Reparative therapy

Reparative therapy (also known as "conversion", "reorientation" or "differentiation" therapy), refers to any of several techniques that are aimed at changing a person's sexual orientation from homosexuality to heterosexuality (or ex-gay). Their claims of efficacy have been refuted, and almost all professionals warn that such attempts are psychologically harmful and the therapy has been condemed unanimously by all mainstream health and mental health organizations. Advocates claim that sexual orientation is changeable and that homosexuality is itself either a psychological disorder, a sin, a tendency toward immoral and harmful behaviours (to oneself and others), or make several of these assertions.

Techniques
Reparative therapy refers to a specific counseling technique for changing gay or lesbian subjects into heterosexuals, but can be used more loosely to describe any formal attempt to alter a person's sexual orientation. A key focus in many reparative therapies includes identifying subliminal emotional needs behind homoerotic desires in subjects - typically referred to as "strugglers" or "ex-gays" by reparative therapists - and attempting to replace them with non-sexual means of expression, usually by encouraging the subject to form an emotional but non-sexual bond with another adult of the same gender. During counselling much stress is placed upon the perceived risks, health and otherwise, of same-sex attraction.

Secular techniques also rely upon reading, sport or physical activity. Reparative therapists generally come from a religious perspective, particularly Christian, and encourage religiousness and prayer.

Religious reparative therapies, such as those practised by Christian transformational ministries, include one-on-one counselling, group counselling, prayer, fasting, reading scripture and meditation. Techniques used in the past (and for a wide array of other psychological and psychatric issues) have included controversial therapies such as electroconvulsive therapy and aversion therapy (such as showing subjects homoerotic material whilst inducing nausea and vomiting through drugs).

Doctrine
Contemporary secular reparative therapy, as championed by leading reparative therapists Joseph Nicolosi and Charles Socarides, holds that homosexuality is the product of a mental disorder they describe as "gender-identity deficit" caused by an alienation from, and perceived rejection by, individuals of the subject's gender. This, it is argued, leads to a quest for bonding and fulfilment, oftentimes in what is perceived to be inappropriate and dysfunctional manners such as compulsive sexual gratification. It describes homosexuality as the need to possess the perceived manhood or womanhood of the object of desire:


 * "The basic premise of reparative therapy is that the majority of clients (approximately 90%, in my experience) suffer from a syndrome of male gender-identity deficit. It is this internal sense of incompleteness in one's own maleness which is the essential foundation for homoerotic attraction. The causal rule of reparative therapy is "Gender identity determines sexual orientation." We eroticize what we are not identified with. The focus of treatment therefore is the full development of the client's masculine gender identity."1

Nicolosi suggests the subject, as a boy, first experiences rejection by his father, then lapses into helplessness and finally retreats to the security of his mother and defensively detaches from his father. According to his theories, this defensive detachment emotionally isolates him from other males and from his own masculinity hence, according to reparative therapists, causing homosexuality.

In general reparative therapists hold that homosexuality is caused by environmental factors, and reparative therapies focus on discovery of historical factors that could have influenced the development of their homoerotic emotions in a subject. See Sexual orientation for more information on this debate.

It is worth noting that reparative therapists hold that a propensity for an emotional bisexuality would seem to exist in all men, for example, as is evidenced by the male need for camaraderie and bonding. It is in the fulfilment of these unfulfilled needs that they believe the cure for homosexual attraction is to be found. Hence, it is not the innate emotional need for same-sex bonding that reparative therapy tries to correct, but what reparative therapists see as its dysfunctional expressions.

Criticisms
The thinking behind reparative therapy has been criticised by psychological and psychiatric health professionals for perceived clinical research bias. Most notably, reparative therapy is based upon the assumption that homosexuality is innately negative or unhealthy and thus that change is desirable, which does not necessarily follow from current research. Critics note that these assumptions seemed to be based more upon religious objections to homosexuality rather than any objective analysis or empirical evidence. Critics also note that reparative therapy research focuses on male homosexuality almost exclusively and rarely takes into consideration female homosexuality, demonstrating further clinical research bias. The motives of reparative therapists have been frequently called into question, some of them having been quoted as saying they would sooner see a "patient" commit suicide than continue living as a homosexual.

Finally, they criticise reparative therapy for its lack of peer review (see Evidence) and the fact that reports are published exclusively in non-peer reviewed journals, in particular Psychological Reports, which has been criticised for its lack of peer review and strong, anti-gay bias.

