Overview of Ethical and Research Issues in Sexual Orientation Therapy

Marshall Forstein. Journal of Gay & Lesbian Psychotherapy. Volume 5, Issue 3-4. 2002.

Historical Perspective

Efforts to change sexual orientation with psychotherapy evolved primarily as a result of the medicalization of homosexuality and the increasing visibility of politically active homosexual individuals and organizations seeking greater acceptance in society. As with any political and cultural movement within the American society, such as the civil rights movement and women’s liberation, countervailing forces have sprung up in opposition to the attempts to find ac­commodation of “outsiders” into positions of equality within the larger soci­ety.

Prior to the pathologizing of same-sex erotic and affectional desire in the modern age, homosexuality was viewed by society as a matter of moral sinful­ness or antisocial behavior and homosexuality became the target of religious groups wishing to “heal” those afflicted with “moral degeneracy.” With the advent of the medical view of psychosexual arrested development, psychoana­lysts joined the movement to treat homosexuality. Buoyed by the association of femininity with male homosexuality, and the theories of unresolved oedipal issues, therapists rushed to the fore to promise that if early childhood problems were treated with intensive psychotherapy, that homosexuality could be “cured.” This psychopathological view of homosexuality (particularly focused on male homosexuality) led to several theories of etiology without any scientific basis in research. The cultural acceptance of homosexuality as an illness pushed cli­nicians, therapists, doctors, and religious counselors to accept homosexuality as pathological without applying the same rigorous scientific principles as was expected in other fields of medicine.

Consequently, almost every branch of the biomedical and social sciences has been used to try to control sexual orientation. Efforts to change homosex­ual orientation to heterosexual have been made with every conceivable tech­nology or psychological theory (Murphy, 1992). Attempts have included electroshock therapy after viewing graphic homoerotic pictures, convulsive therapy, nausea inducing drugs, testicular implants, behavior therapy and psy­choanalysis (James, 1962). Biological attempts to change sexual orientation have included attempts to manipulate the sex hormones with the assumption that both men and women have homoerotic interests because they lack the ap­propriate gender hormone levels. Ironically, giving male hormones to homo- erotically oriented men did not change their sexual orientation, but it did increase the intensity of their homoerotic interests. It is interesting to note that most attempts to cure or change homoerotic desire have faded into his- tory-along with their proponents-while psychoanalytically informed approaches remain among the most durable attempts at “curing” homosexual orientation. Although the official position towards homosexuality of several psychoana­lytic associations has changed, there remains a group of therapists who hold to the older psychoanalytic theoretical position that a homosexual orientation is, at best, an entrenched adaptation to the failure to achieve normative heterosex­ual orientation (Rado, 1940).

Much of the support for the movement to treat the “disorder” called homo­sexuality began with the 1952 classification by the American Psychiatric As­sociation of homosexuality as a “sociopathic personality.” Once this official pronouncement appeared, physicians, therapists and religious organizations began organizing programs to change those who appeared before them with distress about their homoerotic interests. The use of the diagnostic category of “sociopathic personality” played to the fears and anxieties that not only that certain types of sexual behavior were disordered, but inherently dangerous to society at large.

Today, right wing and fundamentalist religious organizations continue to characterize homosexuality as “a threat to society” or a threat to “family val­ues.” Using Biblical invectives against homosexuality (arguably misinterpreted-see Boswell, 1980), the religious and political right eschew science in the name of a “moral position.” Perhaps more interesting to sociological re­searchers is the enormous fear that a small minority population (1-10%, de­pending on the study) could undermine the stability and value of traditional family configurations, as well as heterosexuality itself.

