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from What do clinical studies say?
Attempts to Modify Sexual Orientation:
A Review of Outcome Literature and Ethical Issues
By Warren Throckmorton, Ph.D.
This article appeared in the October 1998 issue (volume 20,
pages 283-304) of the Journal of Mental Health Counseling. It is
reprinted here, by permission of the American Mental Health
Counselors Association, in slightly shortened form, with italics,
some subtitles, and bold print added. Authors wishing to quote
portions should consult the original article, available by writing
the American Mental Health Counselors Association, 801 North
Fairfax Street, Suite 304, Alexandria, VA 22314, or call 800-326-2642.
Dr. Throckmorton is immediate past president of the American
Mental Health Counselors Association. He was named Counselor of the
Year in 1991 by the Ohio Mental Health Couonselors Association, and
is currently Director of College Counseling at Grove City College
in Grove City, Pennsylvania.
Abstract
In light of the American Counseling Association's (ACA)
recent resolution expressing concerns about conversion therapy, this
article reviews the effectiveness and appropriateness of
therapeutic efforts to change sexual orientation. The concept of sexual
orientation is briefly reviewed, and found to be of limited
clinical use.
The article reviews successful efforts to modify patterns of
sexual arousal from psychoanalytic, behavioral, cognitive, group, and
religious perspectives. An ethical analysis of the ACA resolution
is presented. The author concludes that
efforts to assist homosexually oriented individuals who wish to modify their patterns
of sexual arousal have been effective, can be conducted in an
ethical manner, and should be available to those clients requesting
such assistance .
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Since 1972, the mental health professions have been assessing
and reassessing the status of homosexuality in mental health.
During the last three decades, homosexuality has been conceptualized as
a disorder, a possible disorder in the case of the DSM-III
ego-dystonic homosexuality, and most recently, as
neutral as it relates to the mental status of an individual (Rubinstein, 1995).
Recently we have seen the emergence of opposition
to any form of counseling to attempt to change the sexual orientation of a
client from homosexual to heterosexual. Davison (1976), Martin (1984)
and Haldeman (1994) have suggested that psychotherapeutic efforts
to change sexual orientation are unethical.
In 1997, after nearly two years of debate and study, the
American Psychological Association (APA) passed a resolution expressing
concern that clients may request conversion therapy due to
"societal ignorance and prejudice about same-gender sexual orientation"
and "family or social coercion and/or lack of information" (APA,
1997; Sleek, 1997). In March 1998, the American Counseling
Association passed a similar resolution at its annual convention in
Indianapolis (ACA, 1998).
Recent Threats to Practice
The ACA resolution was proposed by the association's Human
Rights Committee, and the motion to accept was made by the
representative of the Association for Gay, Lesbian and Bisexual Issues in
Counseling (AGLBIC). The resolution was titled, "On Appropriate
Counseling Responses to Sexual Orientation"
and proposed to place the ACA in opposition to any form of conversion
therapy. The proposed resolution originally read, "be it further resolved that the
American Counseling Association opposes the use of so-called 'conversion
or reparative' therapies in counseling individuals having a
same-gender sexual orientation; opposes portrayals of lesbian, gay,
and bisexual youth as mentally ill due to their sexual orientation;
and supports the dissemination of accurate information about
sexual orientation, mental health, and appropriate interventions in
order to counteract bias that is based in ignorance or unfounded
beliefs about same-gender sexual orientation." (ACA, 1998, p. 1-2).
During debate over the resolution, the association's
governing council deleted the phrase above, concerning
opposition to conversion therapies (ACA, 1998). Thus, the opposition was maintained
if the conversion therapy portrays "gay, lesbian or bisexual youth
as mentally ill," or a counselor spreads inaccurate information or
has "unfounded beliefs" about sexual orientation (ACA, 1998, p 1-2).
As it stands, the resolution's impact is difficult to gauge.
The resolution seems to discourage efforts to promote a shift from
homosexual to heterosexual orientation, but comes short of clear
opposition. If passed as originally proposed, the resolution
would have had enormous impact on practice. Mental-health
counselors would have been constrained to tell clients who want to
modify their sexual arousal patterns that such an objective is
faulty. Mental-health counselors who believe homosexuality can be
modified would be in danger of being charged with a violation of the
ethics code. Even counselors outside of the membership of ACA would be
at risk, since most states adopt the ACA code of ethics in their
counselor licensing statutes.
Since most states automatically adopt subsequent revisions of
that code, mental-health counselors performing activities deemed
unethical based on a reading of the code would be in danger of review
by state licensing authorities.
This ACA resolution, along with a companion resolution
supporting same-gender marriage, created immediate controversy (Lee,
1998). The association's Western Regional Assembly voted to request
that the governing council rescind the motions, and the Southern
Regional Assembly requested the issue be reexamined (Gerst, 1998).
Given the impact on counselors practicing conversion techniques
and the controversy surrounding the issue, an examination of the
major issues raised by the resolution is needed.