History
The idea of altering a person's sexual orientation is not a new idea and harkens back to the start of psychology itself. By classifying homosexuality as a disorder, psychoanalysis first defined homosexuality as an exclusive sexual orientation and, thus, discovered the possibility of altering that orientation 2. Researchers such as Irving Bieber, Lawrence Hatterer and Sigmund Freud attempted to cure homosexuality through a variety of techniques, including "aversion therapy, nausea-producing drugs, castration, electric shock, brain surgery, breast amputations, etc." For more information see Homosexuality and psychology.

Modern reparative therapy is a re-reading of the earlier, psychological research and stems from the clinical work and theories of Elizabeth Moberly, Ph.D., a British theologian and research psychologist, who coined the term during the early 1980s. In her book, "Homosexuality: A new Christian ethic," which is widely read by reparative therapy proponents, she suggests that homosexuality is the result of environmental factors coupled with a temperamental predisposition - but primarily, a subject's failure to bond with his father, as opposed to the domineering mother theory in Freudian psychoanalysis. By "reparative therapy" Moberly means that homosexuality is a "reparative drive"; that is, homosexuality is a way to cope with or "repair" broken relationships. She does not mean that reparative therapy repairs anything. See her more technical book: "Psychogenesis: The Early Development of Gender Identity."

Initially, reparative therapy was welcomed by many 'Ex-Gay' and gay Christian groups who saw it as a means of reconciling their beliefs with their sexuality and as a way of gaining greater acceptance in their respective churches or ministries. Some of these ministries have since turned away from reparative therapies, disillusioned with promise to change their sexuality.

Once seen as a being on the fringe of the gay rights argument, lately reparative therapy has been adopted by much larger, conservative religious groups, particularly in the USA. Many in these groups see reparative as a kinder way of approaching their opposition to homosexuality. It has also been used by some of these groups to influence public opinion and sway legislators "from supporting equal rights, domestic partnership and hate crime legislation." 

Controversy
Reparative therapy itself is a highly contentious and controversial topic, and the claims of the ex-gay movement are hotly contested, particularly by various professional medical bodies (see Opponents). The general scientific consensus has been that sexual orientation is unchangeable in adults, though this consensus and the cause for that immutability are disputed by reparative therapy advocates. This section seeks to detail and summarise the various controversies and debates surrounding reparative therapy.

Generally, the debate tends to focus on traditional arguments for and against homosexuality. Opponents view these therapies as a product of Christian fundamentalism and intolerance of the gay and lesbian minorities, whilst supporters argue that opposition to reparative therapies is only due to vocal minority groups. These arguments are not necessarily directly related to reparative therapy and are not repeated here. For more information see Religion and homosexuality, Homosexuality and morality and Gay rights.

Proponents
Exodus International, NARTH, PFOX, and the International Healing Foundation, are among the religious and ex-gay organizations which advocate the belief that reparative therapy is genuine and works, along with various minor ex-gay and transformational ministries. During the 1970s and '80s the Aesthetic Realism Foundation promoted their philosphy, based on studying the poetry of Eli Siegel, as leading to change in homosexuals. The groups stopped offering the therapy in 1990.

Conversion therapies are also advocated by various religious family values groups such as the Family Research Council and Focus on the Family.

Specific proponents, such as Charles Socarides, often have gay sons, leading some to suspect they are working out their own psychological issues in public through their advocacy of a therapy that doesn't work.

Opponents
Reparative therapies are opposed by a variety of groups, including gay rights organizations such as GLAAD, Stonewall and Outrage.

More importantly, the vast majority of professional medical and psychological bodies condemn conversion therapies. Such bodies include:


 * American Psychiatric Association
 * American Academy of Pediatrics
 * American Medical Association
 * American Psychological Association
 * American Counseling Association
 * National Association of School Psychologists
 * National Association of Social Workers
 * Royal College of Nursing

On the question of whether therapy can change sexual orientation the APA answers:
 * "No. Even though most homosexuals live successful, happy lives, some homosexual or bisexual people may seek to change their sexual orientation through therapy, sometimes pressured by the influence of family members or religious groups to try and do so. The reality is that homosexuality is not an illness. It does not require treatment and is not changeable."

Some religious organisations also oppose reparative therapies, including The Interfaith Alliance, New Ways Ministries and People for the American Way.

In 1999, the American Academy of Pediatrics, American Counseling Association, American Association of School Administrators, American Federation of Teachers, American Psychological Association, American School Health Association, Interfaith Alliance Foundation, National Association of School Psychologists, National Association of Social Workers, and National Education Association developed and endorsed a statement reading:


 * The most important fact about 'reparative therapy,' also sometimes known as 'conversion' therapy, is that it is based on an understanding of homosexuality that has been rejected by all the major health and mental health professions. The American Academy of Pediatrics, the American Counseling Association, the American Psychiatric Association, the American Psychological Association, the National Association of School Psychologists, and the National Association of Social Workers, together representing more than 477,000 health and mental health professionals, have all taken the position that homosexuality is not a mental disorder and thus there is no need for a 'cure.' ...health and mental health professional organizations do not support efforts to change young people's sexual orientation through 'reparative therapy' and have raised serious concerns about its potential to do harm.

