Can Sexual Orientation Be Changed?

Jack Drescher. Journal of Gay & Lesbian Mental Health, Volume 19, Issue 1. 2015.

This paper was presented at a 2013 conference at the United Nations Church Center in New York City. The conference, “Selling the Promise of Change: International Health and Policy Consequences of Sexual Orientation Change Efforts (SOCE),” was sponsored by the NGO Committee on Human Rights and the NGO Committee on HIV/AIDS. The paper begins with a review of the history of mental health attitudes toward homosexuality from the 19th century to the present. This is followed by a discussion of how SOCE shifted from a clinical debate to a culture war issue. The paper then reviews some research issues raised by the Spitzer (2003) study, some of the problematic clinical and ethical issues raised by efforts to change sexual orientation, and concludes with a summary of the position statements of the American Psychiatric Association and American Psychological Association.

History of Mental Health Attitudes Toward Homosexuality

The Hungarian writer Karl Maria Kertbeny coined the terms “homosexual” and “homosexuality” in an 1869 political treatise that argued against criminalizing relations between individuals of the same sex (Bullough, 1979). He argued that as a normal variation of human sexuality, homosexual behaviors are not immoral and should not be punished. In 1886, psychiatrist Richard von Krafft-Ebing adopted Kertbeny’s term “homosexual,” and his Psychopathia Sexualis popularized its usage in medical and scientific communities. However, unlike Kertbeny, Krafft-Ebing considered homosexuality a “degenerative” neurological disorder.

By the middle of the 20th century, two major competing theoretical views of homosexuality were offered by (1) psychoanalysis, a field dominated by psychiatric physicians, and (2) sexology’s academic researchers. Freud, in the early years of psychoanalysis, refuted Krafft-Ebing’s characterization of homosexuality as an illness, noting that it was found in individuals with no other mental problems and in people “distinguished by especially high intellectual development and ethical culture” (Freud, 1905, p. 138). Instead, he claimed adult homosexuality was due to a “developmental arrest,” a form of “immaturity,” in which normal sexual instincts of childhood persisted into adulthood (Drescher, 2001, 2002a).

Psychoanalysts after Freud, however, based their views on the work of Sandor Rado (1940). Unlike Freud, Rado believed there was no such thing as normal childhood homosexuality and that heterosexuality was the biological norm. He defined adult homosexuality as a phobic avoidance of heterosexuality caused by inadequate, early parenting. His views were highly influential in the pathological models of psychoanalysts of the mid-20th century (Bieber et al., 1962; Socarides, 1968).

Psychoanalysts and psychiatrists theorized about homosexuality from a self-selected group of patients seeking treatment for it and from prison populations. In contrast, sexology researchers of the mid-20th century tried to make sense of human sexual behavior in general populations. In contrast to analytic case reports, sexologists went into the field and recruited large numbers of nonpatient subjects for study. The research of Kinsey and his associates (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Ppomeroy, Martin, & Gebhard, 1953) and of Evelyn Hooker (1957) lent support to a view that homosexuality, like heterosexuality, is a normal variation of human sexual expression. American psychiatry at that time, under the sway of psychoanalytic theory, mostly ignored sexology research and its normalizing conclusions.

In 1970, sexology research was brought forcefully to the attention of the American Psychiatric Association (APA). Organized gay activists, convinced that psychiatry’s pathologizing attitudes about homosexuality were a major contributor to social stigma, disrupted first the 1970 and then again the 1971 annual APA meetings. As a result, APA embarked upon a process of studying the scientific question of whether homosexuality should be considered a psychiatric disorder. APA’s Board of Trustees charged its Nomenclature Committee as the scientific body best suited to address this issue.

