Contents
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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