Professional Care for Unwanted Same-Sex Attraction: What Does the Research Say? 1

Abstract

In recent years, national and international medical and mental-health associations typically have emphasized the potential harmfulness of professional care for unwanted same-sex attraction (SSA or homosexuality) and behavior. State legislatures in the US and legislative bodies in other countries either have passed or are considering passing laws which would penalize professionals who provide professional care for unwanted SSA—to minors and/or adults—including the loss of the license to practice. This paper was written as a response to the present situation in the UK. The paper reviews the universal ethics of all medical and mental-health professionals to avoid harm and do good (non-maleficence/non-malfeasance and beneficence); discusses the documented potential for harm when using every mental-health treatment for every presenting problem; clarifies steps taken by the Alliance for Therapeutic Choice and Scientific Integrity (Alliance), its clinical and research divisions, the National Association for Research and Therapy of Homosexuality Institute (NARTH Institute) and its international division, the International Federation for Therapeutic Choice (IFTC), to promote ethical professional care for unwanted SSA; clarifies the injustice and presumed ideological biases of the medical and mental-health associations’ warning about the potential for harm for psychotherapy only for unwanted SSA and not all psychotherapy approaches; and documents that the research purporting to show this harmfulness, in the research authors own words, does not do so. Recommendations to promote scientific integrity in the conduct and reporting of relevant research are offered.

Lay Summary: There has been a lot of controversy about the potential harmfulness of professional care for unwanted same-sex attraction and behavior (SSA or homosexuality). This paper reviews the ethics of all medical and mental health professionals to avoid harm and do good; discusses the known potential for harm when using any mental health treatment for any problem; clarifies steps taken to promote ethical professional care for unwanted SSA; notes the injustice and possible biases of those who warn about the potential for harm of psychotherapy for unwanted SSA; and documents that the research said to show this harmfulness, in the research authors′ own words, does not do so.

Keywords

Homosexuality Same-sex attraction Psychotherapy Reparative therapy Mental health

Introduction

In July 2014, the United Kingdom (UK) Parliament debated a proposed private member's bill Counsellors and Psychotherapists (Regulation) Bill no. 14120, which would have amended section 60 (“Regulation of Health Care and Associated Professions”) of the Health Act 1999 as follows: “The [code of ethics for registered counselors, therapists, and psychotherapists] must include a prohibition on gay to straight conversion therapy.” The “Complaints and Disciplinary Procedures” of the code would be amended as follows: “(2) A practitioner found by the Council to have breached … that section of the code relating to prohibition of gay to straight conversion therapy shall result in permanent removal from the register.”²

This information came to our attention when reading a professional statement by the UK's Association of Christian Counsellors (ACC 2014) and a news report of this statement in The Guardian (Strudwick 2014). Both the ACC statement and Guardian report made serious allegations about the great risk for “harm” to persons who receive “reparative or conversion therapy,” what the American Psychological Association (APA) has chosen to call “sexual orientation change efforts (SOCE)” (APA 2009). “Sexual reorientation therapy” is another term that is used (Flentje, Heck, and Cochran 2013).

Members of the International Federation for Therapeutic Choice (IFTC)³; and the National Association for Research and Therapy of Homosexuality Institute (NARTH Institute)⁴; our parent organization, the Alliance for Therapeutic Choice and Scientific Integrity (Alliance),⁵ and like-minded, licensed, medical and mental-health professionals refer to such therapy as licensed professional care to help persons to “change”—i.e., manage, diminish, or resolve—unwanted same-sex attractions (SSAs) and behavior. Such professional care may include educational guidance, counseling, therapy, and/or medical services.

Specifically, the ACC statement declared: “we do not endorse Reparative or Conversion Therapy” because of “the potential to create harm” and “in the interests of public safety.” The report in The Guardian commented:

Research by the US clinical psychologists Ariel Shidlo and Michael Schroeder … found “conversion therapy” usually led to worsened mental health, self-harm, and suicide attempts … such treatment routinely led to worsened [sic] self-harm, thoughts of suicide and suicide attempts.⁶ (Strudwick 2014, emphasis added)

The ACC statement and Guardian story reflect the views of four leading mental and medical-health professional associations in the UK. The British Medical Association (2010) voted at its annual representative meeting that “‘conversion therapy’ for homosexuality … is discredited and harmful to those ‘treated.’” The British Association for Counselling and Psychotherapy (2013) mentions the PAHO/WHO (2012) position statement that practices “such as conversion or reparative therapies … represent a severe threat to the health and human rights of the affected persons” (PAHO and WHO 2012, i).