Is Conversion Therapy Ethical and Effective?
The ACA resolution opposed conversion therapy on the grounds
that such therapy is both ineffective and
unethical. This article will examine the effectiveness and ethicality of helping clients
redirect their sexual orientation. First, I will examine the concept
of sexual orientation, followed by a review of the literature
concerning the modification of sexual orientation. Finally, I present
an ethical analysis of the ACA resolution concerning
conversion therapy.
In reviewing the literature concerning sexual orientation
change, several terms have been used. Reparative therapy has been
popularized by Joseph Nicolosi (1991, 1995), a psychologist who
believes that a gay or lesbian adjustment is never a satisfactory
resolution of sexual identity. Thus, counseling is "reparative" in that
it helps restore the client to a more appropriate sexual adjustment.
Conversion therapy is a term used to designate therapy designed
to effect a shift in sexual preference. Some behavioral
counselors speak of modifying patterns of sexual arousal (Barlow &
Durand, 1995). For the purpose of this article, mental-health
counseling approaches that attempt to effect a change in patterns of
sexual attraction and arousal will be referred to as conversion therapy.
Conversion implies a profound change, which is certainly true
when someone modifies sexual orientation.
A Word about Sexual Orientation
Haldeman (1994) suggested that before questions of change in
sexual orientation are considered, clinicians and researchers should
examine "the complex nature of sexual orientation and its
development in the individual" (p. 222). I agree with this caution and
submit that before opponents of conversion therapies attempt to
eliminate sexual reorientation as an acceptable therapeutic goal, they
must confront the same issue.
As Haldeman (1994) asserts, sexual orientation is not a
well-defined concept. There are many suggestions in the literature
concerning the proper method of defining sexual orientation.
The point of departure for defining sexual orientation is often
the work of Kinsey (Kinsey, Pomeroy & Martin, 1948). Kinsey
suggested that sexual orientation ranges along a continuum from
exclusively homosexual (Kinsey rating "6") to exclusively heterosexual
(Kinsey rating "0") (House & Miller, 1997). Gonsoriek, Sell and
Weinrich (1995) recommended assessing "same- and opposite-sex
orientations separately, not as one continuous variable." (p.47). They
suggested treating each orientation as a continuous
variable.
For clinical purposes, such scales would be interesting but
not terribly helpful to assess the impact of efforts to modify
sexual orientation. Why? There are no norms or points along each
continuum where clinicians may designate a given sexual orientation.
Since researchers are mixed as to where on the continuum to declare
a client "truly gay" or "straight," how can clinicians know if
they are aiding clients to change from one sexual orientation to
another?
Gonsoriek et al (1995) noted that the most common means of
assessing sexual orientation is via self-report. However, they
also noted that "there are significant limitations to this
method." (Gonsoriek, et al, 1995, p. 44). The most obvious problem is
the subjective nature of self-assessment. Being homosexual means
different things to different people. Some define their sexual
orientation by their behavior or attractions or fantasies or some
combination of each dimension. After summarizing the difficulties
in defining sexual orientation, Gonsoriek et al (1995) stated,
"Given such significant measurement problems, one could conclude there
is serious doubt whether sexual orientation is a valid concept
at all." (p. 46).
Concerning the potential for assessing change of
orientation, Gonsoriek et al (1995) noted, "Perhaps the most dramatic
limitation of current conceptualizations is change over time. There is
essentially no research on the longitudinal stability of sexual
orientation over the adult life span." (p. 46).
If there is no research concerning change, how can professional associations be
certain that sexual orientation cannot
change? Thus, defining sexual orientation as a concept is a work in progress. Counselors ought
to articulate this lack of certainty in an unbiased manner.
In absence of any sure way to define sexual orientation,
assistance for questioning individuals should not be limited. Even if
one accepts the presumption that sexual orientation cannot be
changed, how does one know when a client's sexual orientation is settled?
Without a more certain way to objectively determine sexual
orientation, perhaps we should place considerable weight on the
self-assessment of clients. Clients who want to change cannot reliably
be told that they cannot change, since we cannot say with
certainty that they have settled on a fixed
trait.
Sexual- Orientation Change is Possible
If any conclusions can be drawn from the literature, it is
that change in sexual orientation is
possible.For instance, in their review of the literature on once-married lesbians, Bridges
and Croteau (1994) found that 25-50% of lesbians in various reports
had once been in heterosexual marriages. While heterosexual
marriage alone may not be a complete gauge of sexual orientation, the
reasons for the marriage should offer some insight into the
sexual identity of the women at the time. Kirkpatrick (1988)
reported that once-married lesbian women often married because they were
in love with their husbands. In examining the reasons for the
shift in sexual expression, Charbonneau and Lander (1991) found two
broad explanations. One group felt they had always been lesbian and
were becoming true to themselves. However, another group viewed
their change as a "choice among sexual options." If counselors are
not to assist clients in their wishes for a shift in sexual
orientation, how would ACA's governing council wish for counselors to respond
to such women wanting to become more settled in their choice of a
lesbian identity?