In 1968, the American Psychiatric Association declined to maintain the no­menclature “sociopathic personality,” but continued to characterize homosex­uality as a mental disorder. Only after much political action to bring data to the scientific body of the APA’s workgroup on diagnoses was a discussion pur­sued to look at scientific studies that did not support the classification of homo­sexuality as a mental disorder. Psychologist Evelyn Hooker’s famous 1957 study put to rest the notion that blinded and independent observers could ascer­tain homosexual orientation by psychometric testing. Along with the lack of any clear and convincing evidence that homosexually-oriented people fit crite­ria for a mental disorder, homosexuality was removed in 1973 from the Diag­nostic and Statistical Manual (DSM) (Bayer, 1987). As it was acknowledged that some homosexually oriented people might have significant distress about their sexuality, the diagnostic category of “sexual orientation disturbance” was created, later replaced in 1980 by “ego dystonic homosexuality.” This served to continue the movement to create opportunities for people to have their sexual orientation “changed” by therapists and religious organizations that continued to believe and promote the notion of homosexuality as a disor­der, illness or moral weakness.

Although the APA removed “ego dystonic homosexuality” from the DSM in 1987, it retained a diagnostic category for treating people unhappy about their sexual orientation under “sexual disorders not otherwise specified.” This continued pathologizing of homoerotic orientation was underscored by an APA study in 1994 that showed most psychiatrists surveyed in Belarus, Brazil, China, India, Poland, Romania, Spain and Venezuela still considered homo­sexuality an illness (Van Hertum, 1994). By this time, all of the American mental health and medical professional associations had clearly issued policy statements declaring that homosexuality was not a mental disorder. Most re­cently, in April of 2001, the Chinese Psychiatric Society removed homosexu­ality as mental illness from its nomenclature.

So why, after the declassification of homosexuality as a mental disorder, is there still such controversy about whether sexual orientation can be changed? After all, regardless of the biomedical or psychological theory guiding the ef­fort, the intention has been to increase heteroerotic interests in men and women and to suppress homoerotic interests. Rarely has there ever been an effort to develop or enhance homoerotic interests in either men or women. Not one of the groups or individuals supporting sexual orientation change therapy has supported that effort, making it clear that the efforts to change from hetero- to homoerotic is based on the underlying assumption that homosexuality per se is abnormal, undesirable, and problematic.

Current State of Knowledge

That some people may have changes in their erotic interests over the course of a lifetime does not provide evidence that, as a group, people with homo­erotic interests can, or should, be treated to change those interests in a durable and psychologically integrative way. There is a fundamental difference be­tween an individual’s erotic interests changing over the life course, and an in­tentional agenda on the part of any particular therapist to change a particular person’s erotic interests because of a fundamental belief that one erotic orien­tation is superior and psychologically preferable to another.

Murphy (1997) writes: “Currently, there is no confirmed method of altering the sexual orientation of people from the fundamental sexual interests, struc­tures and patterns of interpersonal affection that they have as adults… There is no confirmed method of therapy that will fundamentally alter the sexual ori­entation of randomly selected men or women which are confirmably durable in regard to their erotic gender interests” (p. 82).

Who, in fact, are the people who would willingly choose to go to therapists who claim they can change a person’s sexual orientation? What is the social, religious and psychological environment in which they grow up and then rec­ognize homoerotic interests? Given the social mores and Judeo-Christian un­derpinnings of the American social structure, does the process of coming to terms with one’s homoerotic interests necessarily imply a period of internal­ized fear and loathing of homoerotic interests (Shidlo, 1994)? A fundamental desire of all humans is to feel connection, to identify with others like oneself. Discovering one’s sexual orientation to be homoerotic, and presumably differ­ent from one’s family of origin and community, would require a rejection of one’s own self in order to prevent the rejection by others who are assumed to be acceptable in the eyes of society. The psychiatric and psychological litera­ture is replete with discussions about the need for peer identification as one part of the adolescent developing an independent self from that of the family (Hunter and Schaecher, 1987; Ramafedi, Farrow and Deisher, 1991). Adoles­cents who expect their homoerotic interests to alienate them from their peers often face a tremendous psychological stress and isolation in coming to terms with not identifying with peers, family or community. Is it possible to have a coherent, “normative” developmental view of sexual orientation independent of the social and cultural attitudes that stigmatize and marginalize non-hetero­erotic interests?

