This past summer the American public was inundated with full-page ads in several national newspapers about "Hope for homosexuals," and "Change is possible for you too." These ads renewed the heated discussion about homosexuality, about the rights of gays and Christians, about freedom of speech, about the psycho-social status of the homosexual, and about the possibility of change for the homosexual. While most gays and lesbians claim that their homosexuality is something they did not choose and would not change even if they could, many others, especially politically active Christians, feel that homosexuality is a pathology that should be treated.
According to these ads, we were exposed to the fact that there are options available for the person who experiences homosexual feelings. While the ads don't delineate those options, there are several categories of help for the homosexual who is uncomfortable with his/her sexual orientaton. Reparative therapy, the secular process which claims to help gays and lesbians become heterosexuals, is a treatment spear-headed by such authors as Joseph Nicolosi, Charles Socarides, and Jeffrey Satinover. Religious-based treatments are also available, offered by ministries such as Coral Ridge Ministries, Desert Streams and New Direction for Life Ministries, which offer prayer and counseling for the healing of the homosexual. Treatment is even available for children who experience Gender Identity Disorder, as described by psychiatrists such as George Rekers.
The primary issues with the ex-gay ministries/therapies are whether they do what they claim to do, whether they are ethical, and whether their existence is beneficial to society at large (i.e., are we fostering anti-gay prejudice by promoting ex-gay therapy, and what are the resultant implications to our society from this action). My primary concern in this essay is with the ethics of ex-gay therapy and the meaning of their existence for society. Therefore, in regard to the issue of whether or not ex-gay therapy is efficacious, I will assume that there are some people who have experienced radical, positive benefits from these therapies. While there is little agreement on the ultimate benefit of ex-gay therapy, for the sake of argument I will assume the best of such therapies.
There have always been segments of society which have felt homosexuality was inappropriate, and often societies have been fairly well unified against homosexuality. Even in ancient Greece, where age-structured male homosexuality was considered normal, Plato is known to have believed homosexuality to be contrary to nature and harmful to the soul (Phaedrus 250E-251A, Laws, 636C). Historically, religion and philosophy have been the tools used to condemn homosexuality as sinful or ethically improper. In modern society, ever since Dr. KM Benkert brought the term homosexualitaet into Western discourse, there has been an attempt to medicalize homosexuality into a pathology. Most recently, with the rise of political Christian Fundamentalism, homosexuals have again been subjected to a focused social pressure to abstain from homosexual behavior. The integration of religious and medical beliefs about homosexuality have led to an upsurge of attempts to "cure" homosexuals, with the hope of helping them to become heterosexuals.
In this atmosphere of oppression, most gay and lesbian people experience ego-dystonia (another medicalized term) at some point as they come to terms with their homosexuality (Reiter, 1989). There are many theories for the etiology of this condition which causes feelings of worthlessness and self-loathing. Religious Fundamentalists believe that these feelings are caused by a conviction in the soul of the homosexual by God, who, in His grace, is trying to tell the homosexual to change his/her behavior for the sake of their ultimate well-being. Some studies have shown that most people who experience this phenomenon come from authoritarian backgrounds with religious Fundamentalism as a backdrop. Whether this ego-dystonia is experienced for religious reasons or cultural reasons, the phenomenon itself is real. One of the most dramatic witnesses to this is the increased suicide attempts found among gay and lesbian teenagers. One recent study found that "male bisexuality/homosexuality was associated with a greater than sevenfold increased odds of a suicide attempt" than was male heterosexuality (Remafedi, 1998). This self-loathing about their sexual identity, combined with the fact that they have no community support for their minority identity, unlike racial minorities, make this population especially vulnerable to psycho-social difficulties (Linscheid, 1995; D'augelli, 1994)).
