EFFORTS TO MODIFY SEXUAL ORIENTATION: A REVIEW OF OUTCOME LITERATURE AND ETHICAL ISSUES


Contents

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.


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)


One impact of this openness to diverse sexual identities is the emergence of opposition to any form of counseling to modify or to attempt to change the sexual orientation of a client from homosexual to heterosexual. Davison (1976), Martin (1984), and Haldeman (1994) suggest that psychotherapeutic efforts to change sexual orientation are unethical. In 1997, after nearly 2 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 (ACA) passed a similar resolution at its annual convention in Indianapolis (ACA, 1998)


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 in italics above concerning opposition to conversion therapies (ACA, 1998) Thus, the ACA's 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 mental health 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. The ACA resolution opposed conversion therapy on the grounds that such therapy is both ineffective and unethical. This article examines the effectiveness and ethicality of helping clients redirect their sexual orientation. First I 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 (1991,1993), 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 an array of counseling techniques designed to effect a shift in sexual preference. In this context, some behavioral counselors speak of modifying patterns of sexual arousal (Barlow & Durand, 1995) For the purpose of this article, I refer to mental health counseling approaches that attempt to effect a change in patterns of sexual attraction and arousal as conversion therapy. Conversion implies a profound change which is certainly true when someone modifies sexual orientation.


A WORD ABOUT SEXUAL ORIENTATION Haldeman (1994) suggests 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, & Gebhard, 1948) Kinsey suggests that sexual orientation ranges along a continuum from exclusively homosexual (Kinsey rating "6") to exclusively heterosexual (Kinsey rating "0") (House & Miller, 1997) Gonsiorek, Sell, and Weinrich (1995) recommend assessing "same- and opposite-sex orientations separately, not as one continuous variable." (p.47) They suggest 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 counselors know if they are aiding clients to change from one sexual orientation to another?


Gonsiorek et al. (1995) note that the most common means of assessing sexual orientation is via self-report. However, they also note that "there are significant limitations to this method." (Gonsiorek et al., 1995, p. 44) The most obvious problem is the subjective nature of self-assessment. Being gay, lesbian, or bisexual 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, Gonsiorek et al. (1995) state, "Given such significant measurement problems, one could conclude there is serious doubt whether sexual orientation is a valid concept at all." (p. 46) Years earlier, Birk (1980) expressed a similar view saying "there is in fact no such unitary thing as 'homosexuality' ... instead ... there are many, many different homosexuals who collectively defy rigid characterization."(p. 376)


Concerning the potential for assessing change of orientation, Gonsiorek et al. (1995) note, "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 is a work in progress. Counselors ought to articulate to clients this lack of certainty in an unbiased manner.


In the 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. 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% to 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) reports 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) find 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 but 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.


EFFORTS TO MODIFY SEXUAL ORIENTATION
Broadly, opponents of shifting sexual orientation as a therapeutic goal express doubts that sexual orientation can be changed by any means. From a gay-affirming perspective, Martin (1984) and Haldeman (1994) review studies that claimed to demonstrate change in sexual orientation. Their view is that there were no empirical studies that 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 that have demonstrated change. Narrowly, the question to be addressed is: Do conversion therapy techniques 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 through 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., 1962) 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" (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)


Freud generally took a negative view of modifying sexual orientation. However, 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) reports on the psychoanalysis of 106 gay men. Of the exclusively gay clients, 19% finished analysis totally heterosexual. Half of those considered bisexual were considered heterosexual posttreatment. 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 pretreatment 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) describes a supportive, somewhat active, psychodynamic approach to treating gay males. He proposes a traditional environmental explanation for a gay sexual orientation, including fear of women and detachment from male identity. He presents 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 as a gay person 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) reports that in his practice, 20 of 45 (44%) gay men seen in psychoanalytic psychotherapy between 1966 and 1977 achieved "full heterosexual functioning." Macintosh (1994) reports a survey of 285 psychoanalysts who analyzed 1,215 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 (1991,1993) In his review of conversion therapies, Haldeman (1994) critiques Nicolosi's theory of homosexual development but fails to include an evaluation of the successful treatment results claimed by Nicolosi and his colleagues. Nicolosi is the executive director of the National Association for Research and Therapy of Homosexuality (NARTH) His writings detail a multidimensional 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 offers numerous case studies of clients who have moved from a primarily gay identity to heterosexual adaptation. Concerning the function of same-gender sexual orientation in men, Nicolosi (1991) states, "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) calls 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 to attain heterosexual arousal. For instance, Nicolosi, Byrd, and Potts (1998) report 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. Posttreatment, 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 subgroup 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 et al., 1998)