After a review lasting more than a year, the Nomenclature Committee chaired by Robert Spitzer recommended to the Board of Trustees that APA remove “homosexuality per se” from the diagnostic manual. After review and approval by other APA committees and deliberative bodies, in December 1973 APA’s Board of Trustees voted to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders, second edition (DSM-II) (Bayer, 1981; Drescher & Merlino, 2007). Before that removal was formally implemented, psychoanalysts petitioned APA to hold a referendum of the entire membership to overturn the Board’s decision. In 1974, the Board’s decision to remove was upheld by a 58% majority of voting APA members. Following the referendum, APA also issued a groundbreaking position statement supporting civil rights protection for gay people in employment, housing, public accommodation and licensing and the repeal of all laws that criminalized homosexuality between consenting adults.

Sexual Conversion Therapies: From Clinical Debates to Culture Wars

After the 1973 APA decision, cultural attitudes about homosexuality changed in the United States and other countries as those who accepted scientific authority on such matters gradually came to accept the normalizing view. If homosexuality was not an illness, and if one did not literally accept biblical prohibitions against it, and if gay people were able and prepared to function as productive citizens, then what is wrong with being gay? Similar shifts gradually took place in the international mental health community as well. In 1990, the World Health Organization removed homosexuality per se from the International Classification of Diseases (ICD-10).

The international psychoanalytic community, however, took longer to adopt this perspective. Following the 1973 decision, their influence gradually declined in the mental health professions. As normalization took place in the rest of the culture, analysts, in their journals and at their meetings, continued to write and speak about homosexuality in pathological terms. They also continued to deny openly gay men and lesbians the option of training in their institutes for years afterward. However, in response to a threatened lawsuit (Isay, 1996), in 1991 the American Psychoanalytic Association (APsaA) adopted a sexual orientation nondiscrimination policy regarding the selection of candidates and revised it in 1992 to include selection of faculty and training analysts as well (Hoffman et al., 2000; Drescher, 2008).

Following their marginalization from the APsaA, conversion therapists formed their own organization: The National Association for Research and Therapy of Homosexuality (NARTH; Drescher, 1998). NARTH Members regard homosexuality as a mental disorder and argue that those who so desire should receive “treatment” to change their sexual attractions. While the causes of homosexuality (and heterosexuality) are unknown, that is not the case for NARTH members who claim knowledge of its “etiology.” Their theories about homosexuality’s causes and its “treatment” derive from both religious (faith healing) and secular (Radoite psychoanalytic) approaches. Most significantly, NARTH provides religious and social conservatives a dissenting, scientific-sounding voice to counter mainstream mental health views of homosexuality (Drescher, 2009).

NARTH members argue from an illness/behavior model (Drescher, 2002b) that regards any open expressions of homosexuality as behavioral symptoms pathognomonic of psychiatric illness, a moral failing, or some combination of both. This position maintains that illness and immorality cannot provide a foundation for creating a normal identity or serve as a basis for defining membership in a sexual minority. From the perspective of an illness/behavior model, those who engage in homosexual behavior do not merit the kinds of modern legal protections afforded to racial, ethnic or religious minorities and efforts to obtain such protections are defined as “special rights.”

In recent years, social conservatives have adopted the illness/behavior model for political purposes. By conflating “biology” with “immutability,” they essentially argue that if homosexual behavior can be changed in just one person, then homosexuality cannot possibly be an inborn trait like race. Their position is that if homosexuality is not inborn, then gay people should not be considered a minority entitled to legislative protections.

In addition to NARTH, which provides spokespersons with professional degrees to make these arguments, social conservatives have also enlisted so called ex-gays to reinforce their message. One example is the use of ex-gays in advertisements opposing hate crimes legislation intended to protect individuals on the basis of their sexual orientation. A black and white picture shows two men and two women, looking very seriously into the camera as the text reads, “Hate Crime laws say we were MORE VALUABLE as homosexuals than we are now as former homosexuals.” The messages here are twofold: (1) Homosexuality is not innate because we were once gay and now we are not, and (2) hate crime laws should be opposed because gay “rights” are “special rights.”