While there are no scientifically accepted studies which indicate that change is actually possible in such ministries, and no national psycho-social licensing agencies support ex-gay therapies, there is much anecdotal evidence that there are individuals who experience total change in their sexual orientation. There are several confounding issues, one of which is sexual identity fluidity, a clearly demonstrated phenomenon in which sexual orientation changes as a matter of normal psycho-social development regardless of counseling (Bem, 1998; Herdt, 1984). This ties into the issue of bisexuality itself, in which a person has attractions to both genders. A powerful question is voiced among critics of ex-gay therapies: are the heterosexual feelings of those who experience change by the ex-gay therapies merely the surfacing of an inherent bisexuality, or are they entirely new entities brought on by the therapy (Murphy, 1991)? Another confounding issue is the traumatic stories of ex-ex-gays--gays who suffered psychological damage at the hands of ex-gay ministries. Yet, even with the questions raised by these issues, I believe there is a place for ex-gay therapies within the psychological and religious field .
Primarily there is the issue of religious freedom. In a country where religious freedom is one of the most protected of individual freedoms, many people feel that to prevent counselors from engaging in ex-gay ministries would be unconstitutional. This is rightly stated, because if an individual, out of moral conscience, does not want to experience same-gender attraction, then that person should have the right to attempt a therapy of change.
Several problematic issues appear in this debate. These issues center around consent. First, is a person who is experiencing ego-dystonic homosexuality aware of the issues involved with ex-gay therapies? If the person is experiencing a culturally or religiously-induced self-loathing and heterosexism, s/he may perceive that his/her dissonance is caused by moral beliefs concerning the sinfulness of homosexuality, whereas it may actually caused by a misinterpretation of one's self-loathing and heterosexism (Reiter, 1989). It is normal practice for a psychotherapist to examine issues like this when exploring treatment options for the client. On the one hand there is the need to alleviate the perceived distress of the client--in this case their homosexuality--while at the same time exploring the real cause of their distress, which may or may not be caused by homosexuality itself. For example, some psychiatric patients express a perception of paranoia, but aren't best served by hiring security guards to give them a sense of security. On the contrary, they are best served by exploring the sources of the paranoid feelings, and helping alleviate the cause of the problem, not simply the symptom. In the case of ex-gay therapy, self-loathing and internalized heterosexism/homophobia may be the causative agents which lead the client to believe that s/he would prefer not to be gay, and may lead him/her to believe that attempting to become heterosexual is the best treatment course, rather than addressing the deeper issues and accepting his/her inherent sexuality.
The second issue similarly involves consent. George Rekers has produced several studies on Gender-Identity Disorder (GID) in children (Rekers, 1985), which have made it possible for many pediatric psychiatrists to treat what is considered nascent homosexuality in children and teenagers. The question is whether or not it is ethical to treat children and teenagers for something not considered to be a psychopathology in adults. While Rekers and others claim it is easier to treat this behavior when the client is a child rather than waiting until adulthood, it is far from clear that the client is better off after having been treated for nascent homosexuality. While there is evidence that few of the children who undergo therapy for GID become homosexuals, it is far from clear that it is the parents' right to forcibly make such a radical change in the personalities of their children. If early intervention could prevent something like schizophrenia or depression, which are accepted psychopathologies and lead to obvious psycho-social dysfunction in adults, then the ethical considerations would be different. However, since homosexuality was de-pathologized in 1973, and there have been many studies showing the psycho-social health of gay and lesbian persons (D'Augelli, 1995; Gonsiorek, 1991), there is no compelling reason to force such a child into psychotherapy, other than for religious reasons. The religious nature of this issue leads us back to the question of what is the extent to which parents can force their moral and religious beliefs onto their children. While parents have a wide leeway in the American judicial system for raising their children and for moral education, the larger issue is to what extent psychological professionals can be utilized to force religious and moral beliefs onto children.
The third issue again involves consent. Ex-gay ministries are typically staffed by unlicensed counselors with no formal education in psychology. Despite this, many of these ministries require counseling-like interactions as part of the process (Pay ne, 1996). Moreover any attempt at sexual reorganization is a major assault on one's personality, and should only be done by formally trained, licensed professionals. Without national standards, guidelines or restrictions for such therapists, and no way to oversee these ministries, it is not to prevent unlicensed ministries from consciously or unconsciously overstepping their bounds and attempting to treat clients whose situations could require professional care. This leaves little recourse for those clients who have suffered trauma from the few ministries which engage in unethical and coercive practices. Moreover, for those ego-dystonic gays and lesbians who intend to undergo ex-gay therapy, there are no guidelines for which ministry or therapist to choose or avoid, since there are no consumer advocate groups for such ministries or therapies, given that national guidelines and documentation of long-term outcomes do not exist.
