from Clinical/Therapeutic Issues
Mark A. Yarhouse, Psy.D.
School of Psychology and Counseling,
Regent University, Virginia Beach, Virginia, USA
(The American Journal of Family Therapy,
1998, vol. 26, pp. 321-330.
Reprinted by permission.)
What are the ethical guidelines for a therapist counseling a teenager
with same-sex attractions?
As psychologist Mark Yarhouse explains, when the client seeks to live in
accordance with the teachings of his religious community, the therapist
should not impose his personal values. He is ethically obligated to
respect the rights and dignity of such a client, and to acknowledge the
legitimacy of religious diversity.
The therapist should present the facts in a balanced manner so the teenager
(and his or her family) are free to make an informed decision about the
direction of treatment. This discussion should be comprehensive and should
include a discussion of the high rate of non-monagamy in the gay community.
If the teenager chooses not to claim a gay identity, what is the likely
outcome? Research on successful change of sexual orientation is
controversial, and many critics contend that unwanted attractions are not
likely to shift significantly. However, behavioral change does appear to
be achieved by a significant percentage of highly motivated individuals.
And since adolescent sexuality is often in flux, it may be in the client's
best interest to focus on other troubling life issues in therapy--resisting
the temptation to make a hasty decision that could prematurely label his or
her sexual identity.
As psychologist Mark Yarhouse explains, when the client seeks to live in accordance with the teachings of his religious community, the therapist should not impose his personal values. He is ethically obligated to respect the rights and dignity of such a client, and to acknowledge the legitimacy of religious diversity.
The therapist should present the facts in a balanced manner so the teenager (and his or her family) are free to make an informed decision about the direction of treatment. This discussion should be comprehensive and should include a discussion of the high rate of non-monagamy in the gay community.
If the teenager chooses not to claim a gay identity, what is the likely outcome? Research on successful change of sexual orientation is controversial, and many critics contend that unwanted attractions are not likely to shift significantly. However, behavioral change does appear to be achieved by a significant percentage of highly motivated individuals.
And since adolescent sexuality is often in flux, it may be in the client's best interest to focus on other troubling life issues in therapy--resisting the temptation to make a hasty decision that could prematurely label his or her sexual identity.
In contrast, some clients who experience same-sex attraction pursue interventions to change their behavior or orientation (McConaghy, 1993; Nicolosi, 1991). Although there are a significant number of studies reporting change of behavior and/or orientation (especially between 1950-1975; e.g., Mintz, 1966; Pittman & DeYoung, 1971), reorientation or reparative interventions are controversial, and much of the research in this area has been criticized on conceptual and methodological grounds (e.g., Haldeman, 1991). In light of these criticisms, some argue that those who report distress concerning their experience of same-sex attraction should not be provided professional services that have as their goal change of orientation (Davison, 1982; Haldeman, 1991). This approach, however, may not address the underlying issue, as those who do not find professionals to be accommodating may turn to paraprofessional and religious groups for help (e.g., Exodus-affiliated ministries, Homosexuals Anonymous; Haldeman, 1994; Harvey, 1987; Yarhouse & Jones, 1997).
Given the range of opinions on same-sex attraction and behavior, one of the unique challenges facing marriage and family therapists (MFTs) occurs when an adolescent family member experiences same-sex attraction. This is a concern many MFTs may not have thought through, and when faced with this clinical scenario, MFTs may have few resources to draw upon to provide treatment in a competent manner. The purpose of this paper is to begin to examine ways in which MFTs can provide therapy to families when an adolescent reports experiencing same-sex attraction and do so within the framework of existing ethical principles and standards for accountability and professionalism.
For the purposes of this article, it will help to discuss a range of issues under headings related to the two most relevant ethical principles presented in the American Association for Marriage and Family Therapy's (AAMFT's) Code of Ethics: (a) professional competence and integrity and (b) responsibility to clients. The most relevant issues related to professional competence and integrity have to do with having a thorough working knowledge of the topic under discussion and disseminating accurate research findings to family members. Likewise, responsibility to clients entails respect for the welfare and rights of families and individuals. Recommendations to MFTs shall be made with reference to these ethical principles.