Research Concerns

Research about the efficacy of therapy to change sexual orientation has been confused with questions concerning the etiology of homosexuality itself. While research that would explain the origins of any particular sexual orienta­tion would not necessarily imply the need to change any such orientations, there are those who would use such data for the purpose of preventing homo­sexuality from arising as the dominant orientation in any particular individual. Failing to separate out the difference between furthering our understanding of the development of all orientations from the use of this understanding to pro­mote one orientation over another contributes to the stigmatization of homo­erotic interests (McKnight, 1997). In the current climate of increasing visibility of homoerotically interested people-and the political issues of equal civil rights-I believe such scientific investigation must be undertaken with extreme caution, and with sensitivity to the potential misuse of science in the interests of social control over particular kinds of sexual behavior.

There are several areas of interest that have been jumbled together, further confusing essential scientific and ethical questions. The first would be the re­search regarding the origins of any sexual orientation, and the relative contri­butions of genetics, embryological development and intrauterine experience, early childhood experience within and outside the family, and social and cul­tural influences. This research would have to start with a null hypothesis as­suming no preferred outcome on the part of the researchers regarding the development of all sexual orientations, or otherwise the very construction of the necessarily complex research design to study these factors would be bi­ased.

The second would be the construction of studies examining the underlying factors that separate those who would seek change from homoerotic to hetero­erotic from those who more easily find acceptance of homoerotic orientation. Since we have found that suicidality is not uncommon among gay and lesbian teens and adults who are isolated, stigmatized, or unresolved about their sexual orientation (Schneider, Faberow and Kruks, 1989; Ramafedi, Farrow and Deisher, 1991), psychological and social variables would have to be studied to identify individuals for whom homosexual orientation is variably acceptable.

Thirdly, since people in distress about their sexual orientation find thera­pists willing and eager to help “cure” or change them, there is an interplay be­tween who wants help changing and who wants to help. Given that the entire history of psychotherapeutic theory is built upon the very dynamic relation­ship between patient and therapist, this interplay must be understood in all of its complexity: the contribution of the psychological and social experience and beliefs of both patient and therapist.

Thus it would be incumbent on researchers to wonder as much about the question of desire to change erotic interests as a function of social stigma and individual fears and anxieties as they do about the possibility of such change over the long term. The National Institute of Mental Health Task Force on Ho­mosexuality in 1972 concluded that psychological problems of gay people are primarily the function of social hostility and antihomosexual attitudes and be­liefs within the major cultural and socially sanctioned structures. It further went on to say that there was no evidence that psychological problems are themselves derivative from the homoeroticism directly in the absence of the hostile social and political climate. Similarly, a 1994 report from the American Medical Association (published in 1996) stated that “much of the emotional disturbance experienced by gay men and lesbians around their sexual identity is not based on physiological causes but rather is due more to a sense of alien­ation in an unaccepting environment” (quoted in Murphy, 1997, p. 84).

Other important research challenges include the lack of agreed upon criteria for evaluating in a uniform manner those people who fall somewhere between an exclusive homo- or heteroerotic interest. There is currently not one prospec­tive study with blinded observers to evaluate the outcome of therapies in­tended to change sexual orientation. There is no agreed upon classification system for categorizing the participants in such studies, nor is there consensus by any expert panel on the tools used to assess homoerotic and heteroerotic in­terests in a systematic manner. Consequently, there is no consistent method or criteria for either determining sexual orientation at the onset of therapy, nor any way to assess the durability or quality of such “change.”

Research on the efficacy of therapy to change sexual orientation is problem­atic because the protocols to evaluate the starting point and stopping point of such therapy have not been subjected to peer review or reliability and validity studies. Sampling techniques to acquire subjects do not meet current standards of research. Not one study has been published to document the efficacy of a particular mode of therapy, nor has any theoretical basis for true change of erotic desire over the long term been described that is based on extensive clini­cal trials. Furthermore, there is no evidence that the therapy itself, rather than other forces or events, including the powerful wish to deny homoerotic inter­ests and be “acceptable” as a “normal” member of society, is the causative mo­dality for change.

