from Clinical/Therapeutic Issues
REVIEW OF: Tozer, E.E., & McClanahan, K. M. (1999), Treating the purple menace: Ethical considerations of conversion therapy and affirmative alternatives. The Counseling Psychologist, 27 (5), 722-742.
by Charlotte Rosenak, Ph.D.
Overland Park, Kansas
The authors of a recent article in The Counseling Psychologist say that reparative therapy should not be offered to clients who request such therapy. The article is well-written and passionate. The authors believe that offering reparative therapy reveals the therapist's heterosexual bias and a homophobic belief system.
Much of this article is based on the assumption that psychologists, scientists, and professionals at large now agree that homosexuality is a condition that is in no way harmful to clients and/or to society, and that it cannot be changed. In this review, I will first endeavor to highlight materials and ideas that are not disputed in this article, and then thoughtfully critique parts of the authors' arguments that merit further examination and discussion.
Throughout their discussion, the authors use the terms "conversion therapy" and "reorientation therapy" interchangeably. For theoretical and clinical reasons, I prefer to use the term "reparative therapy" to indicate therapy given to persons questioning their sexual orientation and seeking as a part of their therapy to become more heterosexually responsive.
That reparative therapy is controversial is not to be disputed. In fact, the whole issue of homosexuality and related issues is one that many cultures and various bodies within American Society continue to discuss and debate. Churches continue to debate whether or not those who call themselves homosexuals should or should not be in church leadership. States are beginning to consider legislation on whether or not to view homosexuals as having a right to marry. Thus reparative therapy will probably continue to be controversial, alongside other issues related to homosexuality generally.
It is true that in early psychological history (1880's) and up until the 1970's, one finds a majority of writers and researchers within the fields of psychology and psychiatry believing that the homosexual condition is not normal or desirable, and that to pursue sex with one's same gender is pathological.
Many of the formerly tried "conversion therapies" mentioned in this article such as visits to prostitutes, electroshock, deprivation of fluids, castration, forced isolation with a woman, etc., were no doubt ineffective and abusive in nature.
Yet public desire for conversion therapy does remain. There are no doubt methodological problems in studies that purport to demonstrate the efficacy of reparative therapy. (My experience leads me to believe it very rare to find a clinical study relating to efficacy of any kind of therapy that does not have methodological problems.) As the authors explain, the American Psychological Association does not recommend an explicit ban on reparative therapy, but they have issued guidelines requiring therapists to provide their clients with accurate information about sexual orientation and mental health.
The authors write (p. 725), "Despite the complete absence of homosexuality as a diagnosable mental illness, conversion therapy is still in use."
That homosexuality per se is not diagnosable is incorrect. But the current Diagnostic and Statistical Manual of Mental Disorders, IV-Revised (1994) maintains category 302.9, Sexual Disorder Not Otherwise Specified. Examples include "Persistent and marked distress about sexual orientation," p. 538. Therefore, to date, being concerned and distressed about homosexual feelings and desiring to change them is still a condition warranting a diagnosis, and can still be treated in the nomenclature of 2000. (That persons would present themselves as distressed over heterosexual orientation would be highly unlikely.)
The authors posit that reparative therapists only engage in reparative therapy because they believe that homosexuals are somehow inferior. But those who embrace reparative therapy as an option would not necessarily need to believe that those who call themselves homosexuals demonstrate more pathology than those who are heterosexuals. For example, most marital and family therapists would agree that men and/or women who are unfaithful in marriage, i.e., persons who have affairs, are not making a healthy choice. Yet it is not necessary to prove that people who have affairs are more pathological than people who are faithful to their marriage vows in order for the therapist to disapprove and not recommend such behavior. If a person presents with wanting to stop adulterous behaviors, the standard therapeutic response would be to help the person achieve that goal.
Perhaps homosexuals do have wounds that propel them toward the same sex erotically. Unfaithful heterosexuals also have wounds that propel them into their sexual behaviors. Measuring degrees of pathology is a problematic area in the science of psychology. Thus I disagree with the authors that reparative therapists as a whole see homosexuals as inferior and pathological persons, when compared to heterosexuals.
It is also true that many heterosexuals and many homosexuals have severe pathologies relating to other symptoms and behaviors, unrelated to sexual preference.
If it has been demonstrated that to offer clients healing through reparative therapy is harmful to them, then the authors would be correct in saying that the ethical standards of competence, integrity, respect for people's rights and dignity, and social responsibility have been violated. However, reparative therapy as it is currently practiced today, has not been demonstrated to harm clients. There is an abundance of clinical data that suggests reparative therapy can help clients achieve more responsiveness to the opposite sex. There is also empirical data, albeit flawed, in that direction.
To not provide clients with what they request when the request is a reasonable one is irresponsible and unethical. It is also our social responsibility to let people know that the development of homosexuality as we know it today has not been proven to be a genetic inevitability, and that alternatives to embracing the homosexual lifestyle do exist.
The authors recommend that if a client persists in desiring reparative therapy, then termination of therapy is a possible ethical action. I disagree. A more ethical action would be to put the homosexual orientation issue aside, and pursue healing for that individual. What therapists can and should do for all clients is to focus on healing wounds from the person's past, affirming their self-esteem, providing support, helping them to move toward healthy relationships and away from toxic ones, correcting their self-talk, helping them to overcome "don't feel" messages, and helping them learn to be assertive and to set boundaries.
A much-respected behavioral therapist, Joseph Wolpe (1969), made a clinical case report of an individual who worked at more assertiveness and independence in therapy; a surprise result was a change in sexual orientation (stable after a four-year follow-up). This result surprised the therapist and the client.
The debate over the efficacy of ethicality of reparative therapy is far from over. Those who are against reparative therapy may soften their stance if they could realize that this approach can be healing, client-centered, and does not resemble the homophobic and cruel methods of the past.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV-R). Washington, D.C.
Wolpe, J. (1969). The practice of behavioral therapy. New York: Pergamon.