It should also be noted that state licensing boards and federal accreditation boards in the United States have revoked the credentials of counselors, physicians, and psychologists for having engaged in this practice.

Terminology
The language used to describe reparative therapies is itself contentious. Opponents prefer to use the term "conversion therapy".

Sexual Orientation
The main controversy centers on whether or not sexual orientation is determined at birth, and hence whether it is changeable or innate. For more information on these arguments please see Sexual orientation and Environment, choice, and sexual orientation.

Supporters of reparative therapy believe that homosexuality is not a fixed sexual orientation but an emotional or mental disorder which a person can change, and that it should be reclassified as such. They refer to this disorder as same-sex attachment disorder so as to distinguish from a fixed or innate sexual orientation.

Generally, opponents of reparative therapy believe that sexual orientation is fixed and, hence, that reparative therapies will always be ineffective and raise false hopes in vulnerable individuals. Some opponents agree that sexual orientation is changeable but argue that, despite this, there is no, or no great, moral imperative to try to do so or that doing so would not substantially improve the well-being of the subject and, for this reason, consider reparative therapies to be useless.

Evidence
The success or failure of reparative therapy is itself sometimes used in the mainstream debate for and against homosexuality and the past few years have seen a flurry of reports self-published by reparative therapists and ex-gay organisations describing anecdotal evidence of conversions and measuring success rates from 30% to over 70%.

Opponents contest these results and respond that many of these groups do not make a clear distinction between homosexual behaviour and orientation or do not take into consideration that subjects may be bisexual and, for example, may have simply been convinced to restrict their sexual activity to the opposite sex. Similarly, many of the studies released by reparative therapy groups are conducted over short periods of time and there are few follow-up studies to determine rates of relapse over the long-term.

Finally, they criticise the way reparative therapies define success: many of their clients appear to still feel homosexual attraction or their orientation appears to not have been changed and the client is merely celibate. Both results are considered successful, 'partial' conversions by reparative therapists. Reparative therapists respond that the case against reparative therapy has not been proved and this variability in success should not be viewed as a therapeutic failure.

Opponents also highlight that the lack of empirical evidence demonstrates that reparative therapies are experimental or pseudoscienfitic techniques that lack scientific rigour to back them up. Results are not published in peer reviewed journals but tend to be released to the mass media and the Internet (see Science by press conference), random samples of subjects are not used and results are reliant upon the subject's own self-reported outcomes or on the therapist's own evaluations which may be subject to social desirability bias.

The American Psychiatric Association (APA) (which concluded in 1973 that homosexuality is not a mental illness) stated in a 1998 position statement unanimously endorsed by its Board of Trustees that there are no scientifically rigorous studies to indicate the actual "efficacy or harm of 'reparative' treatments" and that conversion therapists have yet to produce "any rigorous scientific research to substantiate their claims of cure... Recent publicized efforts to repathologize homosexuality by claiming that it can be cured are often guided not by rigorous scientific or psychiatric research, but sometimes by religious and political forces opposed to full civil rights for gay men and lesbians." The APA position statement ends with a recommendation for ethical practitioners to "refrain from attempts to change individuals' sexual orientation, keeping in mind the medical dictum to first, do no harm." (see Potential risks).

Reparative therapists respond to criticisms from these bodies, arguing that opposition from the professional psychological and medical community is due to various political forces from within and without. They argue that the lack of evidence supporting their claims is to be expected, as the political pressures by various political groups, in particular gay rights groups, are such that any attempt at proper testing and study are quashed by the APA and other governing bodies.

Spitzer Report
Further controversy ensued in May 2001 when Dr. Robert Spitzer, who was involved in the original declassification of homosexuality as a mental disorder, presented a paper on reparative therapy at the APA annual convention. This paper was widely reported by proponents of reparative therapy as evidence of success of the therapy. However, it is worth bearing in mind that Spitzer did not interview a cross-section of those who had entered into such therapy: rather, most of the respondents had been contacted through the 'ex-gay' groups themselves, and had almost certainly been chosen because they claimed to be 'successes'. Many were employed as counsellors or group leaders by 'ex-gay' groups. At the most charitable, therefore, Spitzer was merely being asked to confirm the positive reports being given by a relatively small number of 'ex-gays'.