In summary, psychoanalytic approaches report rates of change to exclusive heterosexuality ranging from 18% to 44% of clients. Rates for less dramatic shifts in 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
Numerous reports of behavioral interventions have documented the modification of sexual arousal. While Haldeman (1994) primarily reviews 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 that 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. Most commonly electric shocks (also known as faradic therapy) on the leg or finger were paired with slides of attractive male nudes (Feldman & MacCulloch, 1965), although nausea inducing substances and noxious smells have also been used (Colson, 1972) Participants would be shocked for sexual arousal to male pictures but rewarded by experiencing no shock in the presence of pictures of female nudes. Results were mixed. For instance, Feldman, MacCulloch, and Orford (1971) report follow-up results of research conducted between 1963 and 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 report reorientation success with subjects using variations of aversive conditioning.


On the other hand, McConaghy (1976) and McConaghy, Armstrong, and Blaszczynski (1981) found no sexual reorientation from aversive treatment. The different results may have been due in part to the different methods of delivering aversive therapy. McConaghy's experiments used a 5-day, 14-session program with no follow-up sessions, whereas the approaches used by Feldman and MacCulloch (1965,1971), Larson (1970), and Thorpe et al. (1964) used more sessions, which were spread out over a longer period of time, and used follow-up sessions. Even though he acknowledged that "present treatments may reduce or eliminate patients' homosexual behaviour and awareness of homosexual feeling" (p. 563), McConaghy concluded that sexual orientation is unalterable (McConaghy, 1976) However, all that can really be said from McConaghy's work is that a 5-day aversive conditioning experience with no follow-up treatment may not generate heterosexual attraction. His results do not demonstrate that sexual orientation is immutable (Solyom & Miller, 1965)


Citing misgivings about the exclusive use of physically aversive conditioning, Gold and Neufeld (1965) describe a verbally aversive therapy technique later called covert sensitization by Cautela (1967) In this context, covert sensitization refers to the visualization of negative consequences or physical sensations in the presence of same-gender sexual arousal. The procedure is similar to physically aversive conditioning but the aversion is done in imagery. Callahan (1976), Kendrick and McCullough (1972), Mandel, (1970) and Segal and Sims (1972) describe successful reorientation outcomes with the use of covert sensitization. For instance, Callahan (1976) describes the use of covert sensitization and assertiveness training applied to the case of a 25-year-old, single male who was sexually abused at age 6 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 heterosexual adjustment with no same-gender sexual arousal.


Nonaversive classical conditioning techniques using sexually arousing materials have been reported. For instance, McCrady (1973) reports the successful therapy of a 27-year-old gay man who had 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 moved 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) describes 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 & Meyer, 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) describe 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 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 3-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 multimodal approaches. Generally, the cases reported in the behavioral counseling literature support the efficacy of efforts to modify sexual orientation. The multimodal 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) notes, 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) suggest 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 no prior 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 Counseling Approaches
Rogers, Roback, McKee, and Calhoun (1976) reviewed the group counseling 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 counseling, 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 remain in therapy for over two-and-a-half years or have 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 is that these clients were exclusively gay and had not experienced heterosexual intercourse (Birk, 1980) Birk points to pretreatment motivation as a major key in understanding the results. In another subgroup of clients not expressing any pretreatment interest in sexual orientation change, 4 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) present 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 experiences 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 deferring techniques, the counseling approaches seem to agree that necessary counseling tasks include increasing assertiveness, addressing a learned fear of relationship with the opposite sex, 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 (1994) portrays such therapies as unethical, Garnets, Hancock, Cochran, Goodchilds, and Peplau, (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 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.


Even if one asserts that offering a mode of treatment implies a disorder, there is a condition in the DSM-IV that would be the proper object of conversion therapies--Sexual Disorder, Not Otherwise Specified (NOS) (American Psychiatric Association, 1994) 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, 1994, 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.