In many ways, ex-gay political strategies designed to obstruct the gay civil rights movement resemble those used by proponents of “Intelligent Design” (Drescher, 2009). This is not altogether unsurprising, as many of the individuals who support the ex-gay movement also do not believe in evolution of the species (referred to as “Darwinism” by its critics). Their strategies include:

• Present an issue to the public as ifit were a debate in the mental health professions;
• Finance and promote ideological “experts” and “think tanks” (NARTH);
• Personal testimonies (ex-gays);
• Discredit science, motives and methods of mainstream mental health organizations;
• Attack individuals whose work undermines their agenda (Kinsey, LGB professionals, or straight supporters); and
• Confuse the public with pseudo-science and selective scientific citations (conflate homosexuality with pedophilia and gender dysphoria).

The goal of this strategy is not to persuade the mental health mainstream of the correctness of their views (which would involve doing actual research) but rather to try and persuade the public and policy makers on the issues of gay rights (Lund & Renna, 2003; Drescher, 2009).

Research Issues

In 2003, Robert L. Spitzer, MD, published a widely reported study of 200 individuals having claimed to change their sexual orientation (Spitzer, 2003; Drescher & Zucker, 2006). The study’s 200 subjects included 143 men and 57 women interviewed by telephone for 45 minutes to determine if they had changed their sexual orientation. According to Spitzer, a majority reported some change from a “predominantly or exclusively” homosexual orientation to a “predominantly or exclusively” heterosexual orientation.

There were many methodological criticism of the study (Drescher & Zucker, 2006), including

• No follow up or face to face interviews of subjects;
• The use of retrospective rather than prospective accounts;
• A lack of physiological measures of sexual arousal such as plethysmography;
• Difficulty recruiting 200 subjects—it took 16 months; and
• Sample bias in the subject recruitment—approximately 20% of subjects were professional ex-gays who led their own ex-gay ministries.

Despite the study’s methodological limitations, it was published without conventional peer review. Instead, reviewer commentaries (mostly negative) accompanied the study’s publication. Spitzer’s revamping of the American psychiatric diagnostic system in 1980’s DSM-III had given him an esteemed standing among the international scientific community that no conversion therapist has ever achieved (Drescher, 2003). Publishing the study in this manner made it appear as if the Archives of Sexual Behavior was trading on Spitzer’s reputation, rather than on the quality of his study. In a similar vein, for more than a decade, antigay social forces and ex-gay advocates sought to use Spitzer’s reputation to legitimize their approach.

In 2012, Spitzer repudiated his own study. Speaking of the study’s “fatal flaw” in a letter published in Archives of Sexual Behavior, he wrote, “there was no way to judge the credibility of subject reports of change in sexual orientation. I offered several (unconvincing) reasons why it was reasonable to assume that the subject’s reports of change were credible and not self-deception or outright lying. But the simple fact is that there was no way to determine if the subject’s accounts of change were valid.”

He went on to say, “I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some ‘highly motivated’ individuals.”

Clinical and Ethical Issues

Little research has been done on either the benefits or harm of sexual orientation change efforts (SOCE) (American Psychiatric Association, 2000; American Psychological Association, 2009). In published reports by SOCE advocates, the majority who try to change do not and it is not uncommon to overstate claims of benefits while concerns about possible harm are minimized or dismissed (Jones & Yarhouse, 2011).

In the past, SOCE were regarded by professional organizations as private agreements between individual patients and therapists. It was believed, either explicitly or implicitly, that efforts to eradicate homosexuality were a reasonable undertaking from which no harm could come (Drescher, 2002b). In recent years, however, complaints about poor outcomes have led to greater scrutiny. There is now an emerging clinical focus on individuals who, after attempting and failing SOCE, later adopted a gay or lesbian identity. An accumulation of anecdotal accounts paints a disturbing picture: therapists may be doing psychological damage to patients (and families of patients) who fail to convert and who eventually decide to come out as gay.