More practically, I do not know with certainty if I have ever
been successful in "changing" a person's sexual orientation since I
do not know how to precisely define sexual orientation, or if it
is even a valid clinical concept. However, I have assisted
clients who were, in the beginning of mental health counseling,
primarily attracted to those of the same gender, who declare they are
now primarily attracted to the opposite
gender. I fear that resolutions such as passed by APA and ACA will prevent such
outcomes, which are viewed quite positively by the clients who have
experienced them.
What Studies Show Treatment Success?
From a gay-affirming perspective, Martin (1984) and Haldeman
(1994) reviewed studies which claimed to demonstrate change in sexual
orientation. Their view was that there were no empirical
studies which supported the idea that conversion therapy can change
sexual orientation. However, they omitted a number of significant
reports, and failed to examine the outcomes of many studies
which have demonstrated change.
Narrowly, the question to be addressed is: Does conversion
therapy work to change unwanted sexual arousal? I submit that the
case against conversion therapy requires opponents to demonstrate
that no clients have benefited from such procedures
or that any benefits are too costly in some objective way to be pursued, even if
they work. The available evidence supports the observation of
many counselors - that many individuals with a same-gender sexual
orientation have been able to change with a variety of counseling approaches.
Psychoanalytic Approaches
Beginning with Freud, psychoanalytic writers have proposed
multiple explanations for the development of sexual orientation (Bieber,
et al, 1963). According to Bieber, Freud proposed a "continuum
between constitutional and experiential elements" (p.3) as a broad
explanation for a gay or lesbian adjustment. Thus, in certain cases
sexual adjustment could result from mostly nature, and in other
cases, nurture should be considered the prime factor. About
same-gender sexual orientation, Freud wrote to a mother of a gay son, "we
consider it to be a variation of the sexual function produced by
a certain arrest of development" (Freud quoted in Bieber, et
al, 1962, p. 275). According to Bieber, Freud believed the
developmental arrest is stimulated by heightened castration anxiety. For
gay men, females are avoided either to avoid the loss of the male
organ via intercourse, or to avoid unconscious incestual feelings
with mother which provoke fears of castration from father.
Consistent with this view, Bieber interpreted his research and clinical
findings concerning a gay adjustment as pointing to a "hidden but
incapacitating fear of the opposite sex." (Bieber, et al, 1962,
p. 303).
While Freud generally took a negative view of modifying sexual
orientation, quite a number of psychoanalytically-oriented
therapists who followed him, including his daughter Anna (Freud, 1951),
exerted therapeutic efforts to explore change (e.g., Bieber et
al, 1962; Fairbairn, 1952; Mayerson & Lief, 1965; Ovesey & Woods,
1980; Poe, 1952; van den Aardweg, 1986; Socarides, 1978; Sullivan,
1953; Wallace, 1969).
For instance, Bieber et al (1962) reported on the psychoanalysis
of 106 gay men. Of the exclusively homosexual clients, 19%
finished analysis totally heterosexual. Half of those considered
bisexual were considered heterosexual post-treatment. Considering the
entire sample of 106, 27% of the clients reported a shift to
exclusive heterosexuality. When one considers that about one-third of
the sample did not express a desire to change their sexual
orientation, the rate of change is even more impressive.
Bieber et al (1962) also found that 78% of the participants
who became heterosexual wanted to realize this objective. However,
six subjects who became heterosexual had not expressed a
pre-treatment wish to change. Although motivation to change was clearly
important to this effort, individuals may change patterns of
sexual arousal without making such change a primary therapeutic goal.
Hatterer (1970) described a supportive, somewhat active,
psychodynamic approach to treating gay males. He proposed a
traditional environmental explanation for a gay sexual orientation
including fear of women and detachment from male identity. He
presented case information concerning 143 clients for whom an initial
Kinsey rating of sexual orientation was conducted, and follow-up
adjustment was assessed. Of the entire group, 49 (34%) were
considered as having achieved a heterosexual adjustment, with 18 clients
"partially recovered" and the remaining 53% unchanged. Breaking
down the results, it appears that client motivation
and degree of identification with a gay identity
are keys. For instance, only 4.6% clients who were rated "exclusively homosexual" reported a
heterosexual change. The vast majority of these men demonstrated no
motivation to change. However, among the exclusively gay men who
were highly motivated to change, 24% reported a heterosexual
adaptation after counseling. Among 21 clients with a Kinsey 4 or 5
rating, the change rate was 57%. Each of these clients were at least
moderately motivated to realize a heterosexual outcome.
Socarides (1979) reported that in his practice, 20 of 45 (44%)
gay men seen in psychoanalytic psychotherapy between 1966 and
1977 achieved "full heterosexual functioning."