Similarly, the Royal College of Psychiatrists (n.d.) states that “we know from historical evidence that treatments to change sexual orientation that were common in the 1960s and 1970s were very damaging” and specifically mentions that the 2002 “Shidlow [sic] and Schroeder” study showed that such treatment resulted in “considerable harm.” And the UK Council for Psychotherapy (2010) asserts that a person who undergoes “therapy that aims to change or reduce same sex attraction” is at risk for “considerable emotional and psychological cost.”

These and other recent allegations that the harmfulness of professional care for unwanted SSA has been proven scientifically are simply false (Rosik 2013a, 2013b, 2013c, 2013d). Warnings by national mental-health associations of the “potential harmfulness of SOCE” are unscientific, professionally irresponsible, and misleading, if not dishonest (Jones, Rosik, Williams, and Byrd 2010; Rosik 2012).⁷ These observations are explained below.

What Does the Research Say?

1. First, do no harm. Then do as much good as you can. Avoiding and minimizing harm (non-maleficence, non-malfeasance) and doing good for those one serves (beneficence) are the foundational principles of ethical care by all mental- and medical-healthcare professionals. As an illustration, the first principle of the American Psychological Association's Ethical Principles of Psychologists and Code of Conduct (2010) states:

Principle A: Beneficence and Nonmaleficence: Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons.

2. Every approach to medical and mental health care has the potential for harmful or at least unwanted-side effects. And no approach is guaranteed to work for any particular patient or client, even if “taken or used as directed.”

Lambert reports that reviews “of the large body of psychotherapy research, whether it concerns broad summaries of the field or outcomes of specific disorders and specific treatments” lead to the conclusion that, while all clients do not report or show benefits, “psychotherapy has proven to be highly effective” for many clients (Lambert 2013, 176, 169–218). Unfortunately, the research “literature on negative effects” also offers “substantial … evidence that psychotherapy can and does harm a portion of those it is intended to help.” These include “the relatively consistent portion of adults (5% to 10%) and a shockingly high proportion of children (14% to 24%) who deteriorate while participating in treatment” (Lambert 2013, 192, 169–218). Such findings have been reported in the therapeutic and scientific communities for over three decades (Lambert 2013, 169–218; Lambert and Bergin 1994, 143–189; Lambert, Bergin, and Collins 1977, 452–481; Lambert and Ogles 2004; Lambert, Shapiro, and Bergin 1986, 157–211; Nelson, Warren, Gleave, and Burlingame 2013).

As Rosik (2013c) has written

Any discussion of alleged harms simply must be placed in the broader context of psychotherapy outcomes in general … Deterioration rates would need to be established for professionally conducted, change-oriented therapy (SOCE) significantly beyond 10% for adults and 20% for youth in order for claims of approach-specific harms to be substantiated.

In this light, it is unfortunate that the UK Association of Christian Counsellors (2014) has the following ethical guideline for membership: number 5.5. “Members should avoid any action which might cause harm to a client.” If any- and every-action that may occur in counseling “might cause harm to a client,” how does the ACC envision any of its counselors ever attempting to serve their clients? Their position is not science but wishful thinking. As Rosik (2013e) has noted:

Reasonable clinicians and mental-health association representatives should agree that anecdotal accounts of harm constitute no basis upon which to prohibit a form of psychological care. If this were not the case, the practice of any form of psychotherapy could place the practitioner at risk of regulatory discipline, as research indicates that 5 to 10% of all psychotherapy clients report deterioration and as many as 50% experience no reliable change during treatment. (Hansen, Lambert, and Forman 2002; Lambert and Ogles 2004)

3. The IFTC and NARTH Institute have taken steps to minimize the potential harmfulness and enhance the potential helpfulness of professional care for unwanted SSA through education about the Practice Guidelines for the Treatment of Unwanted Same-Sex Attractions and Behavior (NARTH 2010). (See Appendix—below—for the short form of the Practice Guidelines.)