According to the AAMFT's Code of Ethics, MFTs have an ethical obligation to demonstrate professional competence and to work with integrity. In the area of homosexuality, we do this in part by staying abreast of current research findings on same-sex attraction (Ethical Standard [ES] 3.4) and by clarifying with families and individuals what we know (and what we do not know) about homosexuality (ES 3.7). In light of the ethical issues related to professional competence and integrity, it may help to briefly summarize the state of our knowledge about homosexuality in three often-cited areas of research: prevalence, etiology, and the possibility of change of behavior and/or orientation (for an expanded analysis of this research, see Jones & Yarhouse, 1997, pp. 448-476).
For some time it was widely accepted that those who identified themselves as gay or lesbian comprise approximately 10% of the general population, and that as many as 30% of adolescents have had homosexual experiences of one kind or another. These figures are based upon the Alfred Kinsey studies of the 1940s and 1950s (e.g., Kinsey, Pomeroy, & Martin, 1948). More recent research suggests that approximately 2-3% of the population is gay or lesbian. For example, Laumann, et al. (1994) report that 2% of men and 0.9% of women surveyed self-identified as homosexual, and that 0.8% of men and 0.5% of women self-identified as bisexual (cf., Fay, Turner, Klassesn, & Gagnon, 1989). Among adolescents, a recent study of 36,741 American adolescents found that 1.6% of boys and 0.9% of girls had had a homosexual experience in the previous year, and that 0.7% of boys and 0.2% of girls reported a homosexual orientation (Remafedi, Resnick, Blum, & Harris, 1992).
Although same-sex experiences among adolescents are not reported as common, they do occur, and for those families entering treatment with an adolescent who experiences same-sex attraction or who self-identifies as gay or lesbian, many questions remain unanswered. For instance, what causes homosexuality?
It is certainly true that few people choose to be homosexual or to experience same-sex attraction. There are several hypotheses regarding the etiology of homosexuality. The most clearly articulated psychological theories have been psychodynamic and have implicated the parent-child relationship. Critics argue that there is little empirical support for the dynamic theory; however, proponents point to studies implicating early childhood development, including factors such as disordered family relationships (e.g., loss of a parent due to death or divorce), early homosexual experiences, and childhood sexual abuse (see Laumann et al., 1994; Saghir & Robins, 1973).
The psychological theories have recently fallen out of favor. Attention has turned to several possible physiological antecedents, including genetic and prenatal hormonal influences. Research on genetic differences includes twin studies (Bailey & Pillard, 1991) and chromosomal markers that may be associated with a homosexual orientation (the focus here is on the Xq28 subtelomeric region of the sex chromosome; see Hamer, Hu, Magnuson, Hu, & Pattatuci, 1993; Hu et al., 1995).
Support for the prenatal hormonal hypothesis includes abnormal hormone levels in animal fetuses and studies of Lutenizing Hormone feedback (Ellis & Ames, 1987). Some of these studies have failed replication and the theories have been criticized on conceptual and methodological grounds (Byne & Parsons, 1993).
Other research in this area includes direct dissection of the brain. At least three areas of the brains of homosexual males have been reported to be structurally more like those of heterosexual females than heterosexual males: the suprachiasmic nucleus of the hypothalamus (Swaab & Hofman, 1990), the interstitial nucleus of the anterior hypothalamus 3 (LeVay, 1991), and the midsagittal plane of the anterior commissure (Allen & Gorski, 1992; for a critical review of this literature, see Byne & Parsons, 1993).
In any case, both psychological and biological theories for the etiology of same-sex attraction have some empirical support, although no one theory appears to explain why a particular individual experiences same-sex attraction. It may be more accurate to think of shifting ratios of various antecedents to same-sex attraction that differ from person to person and across cultures. In any case, perhaps future research will prove more enlightening than what we know at present, although there is no compelling reason to believe that any one theory can explain such a diverse phenomenon.