MacIntosh (1994) reported a survey of 285 psychoanalysts who
analyzed 1215 psychoanalytic gay and lesbian clients (824 male;
391 female). The survey respondents reported that 23% of their gay
and lesbian clients changed to heterosexuality. Also, the
analysts reported their assessment that 84% of the clients reported
significant benefits from analysis.
Recently a systematic approach to sexual orientation change
has been advanced by Nicolosi (Nicolosi 1991, 1995). In his review
of conversion therapies, Haldeman (1994) critiqued Nicolosi's
theory of homosexual development, but failed to include an evaluation
of the successful treatment results claimed by Nicolosi and his
colleagues. Nicolosi's writings detail a multi-dimensional view of
the antecedents of homosexual arousal and a psychoanalytic approach
to the treatment of individuals who struggle with unwanted
same-gender sexual orientation. Nicolosi offered numerous case studies of
clients who have moved from primarily homosexual identity to
heterosexual adaptation. Concerning the function of same-gender
sexual orientation in men, Nicolosi (1991) stated, "in many
homosexual men, same-sex eroticism is used as symbolic reparation of a
deficit in masculine strength" (p. 157). Because many gay men have
traditionally feminine interests and behaviors as young boys, they
often experience rejection from their fathers and male peers. This
rejection leads to what Nicolosi (1991) called a "defensive
detachment" (p. 57) from father. This defensive detachment leads
the pre-gay male to reject masculinity as portrayed by the father,
but to simultaneously long for a close relationship with a strong man.
Nicolosi and other recent psychoanalytic clinicians have
demonstrated some success in assisting individuals attain
heterosexual arousal. For instance, Nicolosi, Byrd and Potts (1998)
reported the results of a national survey of 882 clients engaged in
sexual reorientation therapy. At the beginning of therapy, 318 of
the sample rated themselves as having an exclusive same-gender
sexual orientation. Post-treatment, 18% of the 318 rated themselves
exclusively heterosexual, 17% rated themselves as "almost entirely
heterosexual" and 12% viewed themselves as more heterosexual than
gay or lesbian. Thus, 47% of this sub-group went from the
self-rating of a Kinsey 6 to less than a Kinsey 2 rating. Of the entire
882, only 13% remained either exclusively or almost exclusively gay
or lesbian after treatment.
Countering claims that reorientation therapies are harmful,
the survey also asked clients concerning psychological and
interpersonal adjustments both before and after therapy. The survey
respondents also reported significant improvements in such areas as
self-acceptance, personal power, self-esteem, emotional stability,
depression, and spirituality (Nicolosi, Byrd, & Potts, 1998).
In summary, psychoanalytic approaches report rates of change
ranging from 19% to 44% of clients. Rates for some modification
of sexual orientation are even higher in some of the reports. None
of the reports document negative side-effects of such efforts,
and indeed seem to show positive results for a significant number
of participants, even those who do not change sexual orientation.
Clients who have had some prior heterosexual experience, and
are motivated to change, seem most likely to report modification
of sexual orientation.
Behavior therapy approaches
There are numerous reports of behavioral interventions which
have resulted in modification of sexual arousal. While Haldeman
(1994) primarily reviewed aversive therapies, a variety of other
behavioral techniques have been employed, including covert
sensitization, systematic desensitization, assertiveness training
and multimodal approaches.
Generally, behavioral counselors point to principles of learning
to explain sexual behavior and attraction. A gay or lesbian
adjustment is most likely to be established when such behavior is
followed by physical and/or social reinforcement, and/or when
heterosexual behavior is followed by negative events, such as
punishment or humiliation. A chain of events which are reinforcing to
one sexual orientation, and aversive to another, would lead to
a greater likelihood to engage in behavior consistent with the
positively reinforced sexual orientation (Greenspoon & Lamal, 1987).
Aversive therapies, beginning with Max (1935), were early
behavioral attempts to change sexual orientation. Treatment
results were mixed. For instance, Feldman, MacCulloch and Orford
(1971) reported follow-up results of research conducted between
1963-1965 concerning 63 gay clients wishing to shift sexual orientation.
Indicators of change were the cessation of homosexual behavior,
only occasional homosexual fantasy or attraction, and strong
heterosexual fantasy and/or behavior. As defined by these
indicators, they reported that 29% of the clients who had no prior
heterosexual experience had changed, while 78% of a group who had some
prior heterosexual experience had changed, yielding a 65% rate for
the entire group. Bancroft (1974), Thorpe, Schmidt, Brown and
Castell (1964) and Larson (1970) also reported reorientation success
with subjects using variations of aversive conditioning.
Callahan (1976), Kedrick and McCullough (1972), Mandel, (1970)
and Segal and Sims (1972) describe successful reorientation
outcomes with the use of covert sensitization. For instance, Callahan
(1976) described the use of covert sensitization and assertiveness
training applied to the case of 25-year-old single male who was
sexually abused at age six by an uncle. The client had several
same-gender sexual experiences through junior high school. He dated
three girls in high school but felt little attraction for them.