Ethical violations in these treatments include subjective informed consent (i.e., telling patients that homosexuality is a mental disorder because the practitioner believes that it is), breaches of confidentiality (i.e., informing religious school authorities that gay students are engaging in sexual behavior), improper pressure placed on patients (i.e., threatening to end a treatment if the patients do not submit to the therapist’s authority), and the relinquishment of fiduciary responsibility to patients who eventually decide to come out as gay (i.e., unwillingness to refer a patient to a gay affirmative therapist when the SOCE fails) (Shidlo & Schroeder, 2002).

In addition, SOCE practitioners rarely adopt stringent selection criteria. Regardless of the probability of success, anyone who wants to try and change can usually find someone who will work with them. Also patient motivation, rather than the skill of a therapist or efficacy of the “treatment,” is usually credited as the primary factor leading to change. This is a set up for “patient blaming” as most people who try to change do not. After “treatment” fails, patients may feel worse and blame themselves, question their faith or their motivation. This may lead to worsening of depression, the onset of anxiety, and possible feelings of suicide. Disturbingly, these anecdotal results are never reported in the SOCE literature.

Some individuals are encouraged to marry during a course of SOCE lasting several years and may have spouses and children when they realize that change has not happened. Sometimes these families break apart. In cases where religious beliefs discourage divorce, mixed orientation couples stay together living in tragic circumstances.

Finally, years of trying fruitlessly to change one’s sexual orientation can delay the decision to come out as gay. When the individual does come out, the experience of SOCE, which can be likened to a concentrated dose of antihomosexual stereotyping, may create intimacy and sexual problems. Haldeman (2001) refers to this as a “spoiled” gay identity.

All of these factors raise another ethical issue: Even if the questionable claims of SOCE’s effectiveness are valid, should the conversion of some “homosexuals” to heterosexuality condone the iatrogenic harm done to other patients who later come out as gay (Drescher, 2002b)? In other words, should it not matter how many gay people are hurt in the process of creating a few heterosexuals?

The two APAs have weighed in on these issues. In 2000, the American Psychiatric Association issued a position statement about SOCE with three recommendations:

1. APA affirms its 1973 position that homosexuality per se is not a diagnosable mental disorder. Recent publicized efforts to repathologize homosexuality by claiming that it can be cured are often guided not by rigorous scientific or psychiatric research, but sometimes by religious and political forces opposed to full civil rights for gay men and lesbians. APA recommends that the APA respond quickly and appropriately as a scientific organization when claims that homosexuality is a curable illness are made by political or religious groups.
2. As a general principle, a therapist should not determine the goal of treatment either coercively or through subtle influence. Psychotherapeutic modalities to convert or “repair” homosexuality are based on developmental theories whose scientific validity is questionable. Furthermore, anecdotal reports of “cures” are counterbalanced by anecdotal claims of psychological harm. In the last four decades, “reparative” therapists have not produced any rigorous scientific research to substantiate their claims of cure. Until there is such research available, APA recommends that ethical practitioners refrain from attempts to change individuals’ sexual orientation, keeping in mind the medical dictum to First, do no harm.
3. The “reparative” therapy literature uses theories that make it difficult to formulate scientific selection criteria for their treatment modality. This literature not only ignores the impact of social stigma in motivating efforts to cure homosexuality, it is a literature that actively stigmatizes homosexuality as well. Reparative therapy literature also tends to overstate the treatment’s accomplishments while neglecting any potential risks to patients. APA encourages and supports research in the NIMH and the academic research community to further determine reparative therapy’s risks versus its benefits.

In 2009, the American Psychological Association also issued a complex peer reviewed report on SOCE. Among its findings, the report:

• Affirms that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality regardless of sexual orientation identity;
• Reaffirms its position that homosexuality per se is not a mental disorder;
• Opposes portrayals of sexual minority youths and adults as mentally ill due to their sexual orientation;
• Concludes that there is insufficient evidence to support the use of psychological interventions to change sexual orientation;
• Encourages mental health professionals to avoid misrepresenting the efficacy of sexual orientation change efforts by promoting or promising change in sexual orientation; and
• Concludes that the benefits reported by participants in sexual orientation change efforts can be gained through approaches that do not attempt to change sexual orientation.