Homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) in 1973. It was replaced by ‘sexual orientation disturbance’- specifically for homosexuals who are in conflict and wish to change their sexual orientation to heterosexual. The term ‘ego-dystonic homosexuality’, which was introduced in DSM-III, captures the same essence. However, this term was eventually removed in 1987 as well, marking the most significant step. Despite these changes, many mental health professionals (especially those who are conservative Christians) continue to regard homosexuality as an abnormality that requires ‘correction’. The last decade has seen a resurgence of research on reparative therapy (also known as conversion therapy) as the dialectic between proponents and opponents of this therapy intensifies.
Theories of homosexuality:
The psychoanalytic perspective indicates that homosexuality results as a developmental disorder (during a pre-oedipal crisis)- when the child failed to attach to same-sex parents or peers. Hence, they develop inferiority towards same-sex others (Morrow & Beckstead, 2004). Father is experienced as distant and cold (Bright, 2004). The child attaches to his mother, adopting a female identity. To compensate for the lost male identity, male child ‘absorbs’ masculinity by ‘feeding upon’ other men (Bright, 2004). Reparative therapists believe that’stronger and more confident gender identification’ would help (Spitzer, 2003). This was later translated as more masculine for men and more feminine for women- a reinforcement of traditional gender roles (Beckstead & Morrow, 2004).
Sanor Rado laid the foundations for reparative therapies (Halpert, 2000). Sanor Rado replaced Freud’s model with one of inherent bisexuality, where heterosexuality is the correct outcome of sexual orientation. Socarides popularized ‘domineering mother and absent father’ model of psychopathology. He proposed a conflict model, where intrapsychic forces come into play, and hence defining homosexuality as an illness. Ovesey (1969) took gender roles into the theory and proposed a behavioral approach that requires engagement in heterosexual intercourse to over phobia of the opposite sex (Halpert, 2004).
What is Reparative therapy?
Reparative therapy has been defined as psychotherapeutic cures that are meant to convert sexual orientation from homosexual to heterosexual. Joseph Nicolsi coined the term ‘reparative therapy’ in 1991.
Some methods utilized by reparative therapy- Electric shocks; surgery (i.e. cauterization of spinal cord, clitoridectomy, castration, ovary removal etc.); hormone therapy (i.e. radiation or steroids.); masturbatory reconditioning, prayer and spiritual interventions.
Unsuccessful converts may experience the following: Increased depression, increased desire for death (suicidal tendencies), internalized homophobia, lower self-esteem, increased misperceptions of homosexuality, increased negative affect towards parents (because of the theory used to explain the cause of homosexuality), increased self-hatred, sexual dysfunction and intimacy avoidance, delayed identity development, loneliness, fear of being a child-abuser, loss of faith etc (Beckstead & Morrow, 2004).
There is evidence showing that conditioning of sexual arousal is poor and that significant change towards a particular sexual orientation is difficult if contrary to one’s established sexual orientation (Morrow & Beckstead, 2004).
Successful converts are made up of two groups: those who engage in heterosexual relationships and those who become celibate. Some unsuccessful converts felt that reparative therapy is a ‘launching pad’ to come out as fully gay. All Mormon clients felt that reparative therapy was insufficient and that many other factors such as ‘accepting and reframing attraction in a positive light’ come into play (Beckstead & Morrow, 2004).
What is Gay-affirming therapy?
Gay-affirming therapy dispels untruths about societal messages; helps client in the identity development process; addresses issues such as coming out, relationships, career and family.
However, therapy that only focuses on adopting a gay identity does little to assist clients who are devout Christians (Gonsiorek, 2004). Conservative religious Christians typically consider any divergence from strict adherence to orthodoxy as a loss of faith. This creates conflict within the gay person because religion plays a huge part in many homosexuals (Gonsiorek, 2004). The condemnation that is overtly expressed towards gay Christians creates huge pressure for change. It is not enough to target only identity formation. It is also necessary to reconcile one’s religious values. Therapists who failed to realize the significance of this leave their clients feeling frustrated and at loss (Beckstead & Morrow, 2004).