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. Those requesting conversion therapy often do so because of a conflict between their homosexual feelings and the culture with which they identify. 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. The prohibition desired by proponents of the ACA resolution is an absolute one. A client's moral objection to same-gender attraction is not acknowledged by efforts to prohibit conversion approaches. On this point, 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." The consensus of those finding success in shifting sexual orientation is that client's desire to change is necessary to be successful. 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 that help them meet their goals.


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. In the eighth principle, counselors are reminded to be "aware of their own values, attitudes, beliefs, and behaviors and these apply in a diverse society and avoid imposing their values on clients" (ACA, 1998) Apparently, this point assumes that the availability of conversion therapy is an imposition of values on clients everywhere. What does the opposition to conversion therapy say.? To conflicted clients who want to explore the possibility of change to a heterosexual orientation, 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 existence of conversion therapy for people who want it does not require the conversion therapist to force it on someone who does not. 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. 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 or questioning 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)


Wolpe (1973) candidly reports on this tension in his work with a gay client in the 1950s. He described the case of a 32-year-old male who had never experienced sexual attraction or relations with women. The man had "formed a succession of attachments to men with whom he had sexual relations" (p. 258) However, he also felt such relations were against his religious beliefs causing severe anxiety. Wolpe chose to attempt to minimize his religious objections via giving him a book to read. While the client felt some guilt reduction, he still wished to "overcome his homosexuality" (Wolpe, 1973, p. 259) Wolpe refused on the basis of a belief in the genetic basis for homosexuality. The client continued in assertiveness training, however, which resulted in significant reduction in anxiety and improvement in job performance. After several months, the man reported to Wolpe that he had become unable to have sex with men and was feeling attracted to a woman. Through the next year, he became sexually active with women and finally married. After a 3-year follow-up, Wolpe described the client's heterosexual sex life as "in every way satisfactory" (p. 261) This case illustrates the potential consequences of a belief in the immutability of sexual orientation. Wolpe felt he could not offer conversion as an option because he had adopted such a view and instead chose to attempt to modify the client's religious orientation. However, as this case and many others illustrate, change is possible. Given the efficacy of conversion approaches, refusing to entertain this option would withhold a relevant treatment option, especially for clients who wish to change due to religious reasons.


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 to address the issue raised in the tenth principle of the ACA resolution.


Should professional associations attempt to regulate the beliefs of clients and counselors?
In the ACA Code of Ethics, two principles make a resolution concerning conversion therapies seem inappropriate. The first relates to respect for clinical differences and the second concerns public statements. According to section C.6.a of the ACA Code of Ethics under the heading of Different Approaches, "Counselors are respectful of approaches to professional counseling that differ from their own. Counselors know and take into account the traditions and practices of professional groups with which they work" (ACA, 1995) Unless conversion therapy can be shown to be generally harmful with no merit for anyone who might want to engage in it, gay-affirmative counselors are exhorted by this principle to respect the practice of those counselors who work with clients wishing to modify their sexual feelings. The resolutions proposed by AGLBIC at the most recent ACA governing council contain no recognition that some people have benefited from such counseling approaches.


Section C.6.b of the same Code of Ethics reads under the heading Personal Public Statements, "When making personal statements in a public context, counselors clarify that they are speaking from their personal perspectives and that they are not speaking on behalf of all counselors or the profession" (ACA, 1995) While I realize that professional associations may take certain positions on matters related to the mission of the association, I propose that this ethical principle is relevant to this discussion. On matters that are not clear and are morally sensitive, the members of professional association governing boards have an obligation to guard the integrity of members who disagree with the governing board. Those counselors who seem driven to politicize and polarize professional associations risk engaging in unethical conduct to achieve their ends.


DISCUSSION
The purpose of this review is 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. Sexual orientation as a concept has limited clinical utility. Since the categorization 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, define 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% to 78% range (Feldman, MacCulloch, & Orford, 1971; Hatterer, 1970; Mayerson & Lief, 1965) Thus, defined in the manner of the Bell and Weinberg study, an impressive majority of clients were able to change 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.


Proposed Guidelines
So what should mental health counselors do when confronted with clients who request sexual reorientation? I propose the following guidelines.


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.


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 consistent with their values, personal convictions, and/or religious beliefs (Nicolosi et al., 1998)


Since religion is one of the client attributes that 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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