Since there have been no objective screening criteria, no consensus about outcome measurement, and no blinded or side-by-side studies, all claims that there is any form of sexual orientation conversion therapy that is effective are without any scientific foundation. To date, not one peer reviewed research study, much less a prospective one that uses reliable and reproducible criteria, has been published in a respected peer reviewed scientific journal.

Research Questions

Many issues remain unclear in the absence of significant epidemiological, clinical or prospective research. Is sexual orientation fixed or fluid? If it can fluctuate during the life course of a particular individual, can it fluctuate in ei­ther direction? For whom and under what circumstances does it change? Is bi­sexuality somewhere between homoerotic and heteroerotic, or an entity unto itself? What percentage of the population experiences true shifts in sexual ori­entation over the life course as opposed to transient efforts to comply with so­cial and religious expectations? Do men and women have similar or different determinants of shifting erotic interests? More fundamentally, why do people want to change their erotic interests? How would the motivation to change from homoerotic to heteroerotic be different in a culture in which one particu­lar sexual orientation was no more valued than another? What are the psycho­dynamic issues that put particular individuals at risk for wanting to change homoerotic orientation to heteroerotic? What distinguishes those men and women who are comfortable with acknowledging their homosexuality from those who seek change?

Ethical Issues

There has been little discussion in the scientific literature about the ethics of sexual orientation therapy. Before the removal of homosexuality from the DSM as a disorder, it was assumed that psychoanalysis could treat the underly­ing “developmental disruption” and extinguish homoerotic desire. Even after homosexuality was no longer considered pathological, the discussion was cen­tered on the etiology of sexual orientation and the rationale for trying to change homosexual to heterosexual, rather than the ethical issues of how such thera­peutic interventions might occur or who might appropriately apply them in the clinical setting.

The question of the ethical nature of the practice of therapy to change sexual orientation has been raised in the political rather than scientific sphere, usually as a result of public gay protests. The ethical debate on the practice of psycho­therapy to change sexual orientation has been conspicuously absent from the professional mental health literature. How is it that the scientific community has stood by almost silently and allowed professionals to report unproven practices without the critical scientific review that is applied to all other medi­cal technologies? Murphy (1997), in his book Gay Science writes:

Though no other efforts at reorientation were as collectively systematic and objectionable as those of Nazi Germany, condemnable reorientation efforts have transpired individually within the confines of private health care relationships around the world and in public institutions, sometimes at judicial order. The efforts to redirect sexual orientation may be in their historical totality just as objectionable as the historically transient but convulsive excesses of the Nazis. Many of the practices historically of­fered would today be summarily judged unethical not only because they violate ethical precepts in favor of informed consent and autonomous choice, but because they do not “fit” the “problem of homoeroticism.” (p. 84)

Ethical Precepts and Sexual Orientation Change Therapy

Religious organizations start with a priori assumptions that they are moral in their basic tenets. Nevertheless, they are not beyond legitimate discussion as to what constitutes ethical behavior of those organizations-or individuals within those organizations-in regard to attitudes and beliefs about homo- erotically oriented people. It is beyond the scope of this paper to argue the pur­ported Biblical basis for condemning homosexuality. It is, however, fair to ask the ethical question concerning the use of religious beliefs and organizational power by individuals acting as therapists to treat people in distress about their homoerotic desires. As a society we respect the right of religion to hold and teach such beliefs up until the point where those beliefs impinge on the very safety and integrity of the health of others. While we sanction the right to teach that life might start at conception, we do not sanction the violence towards those who support a woman’s right to choose an abortion. We might tolerate religious beliefs about the need for marrying within one’s own culture and reli­gion, but we do not support the right for those beliefs to enact violence towards those who choose to bond inter-culturally or interracially. At each juncture, we have had to enact civil laws to protect those who are in the minority, or who do not hold political power, based on the ethical belief that it is wrong to hurt oth­ers on the basis of one’s own particular beliefs. We still continue to see the conflict between religion and science in the battle between creationism and evolution.

More specifically, the ethics of the practice of psychotherapy have been de­veloped as much out of the untoward effects of unethical therapists as by a ba­sic set of ethical tenets. Yet of all the medical arts, psychotherapy has been less rigorously held to the basic tenets of ethical science and medicine. In fact, in some states, one can claim to be a “psychotherapist” even in the absence of any formal psychotherapy training.