In his paper he reported that he had found that 66% of the men and 44% of the women had achieved "good heterosexual functioning" through interventions. Advocates of reparative therapy saw this as the first step towards official acceptance and the legitimisation of reparative therapy. Opponents leveled the similar criticisms at Spitzer's paper: that it relied upon samples selected by reparative therapists themselves, that proper random samplings were not used, small samplings were used (143 men and 57 women), that the subjects appeared to be ex-gay advocates who may have been biased in favor of reparative therapies, and that no follow-up study had been carried out to ascertain the long-term success. Similarly, they pointed to the fact that 60% of participants had previously experienced attraction to both sexes. Spitzer himself played down the results of his own paper, saying that the number of homosexuals who could successfully become heterosexual was likely to be "pretty low" and conceded that the study's participants were "unusually religious." A similar paper presented by Dr. Ariel Shidlo and Dr. Michael Schroeder, which has since been published for peer review, presented much lower success rates.

Spitzer's study was later criticized for its methods. In his study, 66 percent of his sample were referrals from advocates of reparative therapy and 78 percent of his sample spoke favorably of reparative therapy themselves. The study relied on 45-minute self-reported telephone interviews with the participants that couldn't be checked for reliability and were open to the Social desirability bias that may result from many participants being connected with reparative therapy advocates. In addition, only 40% of his sample reported being exclusively attracted to same-sex adults before doing the therapy, while the rest reported being bisexual. Spitzer, however, said the study may not apply to the LGBT population at large. He conceded that the number of people who could convert from homosexual to heterosexual orientation was likely to be "pretty low" and that most of the participants in his study were "unusually religious."

Shidlo and Schroeder study
Another study on reparative therapy was done in 2001 by Dr. Ariel Shidlo and Dr. Michael Schroeder. Their study also relied on a participants connected with reparative therapy advocates in addition to recruitments from the Internet. Their study found that 88% of participants failed to achieve a sustained change in their sexual behaviour and 3% reported changing their orientation to heterosexual. The remainder reported either losing all sexual drive or struggling to remain celibate. Schroeder said many of the participlants who failed felt a sense of shame. Many had gone through reparative therapy programs over the course of many years. Of the 8 respondents (out of a sample of 202) who reported a change in sexual orientation, 7 were employed in paid or unpaid roles as 'ex-gay' counsellors or group leaders, something which has led many to question whether even this small 'success' rate is in fact reliable. 

Potential risks
Conversion therapies are frequently promoted as being helpful and safe. Reparative therapists claim they are helping those afflicted with unwanted and intrusive homosexual thoughts and point to the fact that many of their patients have expressed that they were not harmed by such procedures and, although not always having the desired effect, seemed to have some benefits.

However opponents argue that there is no evidence that reparative therapies are safe, and they may in fact be potentially dangerous. Some of the more extreme therapies that have been used (such as electro-shock therapy and aversion therapy) have long histories of being psychologically and physically harmful. However, such therapies are not commonly used by contemporary conversion therapists.

Opponents go further and claim that "softer" therapies such as the secular conversion counselling therapies may also be dangerous. They compare untested reparative therapies to other experimental therapies such as recovered memory therapy (used in unproven cases of satanic ritual abuse) and dissociative identity disorder, that have much in common with reparative therapies (i.e. they are all experimental therapies that have only been promoted by a minority of therapists and clergy) which have proven to cause emotional pain, devastate people's lives, and even result in suicide. They also claim that such therapies seek to exploit guilt and anxiety leading to further psychological problems.6

While no comprehensive study has been yet carried out into the long-term consequences of conversion therapies, the Schroeder and Shidlo study outlined above found that the majority of respondents reported being left in a poor mental and emotional state after the therapy, and that rates of depression, anxiety, alcohol and drug abuse and suicidal feelings were roughly doubled in those who underwent reparative therapy. Of particular concern was the lack of support given by reparative therapists and counsellors to those who found their programme to be contributing to psychological distress (see the section on ethics, below).

Ethics
Many reprarative therapists have come into conflict with the ethical guidelines laid down by the American Psychiatric Association and American Psychological Association, and indeed many have resigned from those associations, often alleging political bias.