Change of Orientation, Behavior, or Both
Although there may not be consensus as to the antecedents to same-sex attraction, there is general agreement that homosexuality is not changed by a simple act of the will. Interventions designed to change experiences of same-sex attraction and/or behavior include psychodynamic "reparative" therapy (Nicolosi, 1991) and group therapy offered from a psychoanalytic perspective (Hadden, 1966), social learning perspective (Birk, 1974), and client-centered perspective (Smith & Bassin, 1959). Additional interventions include directive behavioral sex therapy (Masters & Johnson, 1979), behavior therapy alone or in combination with pharmaceutical agents (McConaghy, 1993), and church healing ministries (Pattison & Pattison, 1980). The success rates have ranged from 25 to 50% and may be elevated due to self-report and therapist report of change (for a critical review of this literature, see Haldeman, 1991; 1994; cf., Yarhouse, in press).
As was mentioned above, paraprofessional groups have also promoted themselves as places where gay men or lesbians can experience reorientation (e.g., Exodus-affiliated ministries; Homosexuals Anonymous). Other groups (e.g., Courage) promote celibacy and change of behavior rather than change of orientation. However, there are apparently no published controlled outcome studies to support the claims of successful change of orientation, although there are numerous anecdotal reports of change. Behavior change appears to be achieved by a significant percentage of highly motivated individuals.
To summarize thus far, prevalence rates for homosexuality and experiences of same-sex attraction appear to be lower than what was previously reported. Some adolescents experience same-sex attraction or identify as gay or lesbian, and there are several competing theories as to the etiology of homosexuality. No one theory can explain such a diverse phenomenon. Although interventions can be provided to change sexual behavior, there is significant disagreement as to whether sexual orientation can be changed.
In light of the research that is available to date, how can MFTs provide services in an ethical manner when families present concerned about an adolescent's experience of same-sex attraction? As indicated by the AAMFT's Code of Ethics, MFTs have a responsibility to advance the welfare of families and individuals (ES 1), as well as respect the rights of those who seek out services (ES 1.4). Further, MFTs are not to use their professional relationship to further their own interests (ES 1.3). In an effort to remain faithful to the ethical guidelines for accountability and professionalism, recommendations to MFTs include creating a context for shared understanding and providing informed consent to treatment.
Create a Context for Shared Understanding
It should be noted that not every family with an adolescent who experiences same-sex attraction or who self-identifies as gay or lesbian will come into therapy with sexuality as the primary concern for treatment. These families may come into therapy for concerns related to difficulties in the sibling subsystem, the parental dyad, or with developmental transitions that the family is currently facing. In other words, experiences of same-sex attraction are simply not an issue for some families and are not intended to be the focus of treatment.
For other families, however, the fact that an adolescent family member experiences same-sex attraction will be the presenting problem. When MFTs work with these families, it will be important to clarify what the identified client sees as the problem. What concerns do each of the parents have? How are they similar or different? Of the many concerns family members raise, three will be discussed in the space that follows: (a) whether their adolescent will struggle with depression, suicidality, and/or substance abuse; (b) whether homosexuality is a pathological condition; and (c) cultural and religious objections to homosexuality, same-sex behavior, or both.
Some family members may be concerned that teens who experience same-sex attraction may be ridiculed by their peers. They may be concerned that their adolescent will struggle with depression or suicidality, perhaps as a result of social isolation. The research here is somewhat confusing. There is research that suggests higher rates of depression, suicidality, and drug and alcohol use among those who identify themselves as homosexual (e.g., Bell & Weinberg, 1978; Remafedi et al., 1987). MFTs can discuss this research, as well as contrasting interpretations of the research. Some may argue that these concerns are the result of internalized societal disapproval of homosexuality; others may view homosexuality as inherently unstable.
Along these lines, some family members may look to the future, express concerns about the prospects of finding a marriage partner, and fear that those who experience same-sex attraction may not find long-term, meaningful relationships. Although many gay men and lesbians report fulfilling intimate relationships, the rates of nonmonogamy are higher among homosexuals than heterosexuals (Laumann et al., 1994).1 Family members may respond to this research in different ways. Again, some may express concern that homosexual relationships are inherently unstable; others may voice concern that there are few formal means for supporting same-sex unions.