Callahan told his client that same-gender sexual arousal is learned and
"can thus be changed, or accepted as a natural and normal human
experience." (p. 235). The client regarded this explanation as
support for his decision to supplant same-gender arousal with
heterosexual arousal. Then the client was introduced to relaxation training
and developed a list of arousing scenes. The covert
sensitization technique involves pairing negative imagery with gay sexual
fantasies (Callahan, 1976). After the intense phase of this
treatment, the client "reported spontaneous sexual arousal to the sight
of women for the first time." (Callahan, 1976, p. 242). At
four-and-a-half year follow-up, the client was married, and reported
good sexual adjustment with no same-gender sexual arousal.
Non-aversive classical conditioning techniques using
sexually arousing materials have been reported. For instance,
McCrady (1973) reported the successful therapy of a 27-year-old gay man
who had occasional same-sex experiences from age 16. However,
"for both moral and practical reasons, when he entered therapy, he
was highly motivated to increase his heterosexual behavior (and to
decrease his homosexual behaviors)" (McCrady, 1973, p. 257).
McCrady showed the client a nude female and then faded the image into
a nude male. During the course of therapy, the client reported
the onset of heterosexual fantasies. After the fifth session, the
client began referring to himself by saying, "when I used to be
homosexual." (McCrady, 1973, p. 260). Barlow and Agras (1973)
reported similar techniques although in their procedure, the nude male
pictures were faded into the nude female pictures. These
researchers reported physiological measures of changed arousal which
improved in a heterosexual direction at follow-up for all three subjects
in their study.
Systematic desensitization has been used to facilitate a shift
in sexual orientation (Bergin, 1969; Huff, 1970; Kraft, 1967;
James, 1978; Phillips, Fischer, Groves & Singh, 1976; Ramsey & van
Velzen, 1968). For instance, Phillips et al (1976) described a
31-year-old gay man who requested sexual reorientation. The authors note
that "the gay world was losing its appeal" to the client (Phillips,
et al, 1976, p. 226). The client experienced anxiety concerning
heterosexual physical contact and was assisted through two
desensitization hierarchies. He was then able to initiate heterosexual
contact and at 18 months follow-up reported no same-gender sexual
activity.
Many behavioral counselors advocate the use of a variety of
behavioral techniques to achieve sexual reorientation (Barlow,
1973; Barlow & Durand, 1995; Bergin, 1969; Blitch & Haynes, 1972;
Freeman & Mayer, 1975; Gray, 1970; Greenspoon & Lamal, 1987; Hanson
& Adesso, 1972; Marquis, 1970; Rehm & Rozensky, 1974; Stevenson
& Wolpe, 1960; Tarlow, 1989; Wilson & Davison, 1974). For
instance, Stevenson and Wolpe (1960) described the use of reeducation
and assertiveness training in the successful reorientation of two
gay men. In one case, the authors describe a 22-year-old gay man
whose first same-gender sexual experiences began at age 14. The
client had begun to consider himself exclusively homosexual and
viewed counseling as his last possibility before accepting this
conclusion. The counselor suggested to the man that he may have
been "premature in assigning himself to the group of permanent
homosexuals" and that the man's homosexual activity "was chiefly driven
by a wish for friendly companionship with other men" (Stevenson
& Wolpe, 1960, p. 738). After 10 sessions of encouragement of
assertive behavior, the client terminated with plans to marry. The
man reported heterosexual adjustment at a three-year follow-up.
In summary, behavioral approaches to the modification of
sexual orientation progressed from a reliance on aversive approaches,
to the use of sophisticated multi-modal approaches. Generally,
the cases reported in the behavioral counseling literature support
the efficacy of efforts to modify sexual orientation. The
multi-modal approaches attempt to extinguish same-gender attraction and
then provide a variety of behavioral and supportive counseling
techniques to facilitate heterosexual responsiveness. As Kraft
(1970) noted, desensitization techniques are preferable to aversion
techniques because they promote the incorporation of heterosexual
activity as opposed to merely the elimination of homosexual
attraction. Greenspoon and Lamal (1987) suggested that the effects
of office-based conditioning programs can be undone
by lack of reinforcement in heterosexual functioning. They stress the
development of social skills necessary in heterosexual situations through
role-playing, homework and supportive counseling.
Cognitive Approaches
In 1959, Ellis described the treatment of a gay man who was "one
of the first clients treated with a special therapeutic approach
which the therapist developed after many years of practicing
orthodox psychoanalysis and psychoanalytically-oriented
psychotherapy" (p.339). Ellis then described his "Rational Psychotherapy"
which later became Rational-Emotive-Behavior Therapy (REBT). The
client had not ever had heterosexual experience and had a great fear
of rejection. Ellis made no attempt to rid the client of
homosexual feelings, but rather wrote that the goal of therapy was to help
the client "overcome his irrational blocks against
heterosexuality" (p.339). Ellis reported that by the 12th week of rational
psychotherapy, the client "had changed from a hundred per cent fixed
homosexual, to virtually a hundred per cent heterosexual
(Ellis, 1959, p. 342).