While professional ethical guidelines do not explicitly forbid reparative therapy, there are a number of potential clashes, as reported in another paper by Schroeder and Shidlo (see above) in particular on four particular issues: first, patients should not be pressured into therapy (many reparative therapists and those who approach them have strong religious views, and pressure is often placed on counsellees from that standpoint). Secondly, the therapist should not provide misleading information about the 'success rates' of any treatment (the 'success rates' claimed by groups such as Exodus International and Narth are not substantiated by outside studies). Thirdly, the therapist should be prepared to provide alternative courses of treatment to those who were not progressing, or to refer them to counsellors or therapists offering alternative treatments. This often did not happen. Fourthly, the counsellor/therapist would be expected to refrain from direct criticism of the relevant professional associations.

Social pressures
Reparative therapists, working from the assumption that homosexuality is a mental disorder, often argue that their therapies are voluntary and the people seek them out because of negative aspects intrinsic to homosexuality. Opponents argue that reparative therapists ignore research that demonstrates that social pressure plays a key role in an individuals attempt to alter their homosexuality. [3],[4] They argue that harassment, abuse and homophobia, as well as pressure from family, friends and churches [5], may cause high levels of emotional stress for lesbian, gays and bisexuals. In these circumstances, they argue, individuals may feel their only option is to attempt to alter their homosexuality.

Allegations Concerning Teenagers
One of the most controversial aspects of reparative therapy has been the focus on gay teenagers, including occasions where teenagers have been forcibly treated in 'ex-gay' camps. This came to public attention after 'Zach', a Tennessee teenager, posted an internet blog protesting he was about to be sent to such a camp. The camp, run by Love in Action ministries, was subsequently closed by the Tennessee authorities, after it turned out unlicensed staff had been administering prescription drugs to the internees.

A recent report has outlined evidence that 'ex-gay' groups and reparative therapists are increasingly focusing on the young. Given that most psychologists believe such therapies are often psychologically traumatizing when someone is forced into them against their will, some have claimed that this raises the question of when a well-intentioned but controversial intervention of this sort becomes objectionable.

Financial gain
Finally, opponents argue that many reparative therapists may become involved for personal financial gain. They note that participants in conversion therapies frequently have to pay for the treatment they receive, as is true of any psychiatric treatment; and that, whilst many conversion therapists claim to be secular and independent of religion, they receive substantial funding from other, well-funded religious groups such as Focus on the Family.

Transsexual and transgender people
Reparative therapy aimed at gay or lesbian people has also been applied to transsexual and transgender people, since a non-traditional gender identity or a gender identity disorder has been conceptualized by a minority of psychologists as an extreme form of homosexuality. While the Kinsey scale expressed a similar view, the scientific community today rejects this theory.

Medical & Scientific Organisations' Statements On Homosexuality

 * American Psychiatric Association Statement
 * American Psychological Association Statement
 * National Association for Research and Therapy of Homosexuality
 * American Acadmey Of Pediatrics Statement
 * Links To Various Scientific Studies

Reparative Therapy Ministries and Organizations

 * National Association for Research & Therapy of Homosexuality which advocates reparative therapy.
 * The International Healing Foundation is an interdenominational Christian organization which advocates reparative therapy.
 * Exodus International a Christian organization advocating reparative therapy for homosexuals.
 * Courage Apostolate
 * People Can Change, a non-religious group
 * New Direction for Life
 * African American Ex Gay Advocacy Group,
 * Jews Offering New Alternatives to Homosexuality,
 * Evergreen International,
 * Ex Transgenders,
 * Love In Action and Refuge, an ex-gay, Christian ministry and addiction treatment center
 * Parents and Friends of ExGays and Gays, a non-profit ex-gay organization
 * Free to Be Me
 * True Freedom Trust, a Christian, ex-gay ministry based in the United Kingdom
 * Inqueery
 * Loving Homosexuals
 * Christian Parents and Friends

Opposition and Criticism

 * American Psychiatric Association: Position Statement on Therapies Focused on Attempts to Change Sexual Orientation
 * APA FAQ on why they believe changing sexual orientation through therapy is not possible.
 * Ex-gay watch notable news blog for opponents of conversion therapies.
 * The Pseudo-sciene of Sexual Orientation Conversion Therapy detailed summary of the case against conversion therapy.
 * The Courage Trust is a nonprofit, UK Christian Ministry "offering understanding and support for homosexual people" that no longer offers conversion therapy.
 * NOMAD Ex-ex-gay movement information site.
 * Attempts to change sexual orientation
 * Reparative Therapy: A Pseudo Science A personal view by ex-ex-gay Jeffry Ford
 * Dr. Doug Haldeman
 * Parents & Friends of Ex-Straights - Parody website promoting "the right of heterosexuals to choose change".
 * Beware of Reparative Therapy - a commentary by Dr. Rob Killian.

Neutral

 * Bridges Across the Divide links to and quotations from advocates and opponents of conversion therapy