Reparative Therapy For Homosexuality: Is It Ethical? Should It Be Provided?
Over the last few days a wife and husband have been leaving comments on an older advice column that Dr. Schwartz responded to some years ago titled, "I Think I am Gay and I Need Help to Convert to Heterosexual?". The wife wrote in to disagree with Dr. Schwartz' advice to the initial questioner, namely that he think about working on accepting his homosexuality rather than trying to change it. She noted the experience of her own husband who had struggled with homosexual impulses in his younger years, only to later work with a therapist who helped him to become heterosexual. She wanted everyone to know about the professional association this therapist was affiliated with, a group called NARTH who can be found on the web at narth.com.
Reparative therapy for homosexuality is a contentious issue within the mental health therapy professions. Most of us contemporary therapists believe that practitioners who offer it are acting out of and in support of deeply felt but essentially irrational and harmful homophobic cultural prejudices. Our professional groups have gone so far as to explicitly suggest that such work is unethical (see here and here). Though I disagree with the general goals of groups like NARTH, that doesn't stop them from existing. I can't wish them away anymore than they can wish me away. There is little to be gained by not talking about them and what they do, and maybe something to be gained by doing so. So I let the comments through with an editorial as to the effect that I don't agree that such "therapy" is therapeutic.
Just the other day, the husband wrote in to share his own experience. It occurred to me that the whole topic is worthy of an essay in of itself, rather than being limited to a set of footnotes to an older piece. So what I've done is to simply take the husband's comment and reprint it here, followed by my response, followed by some questions I hope that readers will respond to. This is a very difficult issue I think, for reasons that I elaborate below - that incompatible worldviews are clashing and there is an unknown but limited amount of common ground to be shared between proponants of either side. I think this somewhat taboo subject is worth of discussion, and I hope that discussion can be conducted civilly. I don't expect that people will agree however. But points of contact like this one hold out promise that at least different positions can be accurately understood and therefore not distorted.
To put the following exchange into context, it will be helpful to have read over comments at "I Think I am Gay and I Need Help to Convert to Heterosexual?". If this feels confusing, the rest of the context is there.
The husband's response starts just below:
Dr. Mark Dombeck said: "The person leaving the above comment is essentially correct, however. People should not be prevented from knowing all their options, even if some of their options (like NARTH) are probably not in their best interest."
Dear Dr. Dombeck:
I appreciate your admitting that the original poster who is looking for answers has the right to seek all options. I agree with you wholeheartedly, and I hope that he does pursue all avenues and weigh all opinions in order to arrive at the answers only he can decide are right for him.
Where I would part with your espousal is where you say “even if some of their options are probably not in their best interest.” I note that you use the word “probably” not in their best interest, than “absolutely” not in their best interest. I believe you chose the word probably quite purposefully, because as you probably know, there are many individuals who have sought out reparative therapy and have had significant and measurable life changes with respect to same-sex attractions. There is no more unbiased evidence of this fact than the study conducted by Dr. Robert L. Spitzer published in the Archives of Sexual Behavior, Vol. 32, No. 5, October 2003, pp. 403-417. As you probably know, Spitzer's findings challenge the widely-held assumption that a homosexual orientation is "who one is" -- an intrinsic part of a person's identity that can never be changed. The study has attracted particular attention because Dr. Spitzer, a prominent psychiatrist, is viewed as a historic champion of gay activism who played a pivotal role in 1973 in removing homosexuality from the psychiatric manual of mental disorders.
And while you are entitled to you personal opinion that such therapy is “probably” harmful, in his empirical study, Spitzer notes that for the participants, there was “no evidence of harm,” and, to the contrary, he says, "they reported that it was helpful in a variety of ways beyond changing sexual orientation itself." And because his study found considerable benefit and no harm, Spitzer concluded that "the mental health professionals should stop moving in the direction of banning therapy that has, as a goal, a change in sexual orientation. Many patients, provided with informed consent about the possibility that they will be disappointed if the therapy does not succeed, can make a rational choice to work toward developing their heterosexual potential and minimizing their unwanted homosexual attractions."
As for myself, I did have same sex attractions beginning in young adolescence. However, quite sadly, when I sought help to try and understand my attractions, the only “option” I was given was that “I was simply gay and needed to accept myself for who I was." In my heart, I did not feel that this was the truth. This was not fueled by some deep seeded homophobia or religionist viewpoint that told me I had to “turn or burn,” but rather, because of an intrinsic feeling in my heart that despite some attractions toward other males, I simply had no innate desire to share a life journey with another man.