Although he gave no precise rates of change, he stated about
his new approach in 1965, "I have treated, in my private practice
in New York City, scores of homosexual patients during the last
10 years, and I have found that the rational-therapeutic approach
is much more effective...than was my previous psychoanalytic
approach to therapy" (Ellis, 1965, p. 109;).
While Ellis no longer believes that same-gender sexual
orientation is a sign of inherent emotional disturbance, he wrote in 1992
that people are free to "try a particular sexual pathway, such as
homosexuality, for a time and then decide to practically abandon it
for another mode, such as heterosexuality" (Ellis, 1992, p.34).
The most recent indicator of Ellis' belief that client options
should not be abridged was his membership on the Committee of
Concerned Psychologists (CCP) (CCP, 1995). When the APA first considered
a resolution to discourage the use of conversion therapies in
1995, an ad hoc group of psychologists opposed the motion. Ellis was
one of more than 40 psychologists who signed a letter which urged
the rejection of the motion and branded it as "illegal, unethical,
unscientific and totalitarian" (CCP, 1995, p. 4).
Group Psychotherapy Approaches
Rogers, Roback, McKee and Calhoun (1976) reviewed the group
psychotherapy literature for a variety of therapeutic outcomes.
They determined that "homosexuals can be successfully treated in
group psychotherapy whether the treatment orientation is one of a
change in sexual pattern of adjustment, or whether a reduction in
concomitant problems is the primary goal" (Rogers, et al, 1976, p. 24).
Birk (1980) reports probably the highest success rates of
any therapist. Using a combination of behavioral-group and
individual psychotherapy, Birk reports that 100% of exclusively gay
men beginning therapy with the intent to change sexual arousal
were able to attain a heterosexual adaptation. The other criterion
for this subgroup of clients is that they remained in therapy for
over two-and-a-half years, or had achieved their goals prior to
this cutoff period.. Of those 14 clients who had shifted, Birk
reports that 10 of the 14 (71%) were satisfactorily married at
follow-up. Contrary to Haldeman's supposition that the men in Birk's
treatment group may have had "preexisting heteroerotic tendencies"
(Haldeman, 1994, p. 223), one of Birk's criteria for inclusion in this
analysis was that these clients were exclusively gay
and had not experienced heterosexual intercourse (Birk, 1980). Birk pointed to
pretreatment motivation as a major key in understanding the results.
Of those clients not expressing any pretreatment interest in
sexual orientation change, four out 15 (27%) reported a shift to
heterosexual adaptation.
Religiously oriented approaches
Religious affiliation often motivates gay and lesbian clients
to seek a shift in their pattern of sexual arousal (Wolpe, 1973).
Some clients have changed through religiously based
interventions. Pattison and Pattison (1980) presented case studies of 11
white males who reported that they had changed sexual orientation
through participation in a church fellowship. The group self-identified
as gay at an average age of 11. Nine had pre-change Kinsey ratings
of 6, with ratings of 4 and 5 rounding out the group. Following
religious participation, five individuals rated themselves a Kinsey
0, three rated themselves a Kinsey 1 and three a 2 rating.
Many reports of change are testimonials produced by ex-gay
ministry groups. For instance, the Presbyterian Church (USA)
supports OneByOne, "a ministry which educates and equips congregations
in the Presbyterian Church (USA) to minister to those people in
conflict with their sexuality" (OneByOne, nd, p.1). In their
booklet, Touched by His Grace, seven former gay men and four former
lesbians describe their experience of gaining heterosexual adaptation
and spiritual freedom (OneByOne, nd). Exodus International and
Transformation Ministries are prominent support ministries for ex-gays.
As Haldeman (1994) documents, it is true that some ex-gays
have become ex-ex-gays. However, the stories and research reports
of those individuals who consider themselves former homosexuals
should not be minimized. Clearly there are persons who have shifted
their sexual orientation as an aspect of following their religious
beliefs (Davies & Rentzel, 1994; Saia, 1988).
Summary of Counseling Approaches
While no consensus has emerged concerning the most
appropriate means of pursuing sexual reorientation, the reports above
demonstrate that modification of sexual orientation
is possible for some clients. While offering differing techniques, the counseling
approaches seem to agree that necessary counseling tasks include
the following: (1) increasing assertiveness, (2) addressing a
learned fear of relationship with the opposite sex, (3) and the
development of heterosexual social skills. Each approach also emphasizes
the role of motivation and social support for maintaining change.
The inconsistent rates of change may relate more to the
relative lack of systematic research in this area, than to a
hypothesized inability for humans to change sexual orientation. Further
research and clinical study may assist mental health professionals to
better focus such efforts for individuals who want to pursue change.