Problems
Conceptualization:
1. The construct: Sexual orientation
Most research done prior to 1994 looked at sexual orientation dichotomously i.e. either heterosexual or homosexual. Beckstead and Morrow (2004) used Freud’s definition ‘the relative erotic preference for the body of one sex over that for the other’ to illustrate sexuality on a continuum. This is further supported by Haldeman (2000), who stated that, in reality, categories of heterosexual, homosexual and bisexual are generally fluid.
Success has been defined mostly by behavior i.e. engagement in heterosexual behavior and absence of homosexual behavior. It is possible for someone predominantly homosexual to engage in heterosexual behavior without becoming heterosexual (Halpert, 2000). Similarly, it is possible for someone who is predominantly heterosexual to engage in homosexual behavior. About 30% of Spitzer’s participants reported that their heterosexual attractions were limited to their marriage partner. This raises the question of whether heterosexual orientation is merely the ability to be involved in heterosexual intercourse. Spitzer’s (2003) participants are not excluded from the sample if they had homosexual sex after the therapy as long as there is change in sexual attraction (suggesting development of bisexual tendencies instead of heterosexual tendencies). Any movement in the direction is considered success. Thus, success rates are probably over-reported.
The construct of sexuality also encompasses identity, internalized sociocultural expectations, as well as one’s perception of the importance of social and political affiliations. Such variables are subject to change with time (Haldeman, 1994). However, the sole use of behavior as a measure of one’s sexual orientation is rampant. This calls into question the true success rate of reparative therapies.
2. Ignoring the base rate:
According to Joseph Nicolosi, about one-third of male clients develop heterosexual attractions; one-third decreased their homosexual behaviors and the last one third displayed no effect (Spitzer, 2003). Spitzer recruited 200 volunteers who have maintained their change from homosexual orientation for at least five years (successful converts). And from his sample, he concluded that reparative therapy should be continued because none of his participants has any evidence of harm. This conclusion is not valid when taking into consideration the base rate. In another study that was done, out of 202 individuals, 176 (87%) considered themselves as conversion therapy failures and only 26 (13%) considered themselves as successful converts (Shidlo & Schroeder, 2002 in Beckstead & Morrow, 2004). Failure to convert brings about a host of negative outcomes. As such, the question asked should be: Does the small success rate justify what the majority (87%) goes through?
3. Authority of Therapist and Demand characteristics:
In Spitzer’s study, individuals were asked, ‘What were the most important things you talked about in your therapy?’ Topics that were mentioned: Dysfunctional family relationships, traumatic childhood experiences etc. The participants also spoke of how they made connections between such childhood/family experiences with the development of their sexual feelings. All these give a strong suggestion that therapists are imposing their theories onto clients, guiding the entire conversation. As Davison (2005) said: ‘psychological problems are for the most part constructions of the clinician’. Such tactics also run contrary to what a therapist is supposed to do: which is to disseminate accurate information about sexual orientation (A resolution APA passed in 1998); also to provide alternative treatment information (Halpert, 2000). Several studies have shown that abuse, family structure and gender identity do not promote specific sexual orientation (Morrow & Beckstead, 2004). Some participants confessed they lied about the frequency of homosexual desires to please their therapists.
4. Inappropriate generalizations:
Joseph Nicolosi (2003) commented that for many people, gay relationships simply do not work. He supported this proposition with reports from his clients, who are ‘wiped out, depressed, sad, and discouraged’ after intensely pleasurable gay relationships. Nicolosi also pointed out that many of Spitzer’s participants are dissatisfied with gay life because of promiscuity and the ‘unavoidable’ problem of infidelity.
However, the data is limited to a specific population: The people who experienced gay life badly and sought help from mental health professionals for counseling and/or reparative therapy. In other words, they were poorly adjusted and burdened with the inability to integrate their values and homosexual inclinations. Well-adjusted individuals with an integrated sense of self would not be seeking mental health professionals for help; neither would they perceive a need to change their sexual orientation since they are comfortable with themselves. Hence, such well-adjusted homosexuals would not be reflected in Spitzer’s participant pool nor is it likely that Nicolosi would have them as clients. Thus, Nicolosi’s generalization is erroneous.