I spent in total, about three years with a therapist and support group, who essentially tried to lead me down a path of “liberation” – suggesting that I just drop my homophobia and accept who I was (as Dr. Schwartz suggests to the young man in the original post). I remained steadfast in my belief that I was not gay but still impressionable, I continued to listen to the advice and experience they shared. After nearly three years in therapy with no resolution in sight and with gratitude in my heart for their time and knowledge shared, I sad good bye continued on my journey to seek other answers.
After much research, I found an alternative viewpoint in Sigmund Freud’s "Letter to an American mother", American Journal of Psychiatry, 107 (1951): p. 787.” http://www.fordham.edu/HALSALL/pwh/freud1.html
In his letter, addressing the question of whether change is possible, Freud noted that: “in a certain number of cases we succeed in developing the blighted germs of heterosexual tendencies which are present in every homosexual.” And “if (your son) is unhappy, neurotic, torn by conflicts, inhibited in his social life, analysis may bring him harmony, peace of mind, full efficiency, whether he remains a homosexual or gets changed.” Furthermore, Freud notes that he would be open to working with this mother’s son in providing him therapy. Indeed never once does he note that such therapy could bring irreparable harm to his patient. Never once does he say that such therapy is unethical and ill-advised.
This was a revelation for me. That the heralded father of psychoanalysis should unequivocally state that change is possible and he would work with an individual who wanted to undergo the therapeutic process, gave me a commanding perspective that is virtually muted by the “helping” profession today.
Indeed, today, a vast majority of the psychological and psychiatric establishment has slammed the door on such therapy, despite its positive results in many cases (again, I refer you to the Spitzer study). I do believe that Freud himself would be truly disappointed in his contemporaries within the American Psychological Association and the American Psychiatric Association for their highly unethical and blatant censorship of treatment that has helped and can help a countless number of people struggling with feelings same-sex attraction who would otherwise have a choice of treatment and the right to self-determination.
And speaking of the APA, it should be pointed out that in the last decade, the APA has done a 180 degree turn on their long help belief that homosexuality is “inborn” as the majority APA member therapists espouse. Consider that in 1998, the APA stated:
"There is considerable recent evidence to suggest that biology, including genetic or inborn hormonal factors, play a significant role in a person's sexuality."
More recently, that statement was omitted from their documentation and replaced with the following:
"There is no consensus among scientists about the exact reasons that an individual develops a heterosexual, bisexual, gay or lesbian orientation. Although much research has examined the possible genetic, hormonal, developmental, social, and cultural influences on sexual orientation, no findings have emerged that permit scientists to conclude that sexual orientation is determined by any particular factor or factors. Many think that nature and nurture both play complex roles..."
Clearly, the APA is not confident in its own public stance on the matter, and admits that homosexuality can be caused by nurturing influences and that same sex attracted individuals are not simply “born that way.” So to publicly “cut off” access to treatment by their statement that such therapy, which has and can help those who are struggling, is considered unethical and should not be offered is an abomination of ethical, moral and professional practice.
Having read Freud’s letter, I realized that, for the first time, and quite contrary to the psycho-political nay-saying establishment, change was indeed possible.
My journey continued and I eventually found NARTH who referred to a psychiatrist that worked alongside me in delving into my personal story. Together, we relived my journey from a young boy to a young man. It was not easy to go back and revisit a lot of the hurt that I experienced as a young boy, into adolescence and young adulthood, but it was necessary. Oh how healing it was to finally see that their were other answers – and that I was not simply “gay and needing to accept it” but rather I was longing to fully develop my masculinity in a way that I was simply unable to do at the time when most young boys take their first steps in the journey toward manhood.
Among these root causes for me were being raised in a home with a physically and emotionally absent father, who, for the love of his family, worked seemingly around the clock while I was growing up and who, when he was around, for whatever reason, was uncomfortable showing emotion including a simple affirming hug from a father to his young son. At the same time, my mother, who, trying to do the best she could to raise me, felt the need to overcompensate for my father’s physical and emotional absence.
Not having a male role model to help guide my masculinity had its effects. By the time I was of age to engage in organized sports (around age 7 or 8), I simply avoided it (and would do so until well into my 20’s) because as a young boy, I simply never learned how to play. If there was any shame, it was because I would be teased from time to time about my “not measuring up” to the other boys ability to play sports. Oh how I longed to be like the other boys – to be able to be as confident and athletic as they were.