Ethical Principles and Conversion Therapies: Another Look
The psychological literature seems unclear about the ethics of
conversion therapy. While Haldeman (1995) portray such therapies
as unethical, Garnets et al, (1991) in the American
Psychologist, specify "biased, inadequate and inappropriate practice" and
"exemplary practice" when clients present with sexual-orientation
issues. As an example of an exemplary response, Garnets et al
(1991) include this theme: "A therapist does not attempt to change
the sexual orientation of the client without strong evidence that
this is the appropriate course of action, and that change is desired
by the client" (p.968). They presented as an exemplar of this
theme the following comments by a survey respondent, "...I had a
male client who expressed a strong desire to 'go straight.' After
a careful psychological assessment, his wish to become
heterosexual seemed to be clearly indicated, and I assisted him in that
process" (Garnets, et al, 1991, p.968). This course is at odds with the
proposed the APA and ACA resolutions which originally sought to
deem conversion therapy unethical and therefore clinically
inappropriate.
The ACA resolution begins by affirming ten principles
concerning treatments to alter sexual orientation. The first is that
homosexuality is not a mental disorder. While some writers who
practice reparative therapy believe homosexuality is a developmental
deficit (Nicolosi, 1991), it does not seem necessary to believe
homosexuality is a disorder in order to offer counseling to modify
sexual feelings. In fact, counseling as a profession has
traditionally held that one does not need to have a disorder
in order to profit from counseling. Thus, if a client requested such counseling,
offering it would not require the counselor to view the client
as mentally ill.
What Diagnosis Could Fit the Dissatisfied Homosexual?
Even if one asserts that offering a mode of treatment implies
a disorder, there is a condition in the DSM-IV which would be
the proper object of conversion therapies -- Sexual Disorder, Not
Otherwise Specified (NOS) (American Psychiatric Association (ApA)
, 1996). Though the diagnosis of ego-dystonic homosexuality was
removed from the DSM-III, Sexual Disorder, NOS remains in the
DSM-IV with several descriptors, one of which is "persistent and
marked distress about sexual orientation." (American Psychiatric
Association, 1996, p. 538). Certainly, many individuals who seek
conversion therapy could be described in this manner.
The second principle is that counselors should not
discriminate against clients due to their sexual orientation. Contrary to
this principle, banning efforts to modify sexual orientation would
require the ACA to discriminate against those clients who want
to change.
Should Sexual Arousal Take Precedence Over Moral Convictions?
The third principle is that counselors will "actively attempt
to understand the diverse cultural backgrounds of the clients
with whom they work."(ACA, 1998). Nothing in conversion therapy
negates this principle. When such conflicts occur, what makes one set
of loyalties more important than another set? If professional
associations discredit efforts to modify sexual orientation,
they may be implying that sexual arousal is more vital than any
conflicting personality variables or moral
convictions. I believe mental health counselors who practice conversion therapy
do attempt to understand the cultural background of a client who presents in
deep conflict over sexual impulses and deeply held moral convictions.
Principle four requires the counselor to inform clients
concerning the "purposes, goals, techniques, procedures, limitations and
potential risks and benefits of services to be performed."
Nothing in this principle prohibits conversion therapy. As the above
review of the literature demonstrates, it would be a
violation of this point to say that there is no empirical evidence of efficacy
of various conversion therapies.
The fifth principle states that "clients have the right to
refuse any recommended service and be advised of the consequences of
such refusal." This is true of nearly all mental-health treatments.
The sixth principle supports the availability of conversion
therapies. The resolution quotes the ACA code of ethics, section
A.3.b which states that counselors "offer clients freedom to
choose whether to enter into a counseling relationship (ACA, 1998). It
is my experience that clients ask for assistance
with unwanted homosexual feelings. Clients should have the freedom to choose
the approaches which help them meet their goals. The availability
of conversion therapy is supported by this principle.
The seventh principle states "when counseling minors or
persons unable to give voluntary informed consent, counselors act in
these clients' best interests." (ACA, 1998). Mental-health
counselors engaging in counseling to modify sexual orientation have a duty
to act in the client's best interests, whether a minor or an adult.
Since it has not been shown that such counseling is
intrinsically harmful, assisting a minor client who wishes to engage in
such counseling does not violate this principle. When a parent's
and child's counseling objectives differ, achieving a working
alliance with the family requires skill in conflict resolution and
family interventions no matter what kind of problem is presented.
When the Values of the Religious Client are Denigrated
In the eighth principle, counselors are reminded to be "aware
of their own values, attitudes, beliefs, and behaviors and how
these apply in a diverse society, and avoid imposing their values on
clients." (ACA, 1998). But when conversion therapy is
opposed, what does this say to clients? To clients who want to explore the
possibility of change, it means that their wish is diminished,
not to be taken seriously. For individuals who are morally opposed to
homosexuality as a lifestyle, it means that the professions
have denigrated their moral convictions. For individuals who have
successfully changed, who now are heterosexual, it means that the
professions have criticized their
accomplishments.. The most appropriate response when the client's goals and the mental
health counselor's skills do not match is to refer to another
mental health counselor.