Finally, literature coming from many of the ex-gay ministries promotes themselves as agents of "change" out of homosexuality, implying a conversion of same-gender attraction to opposite-gender attraction. Part of a national standard for such ministries would promote "truth in advertising." Unfortunately, because of the entrenched nature of sexual orientation, most of the clients who undergo ex-gay therapy experience little change in sexual attraction (Haldeman, 1994; Green, 1988). While some people experience a reduction in same-gender attraction, fewer experience an increase in opposite-gender attraction. Even so, this process may take several years to develop ( and may require a lifetime commitment to support groups. Most clients are encouraged into celibacy. While there is nothing inherently wrong with celibacy, the issue is that this often isn't portrayed in the advertisements by ex-gay ministries. It seems incongruous that while medications are not allowed to advertise effects which are not experienced by the vast majority of the people who consume those agents, similar restrictions are not placed on organizations which claim treatments for psychological change.
In spite of these ethical questions, I maintain there is a need for ex-gay therapies. While I believe they should come under the jurisdiction of a national licensing agency, there definitely are people for whom ex-gay therapy should be explored, and ethically, no person should ultimately be denied treatment for a condition which causes mental anguish. There is little question that homosexuality, because of massive social stigma, causes mental anguish among many people who experience same-gender attraction (Gonsiorek, 1991). The question then becomes what is in the client's best interest: to attempt a change of sexual-orientation, or to attempt an amelioration of internalized heterosexism and self-loathing?
A necessary requirement for the resolution of the issue of consent is that the client must be fully appraised of the issues involved. Foremost is the client's right to be made aware of the very low success rate of elimination of same-gender attraction, and the even lower rate of increased opposite-gender attraction. Knowing that the most probable outcome of years of therapy and group-support is likely to be celibacy could have an impact on the client's choice of therapeutic routes. A second issue is educating the client about social issues of religion, and the psychological impact of cultures and religion on minorities. Having an understanding of the power of tradition and faith beliefs to construct value systems that may not be justified in larger contexts may allow the client the freedom to choose to change their interpretation of their faith/culture as opposed to attempting to restructure their sexual identity. Also important is discerning whether or not the client experiences, or fears a life of uncontrolled sexual obsessions, and if s/he associates these necessarily with homosexuality as a pathological entity. Knowing that the issue of homosexuality is totally unrelated to issues of obsessions and compulsivity could also impact the client's choice of therapeutic routes.
This latter issue relates to the psychological profile of the majority of people who seek help for ex-gay therapy. Most of the ex-gays with whom I have experience and have read about in the ex-gay and psychological literature refer to sexual lives of homosexual promiscuity and obsessive homosexual thoughts. These behaviors and thoughts are attributed by the ex-gay to a belief about the inherent nature of homosexuality as sinful and pathological. However, studies show that the vast majority of gays and lesbians are as psychologically and socially healthy as heterosexuals, and are no more prone to promiscuity than are heterosexuals (Billy, 1993). This points to a peculiarity in those gays (lesbians do not tend experience this phenomenon) who experience sexually obsessive homosexual thoughts, and who engage in high-risk, anonymous sexual behavior. Many of these gays end up searching for treatment for their homosexuality. While some studies indicate that self-loathing and internalized heterosexism lead to such behaviors, and in fact this may be the case with many such gays, it may also be the case that these gays have a pathological etiology for their homosexual feelings.
Most psycho-social professionals now believe that there are both biological and environmental components to homosexual attraction (Kaplan, 1995). Past psychological theories focused on factors such as a domineering mother, distant father, and sexual abuse as causative factors in homosexuality. While these theories are no longer accepted as necessary and sufficient causes of homosexuality there is evidence that in some cases sexual abuse and emotionally detached/abusive parents can be associated with promiscuous homosexual behavior. It is for this population that ex-gay therapy may specifically be of some benefit.