In hindsight, this early longing had nothing to do with sexual attraction of any kind, but rather, a desire to simply be more confident like the other boys. Bottom line Dr. Dombeck is, at a certain point, a young boy longs to learn how to become a young man. In an ideal world, this teaching will be passed down from the father to his son (or another male role model including a coach, teacher, etc.,) for it simply cannot, by sheer genetic make-up, be taught by mom. As for me, I never learned how to walk in the footsteps of my father, or for that matter, any other healthy male role model. No, I was left to fend for myself, often sad, shameful and alone. As I got older (12-15 years old), and puberty set in, my sexuality as a young man increased, along with the peer pressure to be more sexual physically. I soon found my desire to be more confident like the other “popular, athletic, confident guys increasing from a psychological attraction - to a physical attraction – but more in the sense that if I can just look more like them, I will be more manly and others will accept me. But in this sensitive developmental stage, I began to wonder if I was gay.
Through magazines that my older brother kept hidden in a drawer, and later through phonesex lines advertised in the back of the magazines, I soon found myself falling into pornography of all kinds – gay, straight…it didn’t matter, what I wanted to learn was “how a man was supposed to act.” In a very disordered way, I felt that I was being taught how to “be a man” through pornography.
It was through therapy that I was able to get perspective on my situation and see it for what it was – not the result of nature, but rather, clearly defined by nurture. I continued therapy for about three years, and along my journey, my same sex attraction desires diminished significantly and completely and my understanding of who I was and who I was meant to be increased significantly.
Today, I can attest to the fact that my same sex attraction simply does not exist as it once did. I am married, with three young children and a wife who not only knows my story but was an integral part of my often painful and ultimately healing journey of self discovery and self determination. I credit this transformation with having options and being granted the right to self determination rather than accepting the psycho-political establishment’s assertion that I was simply “gay” and needed to accept myself.
And while I am happy to have completed my journey thus far, it is sad to me that today there are probably tens of thousands of young people, who are in the same situation I was in, and who because of an unrelenting psycho-political establishment negative stance toward the “right” to self determination, may not know that there are alternatives worth seeking if they so choose. And, when and if they find such alternatives, are bombarded with messages from the “helping” profession that such treatment is unethical, harmful and should not be pursued.
I hope that my personal story reaches the original man who posted his struggle, for while I cannot guarantee that his journey will be the same as mine, I would tell him that the "journey of a thousand miles begins with the first step," and I would encourage him to take it.
My (Dr. Dombeck's) response starts just below:
Let me start my response by congratulating you on finding a life situation in which you are content. It sounds like you had a troubled past (not because the content of that past was necessarily disturbing, but because you found that content personally disturbing), and that it was a long and complicated struggle for you to arrive at a place you feel better about. That's great in its own way; a real accomplishment and something to be proud about.
I want to address the gist of your complaint, which I think can be summarized by saying that it seems wrong and harmful to you that mainstream therapists handle cases of "ego-dystonic homosexuality" (e.g., a situation where someone is gay but doesn't want to be) by urging such people to become less homophobic and more self-accepting rather than by offering them therapy to rid them of their unwanted urges. In your view, there should be room for the therapist to agree with the client that it is a good goal to work towards removing (or lessening) homosexual desires and behaviors and to help them with that work. To answer the question of why therapists don't do that requires that we raise up some ethical questions and discuss the nature of the therapy relationship.
The therapist-client relationship is a difficult one to understand initially (or at all) because it is pretty much unlike any other relationship you might find yourself in, with the possible exception of a parent child relationship. A therapist is not a friend, although many clients do feel friendly towards their therapists, and vice versa, many therapists do feel friendly towards their clients. A therapist is a expert guide who is in ones life in order to effect change of some sort. This is not randomly directed change, but rather change with an agenda; it is change which is directed towards the enhancement of the client's mental health. As such, the therapist's agenda is driven by all the various forces in society which help to define mental health. Most prominently among these forces are ethical codes which govern the various therapy providing professions. Ethical codes are themselves grounded in worldviews, or widely shared cultural perspectives on the nature of reality and our place within it. These worldviews are influenced heavily by religious perspectives, economic perspectives and scientific perspectives.