Should the Counselor Change the Client's Religious Convictions?
The ninth principle, related to the above point, is the
statement from the ACA code of ethics (section A.6.a) that counselors
"are aware of their influential positions with respect to clients,
and they avoid exploiting the trust and dependency of clients."
The counseling profession has been oblivious to a double standard
concerning sexual orientation and religious conviction. While the
ACA has opposed the modification of an individual's homosexual
feelings, there has been no movement to avoid the disruption of
an individual's religious convictions. For instance, Barret
and Barzan (1996) in their article concerning spirituality and the
gay experience suggest that "assisting gay men and lesbians to
step away from external religious authority may challenge
the counselor's own acceptance of religious teachings." (p.8).
According to Barret and Barzan (1996), "most counselors will benefit
from a model that helps them understand the difference between
spiritual and religious authority." (p. 8).
The last principle requires counselors to "report research
accurately and in a manner that minimizes the possibility that
results will be misleading." As noted above,
evidence exists for the efficacy of conversion
therapies. However, these findings have not
been consistently reported in the counseling and psychological
literature over the last two decades. A search of the
Journal of Mental Health Counseling, Journal of Counseling and Development,
Counseling and Values and the Journal of Multicultural Counseling and
Development reveals no articles on conversion
therapy. All articles concerning homosexuality espouse the gay-affirming approach
to therapy. I think the information given in this article,
previously unreported in counseling journals, should be widely distributed .
Discussion
The purpose of this review has been to demonstrate that
therapeutic efforts to help clients modify patterns of sexual arousal
have been successful, and should be available to clients wishing
such assistance. I believe the available literature leaves no
doubt that some degree of change is possible for some clients who wish
to pursue it.
The literature on therapeutic assistance for unwanted
same-gender sexual arousal suddenly came to a near halt in the early 1970s,
but clients wishing assistance did not cease to come to counseling.
I personally have experience with clients who have wanted
assistance to change their pattern of sexual arousal and due to their
reports, believe such change is possible.
As stated above, sexual orientation as a concept has limited
clinical utility. Since the definition of sexual orientation is
somewhat arbitrary, I submit it is inappropriate to tell a client that
it cannot be changed or modified. Bell and Weinberg (1978) in
their large study of homosexuality in the San Francisco area, defined
a homosexual as anyone with a Kinsey rating of four or higher. In
the literature cited above, rates of change for individuals with
Kinsey ratings of 4 and 5 were in the 57-78% range (Feldman, MacCulloch,
& Orford, 1971; Hatterer, 1980; Mayerson & Lief, 1965). Thus,
defined in the manner of the Bell and Weinberg study, an impressive
majority of clients were able to modify sexual orientation. Whether
one can say that sexual orientation is being changed depends on
how narrowly one defines sexual orientation, or if it can be defined
at all.
So what should mental health counselors do when confronted
with clients who request sexual reorientation? I propose the
following guidelines.
1. Neither gay-affirmative nor conversion therapy should
be assumed to be the preferred approach. Generally,
gay-affirmative therapy, or referral to such a practitioner, should be offered
to those clients who want to become more satisfied with a
same-gender sexual orientation. Conversion therapy or referral should be
offered to clients who decide they want to modify or overcome
same-gender patterns of sexual arousal. Assessment should be
conducted to help clarify the strength and persistence of the
client's wishes.
2. For those clients who are in distress concerning
their sexual orientation and are undecided concerning reorientation,
mental-health counselors should not assume what approach is best.
They should inform clients that many mental-health professionals
believe same-gender sexual orientation cannot be changed, but that
others believe change is possible. Clients should be informed that
some mental-health professionals and researchers dispute the concept
of an immutable sexual orientation. Mental-health counselors
should explain that not all clients who participate in
gay-affirming therapy are able to find satisfaction in a gay adjustment, nor
are all clients who seek sexual reorientation successful. When
clients cannot decide which therapeutic course to pursue,
mental-health counselors can suggest that clients choose a therapy
consistent with their values, personal convictions and/or religious
beliefs (Nicolosi et al, 1998).
3. Since religion is one of the client attributes which
mental health counselors are ethically bound to respect,
counselors should take great care in advising those clients dissatisfied
with same-gender sexual orientation due to their religious beliefs.
To accommodate such clients, counselors should develop expertise
in methods of sexual reorientation, or develop appropriate
referral resources.
Finally, mental health counselors have an obligation to respect
the dignity and wishes of all clients. ACA and other mental health
associations should not attempt to limit the choices of gays and
lesbians who want to change.
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Updated: 2 September 2008
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