The type of people who seek conversion therapy has been shown to differ from people who do not. People who possess intrinsic orientation (religion as central principle) to religion are more likely to seek reparative therapy compared to those with a quest orientation (open to doubt and uncertainty) (Tozer & Hayes, 2004). Internalized homonegativity mediated the relationship fully. Hence, this could be the main difference.
On top of these, Spitzer’s participants consist of extremely religious Caucasian Christians who are middle-class. This greatly limits generalizing the data to most gay relationships.
5. Social desirability:
Social demand characteristics probably played a big part in Spitzer’s structured interviews. For starters, some questions targeting same-sex behavior incorporated the word ‘lust’ into it. This is not repeated for questions targeting opposite-sex behavior. Example: ‘Frequency of looking with lust or daydreaming about having sex with a person of the same sex’ versus ‘Percentage of masturbation occasions with heterosexual fantasies.’ Lust has a negative connotation and participants would avoid answering in a way as to jeopardize their image.
Interviews are not anonymous; hence participants have great incentive to manage their impression. This is especially since participants are recruited directly from religious ministries and therapists who are probably affiliated to such ministries.
6. Myths as ‘truth’- the role of therapists’ values:
Many mental health professionals who are proponents of reparative therapy based their treatments on religious values. Conservative religious ideologies are based on rigid values and are at odds with scientific enquiry professional psychological practice (Gonsiorek, 2004). However, many continue to write as if these are scientific truths. For example, Nicolosi (2003) wrote that homosexuality is only intense infatuation and that heterosexuality experience is richer, fuller and more emotionally satisfying. Other myths such as sex-crazed homosexuals are also used as a basis for conversion (Beckstead & Morrow, 2004). The religious reasoning is this: Homosexuality is sinful and hence only bad outcomes can be associated with it.
7. Misunderstandings:
There could be probable misunderstandings. In Spitzer’ interview, the item ‘severity of being bothered by homosexual feelings’ seemed to imply that respondents would be troubled by such thoughts. However, in another study, participants may be unbothered by these thoughts because of the belief that ‘Satan is the one planting such temptations in their heads’ (Beckstead & Morrow, 2004). Therefore, a low rating (with ‘1’ indicating ‘not bothered at all’) may not mean that participants are no longer experiencing homosexual thoughts.
The basic issues:
1. The existence of reparative therapies sends a mixed message
If homosexuality is no longer seen as a disease, then there should not be a need for a cure.
2. The client’s choice is not always the optimum choice.
Many therapists refer to sexual orientation as a free choice and that treatment does not hold any judgment on homosexuality. It is merely a reduction of incongruence of a client’s sexual orientation and his/her values and goals (Haldeman, 1994). However, the idea of unlimited client choice is fallacious (Gonsiorek, 2004). An example to illustrate this is: when a client wishes to commit suicide, should the therapist assist him in doing so? Clients may make choices based on ignorance, misinformation, misunderstanding, social desirability, social pressure etc. Choices based on limited understanding impede progress at best and become destructive at worst. Client choice should function as informed consent; instead of substituting for professional decision-making and praxis. As long as there are pressures from family, religion and society, the choice to change one’s sexual orientation is unclear (Morrow & Beckstead, 2004). As have been supported previously, those who seek conversion therapy internalized hostile societal messages and even adopted them as self-labels (Beckstead & Morrow, 2004).
3. ‘Reparative therapy can be done’ does not entail ‘reparative therapy should be done’.
It is not a matter of whether homosexuals can be converted into heterosexuals. It is a matter of whether it is ethical to do so. So the question is: Does the benefits from reparative therapy outweigh the harms caused by it? But the most fundamental question is not scientific; it is political and religious.
Limitations, Gaps and Implications for further research:
More research is needed on the actual success rate of both reparative and gay-affirming therapies. This also includes the total number of clients who seek such treatment, stipulation of the criteria of success, and the degree of injury to unsuccessful converts. A more objective comparison can then be made.