These Practice Guidelines were formally adopted in 2008 and published by NARTH in 2010. Their purpose is to guide the ethical practice of “change-oriented” professional mental and mental-health care for unwanted SSA. The Practice Guidelines have been written, published, and used to educate medical and mental-health professionals—as well as concerned nonprofessionals—about how to enhance the helpfulness and avoid any harmfulness of providing professional care for unwanted SSA.

For example, Practice Guideline 5 advises: “At the outset of treatment, clinicians are encouraged to provide clients with information on change-oriented processes and intervention outcomes that is both accurate and sufficient for informed consent.”

Concerning potential harmfulness, Practice Guideline 6 states: “Clinicians are encouraged to utilize accepted psychological approaches to psychotherapeutic interventions that minimize the risk of harm when applied to clients with unwanted same-sex attractions.”

As many of the “therapists” who reportedly provided “conversion therapy” to persons interviewed by Shidlo and Schroeder (2002) were not professionally trained or licensed (see point 5 below), Practice Guideline 11 is especially relevant: “Clinicians are encouraged to increase their knowledge and understanding of the literature relevant to clients who seek change, and to seek continuing education, training, supervision, and consultation that will improve their clinical work in this area.”

4. “There are no scientifically rigorous studies of recent SOCE that would enable us to make a definitive statement about whether recent SOCE is safe or harmful and for whom” (APA 2009, 83). In the same document, the APA states further: “None of the recent research … meets methodological standards that permit conclusions regarding efficacy or safety” (APA 2009, 2.) The APA similarly emphasizes that “recent SOCE research cannot provide conclusions regarding efficacy or safety” (APA 2009, 3). The APA offered these conclusions after having reviewed all relevant research to date, including the study by Shidlo and Schroeder (2002).

5. In the authors’ own words, the Shidlo and Schroeder (2002) study does “not provide information on the incidence and prevalence of failure, success, harm, help, or ethical violations in conversion therapy” (Shidlo and Schroeder 2002, 249).

Shidlo and Schroeder acknowledge that how they conducted their study limits what any reports of “harm” given by the participants in their study may mean. The authors accurately describe their research as an “exploratory study … based on the retrospective accounts of consumers” who are asked to talk about what their therapists did and what the consumers experienced “on average … 12 years ago” (Shidlo and Schroeder 2002, 250). The authors acknowledge that, like all research using this method, the reports of the alleged consumers’ perspectives on their experience of therapy “may not accurately reflect” what actually happened. Shidlo and Schroeder discuss the potential limitations of the accuracy of the reports of their consumers, in light of the earlier findings of Rhodes et al. (1994) that “retrospective data from clients” are subject to “misunderstandings” about what happened years earlier in psychotherapy. As actual former clients try to make sense of the events of their experience of therapy, they may unknowingly change the details of their story (Rhodes et al. 1994, 481).

Additional problems with how the Shidlo and Schroeder study was conducted further erode the scientific credibility and significance of any of its results. Initial participants of the study were recruited with the following advertisement:

Have you gone through counseling or therapy where you were encouraged to become heterosexual or ex-gay? The National Lesbian and Gay Health Association wants to hear from you. The organization is conducting research for a project titled “Homophobic Therapies: Documenting the Damage.” (Shidlo and Schroeder 2002, app. A)

Such a recruitment statement is an example of research based more on ideology than on objective, scientific inquiry, and clearly introduces bias into the study.

•

There is no evidence—besides the interviewees’ claims—that: ○

They actually participated in “conversion therapy.”

○

They actually experienced the harms they claimed to have.

○

Any actual harm did not preexist their experience of “conversion therapy.”

○

Any actual harm occurred as a result of, during, or after, the sessions of “conversion therapy,” instead of as a result of an experience outside of “therapy.”

•

While approximately two-thirds of the “therapists” reported by the presumed former clients were described as “licensed mental health practitioners,” one-third of the “therapists” were “unlicensed counselors,” including “peer counselors, religious counselors, and unlicensed therapists.” The APA (2008) likewise uses the term “SOCE” to refer to pastoral and other nonprofessional—as well as professional—approaches to help persons deal with unwanted SSA and behavior. Shidlo and Schroeder—and the APA—did not clarify what kinds of “harm” were associated with which kind of therapist. This study does not and cannot—based on how it was designed and conducted—show that, if consumers were harmed, this harm resulted from the actions of licensed mental-health professionals who provided “conversion therapy” vs. nonprofessional caregivers.