I will not address in this paper the question of the ethics of pastoral or reli­gious counselors, or of consumer self-help groups portraying themselves as able to change homosexual orientation. But for trained licensed psychothera­pists there is a clear ethical responsibility to not confuse their personal reli­gious or political beliefs with the science and practice of psychotherapy.

How then can we construct guidelines on how an ethical therapist might proceed with a patient who presents wanting to change their homosexual de­sire? What principles from the history of medicine might be borrowed to in­sure that both patient and therapist are on firm ethical grounds for proceeding with an inquiry into sexual orientation? It may be useful to reflect on how med­ical treatments in general have evolved along with both scientific and ethical guidelines.

Medical treatments fall into one of several categories. Most medical treat­ment derives from pathological states: infection leading to antibiotics, disrup­tion of normal function leading to surgery, medications to enhance cardiac function, and so forth. These treatments derive from first identifying the un­derlying pathology, and then showing that the proposed treatment has a rea­sonable chance of improving quality of life, even if the disease process is not cured or stopped in its progression. The approval of treatments requires con­siderable study and review by peers who understand the pathology and are in a position to evaluate the risk/benefit ratio, and whether the treatment in ques­tion makes a statistically significant change in outcome. The degree of pathol­ogy and the risk for morbidity and mortality of not treating the underlying problem directly relates to the degree of significance expected for any given outcome. For example, whereas in the past vaccinations were deemed useful in forestalling epidemics only if they had a near 100 percent effectiveness, dis­cussion now includes the use of an HIV vaccine that only approaches perhaps 30 percent. In the past this success rate would have been considered unaccept­able. Given the impact that even a partially successful vaccine would make on the global AIDS epidemic, what may have been unethical in another situation is now on the table for discussion.

What drives these discussions on AIDS are as much ethical issues as scien­tific ones. Thus the seriousness of not treating a condition always needs to be weighed against the risks of treatment. The less essential the need for treatment in terms of psychological or physical health, the more rigorous must be the scrutiny of the treatment itself. If mortality rates from cosmetic plastic surgery were significantly higher than they are, the ethics of such treatment might well be brought into question. In the absence of empirical data that show clear and decisive benefit without risk of doing harm, how can treatments of a homosex­ual orientation, which is not a pathological condition, be sanctioned by soci­ety? Who decides what is reasonable risk? What are the roles of the consumer and the provider in this decision-making?

Such questions have led to certain agreed upon principles for medical treat­ments. When a new treatment is being considered, several questions must be asked and answered in order to follow traditional methodology for approval of new treatments:

1. What is the underlying condition being treated? Is the condition life threatening, or simply annoying? Is the condition based on biological pathology or social preferences?
2. What is the procedure for addressing the underlying condition? What basic science supports the treatment? In the absence of a basic scientific understanding of the treatment, are there other precepts or reliably con­sistent principles (like a reproducible psychological theory with re­search data behind it) that support a particular treatment? Have sufficient peer reviewed studies been conducted to support the particular interven­tion in question?
3. What are the risks and benefits of the proposed treatment? How were the risks and benefits assessed and communicated to the patient?
4. What population was studied and can the data be extrapolated to other populations?
5. What process was used to insure that the subject was indeed a “qualified subject,” meaning did the condition being treated in all subjects have enough similarities to provide the evidence that the particular interven­tion was in itself responsible for the outcome and not by chance itself?

In light of the fact that a homosexual orientation has not been considered a psychologically pathological condition since 1973, ethically there would have to be a considerable burden to show that unproven treatments are clearly in the best interest of the patient. A useful analogy is that of cosmetic surgery, used not to correct an underlying medical condition, but to improve physical attrib­utes because of the social pressure to enhance beauty, or to forestall the inevi­table changes associated with aging. When a person presents requesting for cosmetic surgery, it is a standard of care to insure that the patient is aware of the risks and benefits, and to ascertain if there is an underlying psychological condition that would make even a good outcome insufficient or unacceptable to the patient. One would not, for instance, accede to performing surgery on someone who had a body dysmorphic disorder, for whom the particular surgi­cal procedure would not be sufficient to resolve the underlying conflict over body image. While many people would harbor feelings that certain aspects of their bodies are less than what they would desire, body dysmorphic disorder can be a disabling condition which is not resolved by trying to appease the pa­tient’s wishes to physically change his body.