Some family members may also believe that homosexuality is pathological; they may view same-sex attraction as signaling mental illness. MFTs can review with family members how mental health professionals view homosexuality at this time. In 1973, the American Psychiatric Association removed homosexuality from its official nomenclature of mental disorders. At the same time, MFTs can admit that there is some disagreement even among mental health care providers as to the status of homosexuality. For example, Pope, et al. (1987) report that over one in five therapists surveyed treat homosexuality per se as pathology. Similarly, Jensen and Bergin (1988) report that 57% of therapists surveyed agreed with the statement that heterosexual relationships are preferable for a positive, healthy lifestyle. It is no surprise, then, that family members may be divided or confused about how to respond to an adolescent who experiences same-sex attraction.
In addition to concerns about depression, suicidality, and the status of homosexuality as a mental disorder, some family members may object to homosexuality and/or homosexual behavior on cultural or religious grounds. In some cultures, same-sex behavior and homosexual identification may be viewed as contributing to cultural genocide, akin to the use of contraception (Greene, 1994). Similarly, family members may be part of an organized religion that affirms the inherent worth of people in general but disapproves of or condemns same-sex behavior. MFTs can be sensitive to religious diversity, recognizing that some who experience same-sex attraction disagree with the perspectives on human sexuality articulated in the Jewish faith, various Protestant denominations, and the Roman Catholic Church; others agree with the historical teachings concerning the moral status of same-sex behavior and seek to live in accordance with the teachings of their religious community.2 MFTs have an opportunity to create an environment to hear these cultural and religious values when they work with families struggling with an adolescent's sexuality.
Of course, family members can also frame their concerns as religious or cultural when they are really related to an irrational fear of homosexuality in and of itself. Again, family therapy can allow room for these fears to be identified and shared.
Some therapists may disagree with the idea that therapy should be a place for sorting out these beliefs and values, arguing that MFTs should be proactive in shaping the family culture toward acceptance of same-sex behavior and identity (Davison, 1982). The primary ethical concern with this stance is that it surreptitiously changes the role of the therapist and may border on using our professional relationship to further our own interests (ES 1.3). Granted, there may be some professional latitude for how to proceed; however, one role MFTs have historically taken on is that of creating a context for shared understanding, so that each family member can articulate his or her value commitments (in keeping with ES 1.4, which suggests MFTs respect the rights of clients to make decisions and assist them in understanding the consequences of their decisions), and so that cultural and religious concerns can be expressed. There is no compelling reason to make an exception to the stance MFTs usually take with families, as our role so often includes protecting the dignity and rights of individuals in the family context and identifying and removing constraints that keep families from functioning and problem-solving in healthy and adaptive ways.
Provide Advanced Informed Consent
After a time of reflection on the fears or concerns, beliefs and assumptions, and cultural and religious values concerning homosexuality and same-sex behavior, clients face the decision of what direction to go in therapy. An adolescent may decide to consciously identify him- or herself as gay or lesbian. Or he or she may pursue treatment aimed at changing sexual behavior or experiences of same-sex attraction. Informed consent helps MFTs insure a client's sense of autonomy and self-determination. Given the state of knowledge about homosexuality at this time, and in light of the degree of controversy surrounding the research in this area, a comprehensive presentation is important for clients to make a truly informed decision. It should be noted that McConaghy (1993), a highly regarded specialist in the area of human sexuality and sexual behavior, argues that there is no need for adolescents to decide at this stage in their development to commit themselves to being either homosexual or heterosexual; adolescent sexuality is often unfocused and diffuse. He discusses with teens and their parents a range of issues, including
In addition to these suggestions, advanced informed consent may also include a thorough discussion of what sexual orientation actually is3, alternatives to professional treatments (e.g., 12-step groups and other paraprofessional organizations), possible benefits of pursuing treatment at this time, and possible outcomes with or without therapy.
