple. It’s no more relevant than the serial rapist is to the average loving heterosexual couple.
Holsinger then returned to the topic of foreign objects which were removed in emergency room settings. But he utterly failed to recognize, as Geist did, that many of these patients were heterosexual men and women. From Geist, Holsinger undoubtedly read that:
Anal erotic practices are incorrectly presumed by many to be limited to male homosexuals. A significant number of heterosexual men, heterosexual women and lesbian women also enjoy and practice anal sexual stimulation. Bolling’s mid-1970s study, which included a wide cross-section of gynecology clinic patients, revealed that 25 per cent practiced analingus. Eight percent of the women included anal intercourse as a regular part of their sexual repertoire.
Most of Geist’s paper describes injuries resulting from heterosexual activities, including vaginal and anorectal injuries to women during consensual activity. The paper also includes a large section describing injuries sustained during adult heterosexual rape and child sexual abuse. None of that was even hinted at in Holsinger’s paper. Instead, Holsinger cherry-picked from all of this evidence a few short passages to lambaste consensual relationships among gay men.
An Oddly Padded Bibliography
It’s at this point in the paper where Holsinger brought up the practice of “fisting”:
The most severe type of anorectal trauma follows fist fornication which during the 1970s was practiced by approximately 5% of the male homosexual population.
Five percent of a small minority seems hardly worth mentioning, but Holsinger went ahead and talked about it anyway. And this is where his bibliography gets interesting. His bibliography includes a letter to the editor by Carlo Torro with the eye-catching title, “Delayed death from ‘fisting’,” a letter that Hollinger didn’t refer to in the text of paper.6
And why didn’t Holsinger describe the contents of the letter? The reason is obvious. The letter describes a woman who had died of sepsis as a result of engaging in this practice with her husband! Of course, there’s no hint of this in the letter’s title. The only possible reason for Holsinger to include the letter in the bibliography is to gain whatever advantage he can from the letter’s title.
This is probably among Holsinger’s most egregious abuses of the medical literature. He has already denigrated consensual relationships of gay men by using examples drawn from emergency room traumas that include heterosexual couples. As if that weren’t enough, Holsinger padded his bibliography with an entry that has nothing to do with gay men whatsoever.
And that’s not just a one-time “mistake” either. He padded his bibliography again with another paper that he didn’t reference in his article, one by David B. Busch and James R. Starling, titled, “Rectal foreign bodies: Case reports and a comprehensive review of the world’s literature.”7 Given the title of the paper and the context in which it appears in Holsinger’s bibliography, one might assume that the paper presents case reports from all over the world of gay men sticking things inside themselves.
Well, they’d be wrong. The authors introduce their report with two case cases, both of whom were straight. One was a 39-year-old married man with a perfume bottle inserted in his rectum. Busch and Starling used these two examples to illustrate an important point:
As in the great majority of published cases, both patients reported no history of a gay life-style. It does not seem possible to generalize about the sexual preferences of male patients (ratio of heterosexual, bisexual, and homosexual patients) presenting with rectal foreign bodies, since very few of the reports provide such information. … Obviously both anal intercourse and foreign body insertion involve stimulation of the same area of the body, but the literature fails to provide sufficient information from which to draw any conclusions about whether foreign body self-insertion is in fact predominantly performed by men practicing anal intercourse.
It’s not unusual for bibliographies to include sources which aren’t referenced in the body of a paper. Bibliographies often provide additional reference material should someone want to investigate further. But one would expect the bibliographic entries to be relevant, and these two entries clearly are not.
So why did he include these two papers in his bibliography? Did he suppose the other members of the UMC committee would look up these bibliographical references for further study? The answer is more likely that he assumed that they wouldn’t. After all, very few people do. And so adding these two provocatively-titled entries to his bibliography is all the more suspicious, especially now that we’ve seen how selectively he quoted from the studies that he did mention in his text.
Holsinger closed his “scientific” portion of his paper with a discussion of anal cancer, which is more common among gay men than straight men. At that time, it was strongly suspected that the human papillomavirus (HPV) was the culprit. What we now know is that those same HPV strains are also responsible for causing cervical cancer. In fact, for gays and straights alike, the single greatest risk factor for contracting HPV is sex with men, who are the primary carriers of HPV. While we know this to be true today, it may not have been so clear in 1991. So I’m willing to give Holsinger something of a pass on this one.
The whole point of Holsinger’s paper is to draw a sharp contrast between gay relationships and heterosexual relationships. But to do so, he culls his evidence largely from papers which describe injuries from nonconsensual intercourse to denigrate consensual relationships, he describes odd sexual practices that are enjoyed by heterosexual couples to denigrate the minority of gay couples who indulge in those same practices, and he misleads his readers by padding his bibliography with more references to papers explicitly describing injuries experienced by heterosexual men and women to imply that they describe gay men instead.
In other words, to describe gay sexual acts, more often than not he turned to papers which describe injuries sustained through heterosexual activity. And then he used this evidence from heterosexual activity to say that “when the complementarity of the sexes is breached, injuries and diseases may occur as noted above.” But what does this evidence suggest about “complementarity” in heterosexual relationships? Holsinger doesn’t answer.
But worse, Holsinger made the fatal error of ignoring the bonds of affection and devotion that arise in gay and lesbian couples. He reduced the rich complexity of their relationships to pipe fittings and how they interlock with each other. But the interlocking parts that fit together in relationships are those parts that fit sublimely. They have absolutely nothing to do with pipes or connectors or any other analogies drawn from the local Ace Hardware store.
Whatever pretensions Holsinger may have had to presenting a scientific argument, this paper does not rise to that level. In fact, Holsinger deployed many of the same tactics other anti-gay extremists use in writing common anti-gay tracts. The result is not science, but propaganda.
The Human Rights Campaign’s Joe Solmonese, in opposing Holsinger’s nomination, points out that, “it is essential that America’s top doctor value sound science over anti-gay ideology.” This paper shows no evidence that Holsinger holds to such values. What he wrote was no error, nor is it a simple misreading of the medical literature. In fact, it is simply impossible to write what he wrote by accident or in error.
Holsinger wrote this paper as part of a church inquiry where the greater considerations for Truth ought to hold sway. This makes Holsinger’s actions all the more disquieting. If he’s willing to commit an act of false witness on behalf of the church — in the service of his God — what assurances can we have that he will act differently on behalf of the nation?
3. Christophersen, Jette; Menné, Torkil; Friis-Møller, Alice; Nielsen, Jens O.; Hansted, Birgitte; Øhlenschlæger. “Sexually transmitted diseases in hetero-, homo- and bisexual males in Copenhagen.” Danish Medical Bulletin 35, no. 3 (June 1988): 285-288.
Bush, Robert A., Hr.; Owen, William F., Jr. “Trauma and other noninfectious problems in homosexual men.” Medical Clinics of North America 70, no. 3 (May 1986): 549-566.
Geist, Richard F. “Sexually related trauma.” Emergency Medicine Clinics of North America 6, no. 3 (August 1988): 439-466.