•

Ironically, a careful reading of the report of this study, which admittedly was intended to “document the harm” experienced by consumers of “conversion therapy,” also showed the opposite result. In particular, the results suggest that pre-existing suicidality was at least managed, not induced, by the participants’ experience of the care they received (Whitehead 2010, 161–165).

6. Medical and mental-health professionals, and their patients and clients, would not allow the kind of “evidence” provided by the Shidlo and Schroeder (2002) study to prevent them from receiving wanted treatment for any other concern.

Imagine how someone who has experienced a helpful medical or mental healthcare product or service would feel, if their product or service were forbidden them based on the kind of information provided by the Shidlo and Schroeder (2002) study. Otherwise-satisfied customers would be refused the chance to continue—and willing, new customers to start—receiving these products for services based on complaints—but no clear evidence—of harmful side effects. Those complaining would not have to prove that they actually received the products or treatment—or that they had used them as directed. The complainers would not have to prove that they actually experienced the side effects they claimed, or that the side effects did not already exist prior to their treatment. Nor, would complainers have to prove whom they received the product or service from, while admitting that some of the care providers were professionally licensed, but as many as a third were not.

Most people would not accept their favorite pain reliever or medical treatment being taken off the market based on such minimal “evidence.” Retrospective (“anecdotal”) reports—based on what allegedly happened an average of twelve years ago—are not an acceptable standard of evidence for stopping or preventing others from receiving care which has been found helpful—by some. The various professional organizations which are so quick to accept the truthfulness of any complaints about the harmfulness of professional care for unwanted SSA are also too quick to deny the validity of over a century of professional reports which document wanted changes in SSAs and behaviors (APA 2009; Jones, Rosik, Williams, and Byrd 2010; NARTH 2009; Phelan 2014; Rosik 2012).

As a rule, IFTC, NARTH Institute, and allied medical and mental-health professionals do not attempt to “cure” SSAs and behaviors. Rather, we agree that change in “sexual orientation” is not typically categorical in nature and observe that clients may experience changes on a continuum that is personally meaningful and satisfying (NARTH 2012). While not agreeing that “SOCE” is beneficial, even the APA admits that “the recent research on sexual orientation identity diversity illustrates that sexual behavior, sexual attraction, and sexual orientation identity are labeled and expressed in many different ways, some of which are fluid” (APA 2009, 14, cf. 2). Fluidity in sexuality, “sexual orientation,” “sexual orientation identity,” and relationships—without professional assistance—seems especially prevalent among adolescents (APA 2009, 76) and women (APA 2009, 63; cf. Diamond 2009, 2013; Farr, Diamond, and Boker 2014) and has been documented as occurring among men as well (Laumann et al. 1994; Diamond, 2013, 2015).

7. There is a violation of some clients’ right to “self-determination” and a potential for harm, for not offering—let alone forbidding—professional care for unwanted SSA to persons who freely choose to seek such care.

Another foundation for ethical, beneficial practice is respect for clients’ and patients’ right to “self-determination.” As “Principle E: Respect for People's Rights and Dignity” of the APA (2010) Ethical Principles states: “Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination” (emphasis added). Surely, this must include the rights of persons to choose to manage or resolve same-sex attractions and behaviors. This right to self-determination must also be viewed in the context of the principles of beneficence/non-maleficence noted above. As such, this right does not equally apply to gender reassignment and other related procedures which have documented harm, as discussed elsewhere in this issue.

Also, there would appear to be the potential for grave harm caused to some people by neglecting to provide such care for those who want it. There are significant medical and psychological health risks which co-occur with engaging in same-sex behavior (CDC 2014; NARTH 2009, sec. III, “Response to APA Claim: There Is No Greater Pathology in the Homosexual Population than in the General Population,” 53–87; Whitehead 2010).