Regardless of the lack or presence of specific environmental influences, most people would regard high-risk, anonymous sexual behavior as maladaptive and psychologically unhealthy. Many of the ex-gays with whom I have experience and have read about in the ex-gay and psychological literature who have described a true change in personal sexual orientation seem to come from backgrounds of such maladaptive behaviors. Such case-histories beg the question of the nature of the successful ex-gay: are they homosexuals who have become heterosexuals, or are they sexual compulsives who have gained control of their sexual obsessions and compulsions? Ignoring the elaborate psychoanalytic theories of homosexuality, preferring a more simplistic model of the cognitive-behaviorist, it seems likely that the majority of compulsively promiscuous homosexuals who become monogamous heterosexuals have actually been healed from sexual addiction, not homosexuality. The association of sexual compulsivity with homosexuality is readily explainable by social factors, and complaints of homosexual compulsions often reveal a common history of repeated childhood sexual abuse.
With the presence of many types of sexual dysfunction in Western society, ministries/therapies which deal with specific sexual dysfunctions are greatly needed. Because of this need, I support the continued presence ex-gay ministries, with the caveats described above. Some may argue that what these clients really need is to learn better relational and sexual skills. However it may well be that there is some biological component to homosexuality that these people lack, and therefore experience homosexuality because of trauma inflicted on them as young people and not as a naturally occurring process. If this is the case, it would help explain both the high rates of promiscuity and psychopathology among this small segment of the homosexual population, as well as the high association of successful sexual reorientation among this population.
Regardless, after the patient has been educated about the psycho-social issues involved with sexual-reorientation therapies, and s/he still wants to pursue such therapy, there is little ethical ground for the therapist to refuse to treat the client, or to refer him/her to a therapist who would treat him/her. To refuse to refer or treat would be to deny the patient's right to religious freedom, assuming the patient's reasons for seeking treatment was for religious reasons, and would constitute an act of discrimination. Even if the client's reasons were not based upon religion, s/he has the right to attempt self-fulfillment, creating him/herself in the vision that s/he has for him/herself. While the therapist may not agree with that vision, it should be agreed that radical personality reorganization would be safer under the direction of a trained professional than by oneself or an untrained lay-person. Assuming that if the client has gotten as far as to seek treatment and agree to the risks and time involved in reorientation therapy, it is likely that s/he has the motivation to seek treatment wherever it is available, whether from a licensed professional or not.
In conclusion, it is clear that there are many unanswered ethical questions regarding ex-gay therapy. Several of these issues can be resolved by providing the client with an informed consent of the process and outcome possibilities. Issues involved with child reorientation therapy are much more complex and cannot be treated by this essay.
However, it does seem clear that there are issues involved with adults who seek ex-gay therapies for themselves which provide a solid ethical framework for treating particular clients. Especially if such clients are experiencing sexual obsessions and compulsions, there seems to be an imperative to treat. If the client perceives a need to engage in sexual reorientation therapy to alleviate these complaints, there is no reason the therapist should refuse that request, or at least refer the client to someone else. The primary concern is for the safety of the client and his/her mental health. Part of the psychological treatment of a client as a unique individual involves not only using standard treatment protocols, but also tailoring those protocols to the needs, rights, and history of each client. Given the pluralism embraced in American culture, it becomes apparent that it is counter-productive to deny a client the right to sexual-reorientation therapy.
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D'Augelli, Anthony. "Preventing mental health problems among lesbian and gay college students." Journal of Primary Prevention 1993; 13(4): 245-261.
D'Augelli, Anthony. Lesbian, Gay and Bisexual Identities Over the Lifespan. New York: Oxford University Press, 1995.
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Murphy, Timothy. "The ethics of conversion therapy." Bioethics 1991; 5: 123-138.
Payne, Leanne. Healing Homosexuality. Grand Rapids: Baker Book House, 1996.
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