All of this is to say that therapists are not passive players but rather active ones. They have a point of view and do provide advice based on what they believe is best and ethical practice. Clients don't always want to listen to this advice, and sometimes they actively disagree with it. However, therapists still need to provide that advice (as informed by their ethical codes and best-practice guidelines) so as to fulfill their role. To do otherwise is to harm clients who have impaired judgment. Clients come in and request therapist buy-in for all sorts of self-destructive and other-destructive behaviors. Therapists' job is to help client reality test (which means - pay attention to shared social reality and to consequences of behaviors). Therapists do advice people to abandon course of behavior that seem harmful. Therapists are not there to make you feel better; they are there to help you *get* better. That's two separate things sometimes.
Ethics are based on a socially-shared understanding of what is the right action in a given scenario. With regard to homosexuality in America, there is presently a sort of ongoing clash between two worldviews which can be badly summarized as socially progressive vs. socially conservative. What is a therapist's ethical duty to a client presenting with ego-dystonic homosexuality will appear different depending on which of these worldviews you subscribe to.
The progressive view is that homosexuality is normal and largely biologically determined. What is ethical in this view is to help clients who are conflicted about homosexuality to become more comfortable with it. Not to urge them to be homosexual if they don't want to be homosexual, but rather to become okay with being homosexual if that is what they want to do.
In contrast, the conservative view is that homosexuality is not natural but rather a pleasure-driven choice people make and can unmake. The ethical thing to do under this world view is to teach a conflicted homosexual person that they have a choice to make and can decide how they want to be. The progressive criticism of this position is that 1) in most cases, the idea that there was a choice as to whether to have homosexual desires or not is false (although behavior can be controlled for sure), 2) there is an implied correct answer (e.g., heterosexuality is implied to be superior to homosexuality) which is not true.
These are not compatible worldviews! What is ethical from one perspective seems unethical from the other. You felt harmed by your initial therapist and then ultimately helped by your second therapist. Since these therapists may have had very different worldviews, each may have acted ethically within their own understandings of ethics, however.
Your testimony says that you were attracted to men, but never felt that you wanted to be in a gay relationship. You also suggest that all forms of porn turned you on including hetero and homo porn. I read bisexuality more than homosexuality (or perhaps even just ODC sort of fixation without any real desire?), but only you can say really. The advice you got from Therapist 1 may have not applied well to your case. This does not mean that it was bad advice for people who were actually homosexual. A failure here on the part of the therapist is perhaps to have not fully teased out your underlying state before providing advice. But we don't know the actual circumstances or what you told this therapist, so it's hard for to know whether this was actually the case.
For the years you spent with Therapist 1 you were in a situation where the two of you apparently had very different understandings of what your problem was. You felt you were a heterosexual person and the problem was how to get rid of homosexual urges. He apparently acted under the assumption that you were a self-hating homosexual person and the problem was how to help you become more comfortable in your own skin.
I've already suggested that I don't think it is the responsibility of a therapist to agree with a client's interpretation of the problem. However, there does need to be some agreement between therapist or client as to what the problem is after a while, or the therapy is likely to amount to wasted time. It is a shame that your inability to agree on what the problem actually was went on for so long. It is the therapist's duty to recognize that there is no shared goal and force the issue to a head. This should not have taken three years; it should not have required you to rebel and leave therapy in the manner you did. Rather, in a more ideal circumstance, it would have been nice if the therapist essentially recognized the impasse and essentially told you that he was not able to help you under the circumstances. His duty then would be to refer you to another therapist.
The question then arises whether it would be his duty then to refer to a therapist who would agree with your assessment of the problem (e.g, a NARTH style therapist) or not. Having thought about this for a day or so, I maintain that this would not have been his duty, provided that he felt confident in his assessment of your problem (e.g., that you had a shame problem and not a sexual one). This would have been a situation where a consult with other therapists would be useful so as to gain a consensus view, but my take on it is that he would owe you a referral to another *qualified* therapist; not to a therapist who would simply agree with you and do what you wanted. Again, this is the difficult issue of the therapist's duty to provide guidence when the client's own judgment may be compromised. The question which is here extremely hard to answer definitively is whether your judgment was compromised or not.