Similarly, given the social and religious disapprobation of homosexuality in society, it would be “normative” for a person who finds himself homo- erotically driven to want to change that part of him to find acceptance and ap­proval by families, and institutions, or even a supreme being. This alone would require a significant exploration by any ethical therapist as to the motivation in each particular case in which therapy to change from homoerotic to hetero­erotic desire is sought. Thus, the essential question is whether in fact it is ever ethical for a therapist who believes that homosexuality is inferior to heterosex­uality to engage in therapy with someone who is conflicted over sexual orien­tation.

To consider these issues, some basic guidelines for ethical practice may provide some clarification. When approached by a patient who wants to change their homosexual orientation, a therapist would employ these minimal standards of ethical practice. Any ethical intervention would at minimum in­clude:

1. Informed consent that includes a statement of what the intervention is, on what it is based, and what the risks and/or benefits might be, includ­ing outcomes which could seriously hinder social, sexual, and psycho­logical functioning. In all medical procedures it is expected that we inform patients of the statistical risk for any untoward potential event. These risk ratios are developed over years of studying the outcomes of particular procedures. It would be ethically necessary to inform the pro­spective patient that there are no studies as of yet published in peer re­viewed, scientific, respected journals to provide these data. It would be incumbent on the therapist to provide a written statement to the effect of: “while it might be possible to increase heterosocial comfort and enhance whatever heterosexual interests might already exist, there is no evidence that therapy of any kind can induce new, sustainable heteroerotic inter­ests in someone with a significant homoerotic orientation.”
2. A clear and comprehensible statement of the current level of knowledge and the scientific basis for the intervention. This would include a clear acknowledgement that the therapist is engaging in a modality of treat­ment that is not considered appropriate to the situation for which the patient presents. This would require providing written policies and guidelines from the professional organization appropriate to the profes­sional discipline of the practitioner. A clear statement that all U.S. men­tal health associations do not consider homosexual orientation to be a disorder must be provided to the patient.
3. Patients should know the status of the practitioner’s standing in the pro­fessional community and with relevant licensing entities.
4. Therapists who have a clear belief system that finds homosexuality un­acceptable must make it clear that they hold such beliefs.
5. Therapists who hold such beliefs and claim to be able to help the patient change sexual orientation would ethically be required to encourage a second opinion from a therapist who holds to the positions of the major mental health associations that officially designate sexual orientation conversion therapy to be outside the bounds of ethical, clinical standards of care.

Therapists ultimately have a fiduciary responsibility to their patients, to put the best interest of the patient above all, and to do no harm. While therapists hold all sorts of values that might differ from their patients, they carry the re­sponsibility to investigate whatever underlying motivations and conflicts the patient brings, exploring without judgment or shaming the patient. Powerful transferences and countertransferences arise in any therapy, but where patients feel the disapproval of family, society and often even God, therapists have an even more profound obligation to not support self-negating or self-loathing feelings which accompany the wish to change from homosexual to heterosex­ual. For any therapist to have a particular agenda to change someone’s sexual orientation undermines the essential ethical requirement to, above all else, put their own beliefs and those of the church and state secondary to the needs of their patient. Since homosexuality is not a pathological psychological disor­der, therapists must first help patients to understand why they feel the way they do, without promulgating a particular belief that such feelings are wrong and changeable.

When a patient goes to a therapist who supports the pathological notion of homoerotic orientation, and who then claims to be able to alter that orientation through intensive therapy, the process is ethically compromised from the be­ginning. Indeed, in the treatment of individuals conflicted over their homosex­ual orientation, perhaps the only ethical situation would be one in which the therapist does not believe that it is necessary to change sexual orientation to find happiness, intimacy or love.