Homosexuals from other faith-groups are under-represented. Chandler (1996) pointed that religious groups that advocate reparative therapy typically have absolute distinctions between good and evil; make use of fear tactics and deception; make use of affection and approval (belonging to group); do not tolerate questioning; misrepresent or distort information (Halpert, 2000). Unless other faiths consist of similar characteristics, research done on conversion therapy may not apply beyond conservative Christians and the Jewish community.
There is gross under-representation of women in conversion therapy (Morrow & Beckstead, 2004). The dominant psychoanalytic theory used to explain male homosexuality does not cover female homosexuality well (patriarchal model). Also, there are far fewer females who turn up for reparative therapy. Thus far, there is no research establishing reasons for this.
A large part of the gay community is unaccounted for. In Spitzer’s study (2003), he mentioned this: ‘Participants reported ‘ greater sense of masculinity in males, and femininity in females’’ This is further amplified by getting the females for ‘beauty-therapy’, implying that it is butch-lesbians who are being worked on (Bright, 2004). Spitzer also wrote that gay male patients ‘suffer from a lifelong feeling of being on the outside of male activities and not feeling like one of the guys’. This suggests that most of the gay males who seek treatment are effeminate males. As such, result cannot be generalized to masculine gays and feminine lesbians. Thus, research is in great deficit as more than half of the gay community consists of straight-acting gays, masculine gays, feminine lesbians and androgynous lesbians.
Many studies that were done via the internet reached those who are better educated and of higher socioeconomic status (Lease, Horne & Noffsinger-Frazier, 2005). Given that the internet is a powerful in connecting people, this is a convenient method of acquiring participants. However, less educated and less well-off homosexuals are left out. Most research has been conducted in the United States of America. Hence, results may not be generalizable to countries beyond its coast- especially Asian countries. Most of research on conversion therapies has used conservative Christian, White, middle-class, middle-aged and male samples (Morrow & Beckstead, 2004).
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References:
Haldeman D. C. (1994). The practice and ethics of sexual orientation conversion therapy. Journal of counseling and clinical psychology. 62(2), 221-227.
Davison G. C. (2005). Issues and nonissues in the gay-affirmative treatment of patients who are gay, lesbian or bisexual. Clinical psychology: science and practice. 12(1), 25-29.
Gonsiorek J. C. (2004). Reflections from the conversion therapy battlefield. The counseling psychologist. 32(5), 750-759.
Lease S. H., Horne S. G. & Noffsinger-Frazier N. (2005). Affirming faith experiences and psychological health for Caucasian lesbian, gay, and bisexual individuals. Journal of counseling psychology. 52(3), 378-388.
Tozer E. E. & Hayes J. A. (2004). Why do individuals seek conversion therapy? The role of religiosity, internalized homonegativity, and identity development. The counseling psychologist. 32(5), 716-740.
Beckstead A. L. & Morrow S. L. (2004). Mormon clients’ experiences of conversion therapy: the need for a new treatment approach. The counseling psychologist. 32(5), 651-690.
Bright C. (2004). Deconstructing reparative therapy: an examination of the processes involved when attempting to change sexual orientation. Clinical Social Work Journal. 32(4), 471-481.
Halpert S. C. (2000). ‘If it ain’t broken, don’t fix it’: ethical considerations regarding conversion therapies. International journal of sexuality and gender studies. 5(1), 19-35.
Spitzer R. L. (2003). Can some gay men and lesbians change their sexual orientation? 200 participants reporting a change from homosexual to heterosexual orientation. Archives of sexual behavior. 32(5), 403-417.
Morrow S. L. & Beckstead A. L. (2004). Conversion therapies for same-sex attracted clients in religious conflict: context, predisposing factors, experiences, and implications for therapy. The counseling psychologist. 32(5). 641-650.
Nicolosi J. (2003). Finally, recognition of a long-neglected population. Archives of sexual behavior. 32(5), 445-447.