It might sound insulting, or at least inappropriately paternalistic, to hear my analysis as above, because I'm asserting that in this situation, the therapist has to substitute his judgment for that of his client if he believes the client's judgment is compromised (which he apparently did), and that means, in your personal situation, that he would not be agreeing with you and you would feel not heard/invalidated. "How dare the therapist act like he knows what is best for me more so than I do myself!", you might say. Consider that the same therapist is asked to do exactly that when working with psychotic clients, addicted clients, self-harming clients, etc. all the time - people who have very strong feelings about what will be good for them, which end up not being so good for them, and maybe it will make more sense. It's not always easy being a therapist. Therapists are not there to be your friend or to please you; they are your therapist, and that means that they can and do have an almost parental-seeming duty to provide clients with ethically and scientifically informed structure and guidance when that is the right thing to do, even when clients don't want to hear it. It is hard to know what the right call to make is in every situation. If the therapist makes the right call, he ends up being helpful, or at least helps society (for instance in cases where a therapist has to break confidentiality to prevent suicide or homicide). If the therapist makes the wrong call, he ends up pissing off the client who is also not helped.
Here are some questions I don't know the definitive answers to but which are relevant to this situation: "Who ultimately defines one's personal reality?" Is it one's society who has the right and responsibility to do that, or is it the right of the individual, or is it shared between the two? Should your own assessment of the situation be the guide, or should it be the therapists? Be careful how you answer the question because your answer has to be something that can equally apply to therapist working with psychotic people, addicted people and self-harming people as it will to people who deal with ego-dystonic homosexuality.
Here's another question that I think I do have a better grip on: "Does the fact that something feels good make it true/useful/healthy?". The answer here is "No". There are many things in life that feel good which are unhealthy. Sometimes then you have to select between things being true/useful/healthy and things feeling good. The conventional conservative position defines what is healthy by saying something to the effect that "homosexuality may feel good but it is bad for you and for society". The progressive position is different in that it defines what is healthy by saying that what is unhealthy is feeling ashamed about homosexuality; not homosexuality itself. In your case, it felt good to you to go in a hetero direction from an initial position of hetero/homo confusion. That might have been completely the right decision, or it might have represented the triumph of shame, the formation of a foreclosed identity and the substitution of a conventional and false persona for an authentic one. Maybe it means both of these things; maybe they're not incompatible positions, as The Grand Inquisitor might have argued.
I do see strong hints of shame at work in your letter. Your excitement over finding the Freud letter from which you quoted the phrase "blighted germs of heterosexual tendencies which are present in every homosexual" for one thing. Also, your statement to the effect that it was healing to
"finally see that their were other answers – and that I was not simply “gay and needing to accept it” but rather I was longing to fully develop my masculinity in a way that I was simply unable to do at the time when most young boys take their first steps in the journey toward manhood."
Both quotes suggest that in your view homosexual men are not fully developed in terms of their masculinity. This position, in my view, is both homophobic and inaccurate, implying as it does that gay men and women are essentially immature. Dr. Freud did hold this belief, I am to understand, but it is not one that many therapists, including "Freudian" style psychodynamic therapists, would subscribe to these days. These days, many of the good doctor's theories and positions are no longer looked on as particularly current or valid.
What makes this sort of issue especially difficult to tease out is that we humans really only have our feelings and our thinking brain to help us arrive at answers that make personal sense. No one can know who a person is inside better than themselves though many voices will compete for the right to define people. Despite this truth, there is also always the possibility that one's self-understanding is incomplete or compromised by shame or other warping factors. In the end I suppose one has to go with one's gut and the best advice available and hope that it works out. In your case, it seems to have worked out, which is surely a good thing.
Life is a messy thing, and this interchange is a particularly good example of how messy things can get - how therapists and clients alike can be challenged to act ethically - an illustration of the limits of ethics - and a good example of how complicated it can be to know what the right thing is to do.
How do you (Dear Reader) appreciate this complicated case? Just below, I'm (Dr. Dombeck) posting some questions I hope that readers will address as they think about the issues at play here:
- Is there a right answer here? Is there more than one right answer? What is your take?
- What is the duty of the therapist as you see it? What is the duty of the client.
- Should ego-dystonic homosexuality be brought back into the DSM as a diagnosis?
- Should people who want not to be gay be referred over to a NARTH style therapist who will offer them treatment for their homosexual desires, or is this generally going to be a bad idea?
- Do you believe it is it possible for a homosexual person to undergo therapy and emerge from the other side as a heterosexual person? Is this husband's testimony evidence that this therapy can work?
- What defines homosexuality? Is it based on how one behaves? Is it based on what someone desires? If you don't act gay, but you desire gay, are you gay?
- Is it possible to control sexual desires? Is it ethical to control sexual desire (and when? - We ask pedophiles to control their desires but that is because when they act out they harm other people. If a homosexual person "acts out" they cause no more harm to occur than a heterosexual person "acting out" their sexuality).