Anecdotal and correlational studies clearly document that sexual abuse and other emotionally traumatic events are more common in the childhoods of persons with sexual minority (non-heterosexual) attractions and behaviors than those with heterosexual (Austin et al. 2008; Corliss, Cochran, and Mays 2002; Friedman et al. 2011; Lahavot, Molina, and Simoni 2012; Stoddard, Dibble, and Fineman 2009; Steed and Templer 2010; Tomeo et al. 2001; Wells, McGee, and Beautrais 2011; Whitehead 2010). Sexual abuse in particular has been shown to precede the development of gender nonconformity (Alanko et al. 2011; Roberts, Glymour, and Koenen 2013) as well as of SSAs and behavior for some, albeit not all, persons (Fields, Malebranche, and Feist-Price 2008; Walker, Archer, and Davies 2005).

While further research is needed to clarify the extent of any causal connection between traumatic childhood events and the development of SSA and behavior, their co-occurrence is undeniable. Professional compassion warrants assisting those who want to try to manage and resolve SSA behaviors—and the underlying feelings and experiences which may motivate them.

Conclusion

Moving forward, it is necessary that national and world medical and mental-health associations deal with the issue of therapeutic choice concerning unwanted SSA in a professionally responsible manner with scientific integrity. Persistent warnings that professional care for unwanted SSA has “the potential to harm” those who receive it are misleading and a disservice to the general public. Organizations like the American Psychological Association, the World Medical Association, and—most recently—the Association of Christian Counsellors in the UK, in effect, deceive the public when they—not inaccurately—warn that there is a potential for harm, but then do not qualify this warning by clarifying that (1) all mental-health services for all personal and interpersonal concerns have a potential for harm and (2) responsible science has not yet shown whether the degree of risk for harm from professional care for unwanted SSA is greater, the same as, or less than the risk for any other psychotherapy. Recent studies attempting to “document the harm” of professional care for unwanted SSA (Flentje, Heck, and Cochran 2013; Dehlin et al. 2014) suffer from major research design problems similar to the Shidlo and Schroeder study (Rosik 2014).

Overall, we agree with Shidlo and Schroeder (2002) that more “complementary research (is) needed.” Such research ideally “would include interviews with sexual orientation conversion therapists and analysis of psychotherapy sessions by independent third-party observers.” In the absence of clear, reliable, and valid scientific evidence, it is difficult to avoid the conclusion that professional organizations like the American Psychological Association, the UK Association of Christian Counselors, various state and national government legislatures, and even media such as The Guardian, are working to prevent mental-health professionals from offering educational guidance, counseling, and therapeutic care for persons with unwanted SSA and behavior based on ideological, and not scientific or professional, grounds. Persons who experience unwanted SSAs and behaviors have the right to receive professional care to try to change (i.e., manage, diminish, or resolve) these feelings and behaviors if they choose to do so.

Footnotes

Biographical Note

Philip M. Sutton, Ph.D., served from 2011 to 2014 as the director of the International Federation for Therapeutic Choice (IFTC), which is the international division of the Alliance for Therapeutic Choice and Scientific Integrity and its NARTH Institute. He is a licensed psychologist in Michigan, and a licensed marriage and family therapist and clinical social worker in Indiana. As a layman, Dr. Sutton cofounded a Courage Apostolate group in 2000 and helped lead the group through 2014. He has presented at national Courage conferences.

Appendix

1.

An earlier version of this paper has been published as Sutton, P.M. (2014). What Research Does and Does Not Say about the Possibility of Experiencing ‘Harm’ by Persons Who Receive Therapeutic Support for Unwanted Same-Sex Attractions or “Sexual Orientation Change Efforts (SOCE)”. Journal of Human Sexuality 6, 152–175, and posted on the website of Core-Issues Trust in the UK, with an added foreword and preface, .

2.

3.

4.

5.

6.

This report was retrieved on January 15, 2014. When attempting to retrieve this report again on February 6, 2014, the link no longer worked. Instead, a report by the same name was retrieved from . In this revised Guardian report, the claims of “harm” due to “conversion therapy” are described as follows: “Research by the US clinical psychologists Ariel Shidlo and Michael Schroeder has shown such treatment routinely led to worsened mental health, self-harm, thoughts of suicide, and suicide attempts.”

7.

The IFTC (2011, 2012, 2013, ) has offered interventions at the Organization for Security and Co-operation in Europe (OSCE), Office of Democratic Institutions and Human Rights (ODIHR), Human Dimension Implementation Meetings (HDIM) in Warsaw, Poland, on these and related concerns.

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