MFTs also face a decision about what direction to go in treatment. Therapists' professional competence and the values therapists hold may impact their capacity to provide treatment. Concerning values, Tjeltveit (1986)4 suggested that therapists consider referring clients when moral, religious, or political values are central to the client's presenting problem and (a) the limit of professional competence has been reached, (b) therapists experience significant discomfort with their client's values, (c) they are unable to work objectively, or (d) they have reason to believe that if they continue they will impose their value commitments on their client. When a family reaches a decision about the direction of therapy, MFTs must decide whether or not they can provide treatment. This decision is made with reference to therapists' competence as well as their values. A referral may be appropriate if an adolescent pursues change of behavior or orientation, or it may be appropriate if an adolescent requests gay-affirmative therapy. In either case, when competency is a concern, or when value conflicts occur, MFTs have an ethical obligation to consider an appropriate referral (ES 1.6).
It should be noted that in clinical practice even this dichotomy may appear artificial. MFTs can help families support their teen as he or she navigates adolescence by attending to systemic concerns and issues related to self-esteem, social relationships, academic competencies, and so on, without focusing exclusively or even primarily on sexuality. In light of McConaghy's (1993) research and emphasis on adolescent sexuality being unfocused and diffuse, this may be one of the most helpful uses of family therapy.
In any case, the ethical concern is that as families sort out which direction to go in therapy - to pursue gay-affirmative treatment, to change experiences of same-sex attraction or behavior, or to focus primarily on supporting their teen through a myriad of challenges in adolescence - MFTs should respect the rights and dignity of those who seek out their services. MFTs have an ethical obligation to put family members in the position to make a truly informed decision about their work in therapy.
Several professional and ethical questions are raised when families present for therapy concerned about an adolescent's sexuality. MFTs are encouraged to reflect on ways to provide therapy in a competent and ethical manner. Although there is little consensus today as to the etiology of same-sex attraction, and despite ongoing debates concerning treatment options for gay men and lesbians, MFTs are in a unique position to provide the space needed for frank and honest discussions of the available research, the fears and concerns related to same-sex behavior and identity, and the cultural and religious values that families bring to therapy concerning human sexuality and sexual behavior.
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1 In the original American Journal of Family Therapy article, I cited Laumann et al. (1994) concerning rates of nonmonogamy; the Laumann et al. study reported higher rates of lifetime sexual partners. For rates of nonmonogamy, see Blumstein, P., and Schwartz, P. (1990), Intimate relationships and the creation of sexuality. In S. A. Sanders & J. M. Reinisch (Eds.), Homosexuality/heterosexuality: Concepts of sexual orientation (pp. 307-320); New York: Oxford University Press. See also McWhirter, D. P., & Mattison, A. M. (1984), The male couple. New York: Prentice-Hall.
2 This is evidenced by the formation of Courage, a support group for Catholics who experience same-sex attraction and are attempting to live celibate lives in accord with the official teachings of the Roman Catholic Church. Others who experience distress about their experience of same-sex attraction become involved in various support groups and 12-step groups (some of which are have as their goal change of sexual orientation); still others come to therapists for help.
As was mentioned above, many people are content with their identity as a gay man or lesbian. Support groups and pro-gay organizations such as Dignity and Parents and Friends of Lesbians and Gays emphasize the integration of same-sex impulses into a gay or lesbian identity and provide information on a range of issues related to homosexuality.
3 Essentialists and constructivists debate the meaning of sexual orientation. Essentialists argue that sexual orientation is a real thing or essence. Proponents of this view often reference research implicating physiological antecedents related to experiences of sexual attraction. Some (but not all) essentialists argue that this essence is tied to the core of one's self as a human being, and because this real essence is a part of what properly defines the core of the person, same-sex behavior is naturally occurring, morally blameless behavior (Sullivan, 1995).
Constructivists, in contrast, view sexual orientation as a social construct, so that the term "homosexuality" does not refer to something real but is a linguistic construct fashioned by a society for discussing sexual preferences (Greenberg, 1988). There are a variety of expressions of constructivism, some of which implicate early childhood development in the construction of a homosexual identity (Troiden, 1993).
4 Cited in Corey, G., Corey, M. S., & Callanan, P. (1998). Issues and ethics in the helping professions (5th edition). Pacific Grove, CA: Brooks/Cole.