Evan J. Waldheter, M.A.
Sexual orientation conversion therapy is highly controversial. Despite support from a minority of mental health professionals and religious organizations, the practice of conversion therapy has been criticized by many for being scientifically unsound and potentially harmful, reinforcing of societal heterosexism and homophobia, and in violation of fundamental ethical principles. This article provides a brief overview of the history and nature of conversion therapies, and describes the current debate. The primary objective of this article is to update previous work in this area by illustrating key ethical problems inherent in the principles and practice of conversion therapy with respect to the American Psychological Association’s most recent (2002) ethics code and the Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients adopted by the American Psychological Association in 2000.
Update on Ethical Issues in the Practice of Sexual Orientation Conversion Therapy
Sexual orientation conversion (or reparative) therapy is currently at the center of a fierce scientific, political, and religious debate. It is understandable that distressed lesbian, gay, and/or bisexual (LGB) individuals might consider sexual re-orientation to be an appealing option, given the reality of societal prejudice and discrimination as well as the presence of internalized homophobia in many members of the LGB community (Eubanks-Carter, Burckell, & Goldfried, 2005; Herek, 1996; Stein & Cabaj, 1996). However, only a minority of mental health professionals and pastoral counselors currently practice conversion therapy (Spitzer, 2003). Indeed, these therapies are very much outside the mainstream of contemporary mental health practice, given significant concerns regarding their safety and efficacy, as well as their potential for reinforcing societal intolerance, stigmatization, and pathological views of homosexuality. In addition, clinicians practicing these therapies have been sharply criticized for being unethical.
This article provides a brief background on the history, theoretical perspectives and clinical approaches, and current empirical knowledge base with respect to conversion therapies, followed by an overview of the arguments for and against these treatment modalities. The focus of this article, however, is on the ethical problems inherent in the principles and practice of conversion therapy. A comprehensive discussion of the ethical implications of these treatment approaches has been provided elsewhere (e.g., Haldeman, 1994; Halpert, 2000; Schroeder & Shidlo, 2001; Tozer & McClanahan, 1999); most previous work in this area used the Ethical Principles of Psychologists and Code of Conduct published by the American Psychological Association (APA) in 1992 as the basis for arguments against the practice of conversion therapy. This article updates previous work by illustrating key ethical problems inherent in the practice of these techniques with respect to the most recent ethics code (APA, 2002) as well as the Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients (Division 44/Committee on Lesbian, Gay, and Bisexual
Concerns Joint Task Force, 2000). Specific reference to APA ethical guidelines is particularly germane to this discussion, given that a significant proportion (i.e., close to 50%) of currently practicing conversion therapists may be psychologists (Shidlo & Schroeder, 2002; Spitzer, 2003).
Overview: Historical Background
According to most proponents of sexual orientation conversion therapy, these techniques are based on the premise that homosexuality is pathological or problematic, and is worthy of being treated or repaired (e.g., van den Aardweg, 1986). Prior to the early 1970s, this view of homosexuality was shared by a significant number of mental health professionals (e.g., Bieber et al., 1962; Rado, 1969; Socarides, 1968), who advocated for treatment (Silverstein, 1996). However, due to accumulating empirical evidence that homosexuality was neither pathological nor associated with increased rates of psychopathology (see Gonsiorek, 1991, for a review), as well as political advocacy and professional appeals, a significant shift occurred around this time. In 1973, the American Psychiatric Association removed homosexuality as a diagnosis from the 2nd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II), and began to support a view of homosexuality as a normal variation of human sexual experience. In 1975, the APA took similar action and issued a formal resolution that de-pathologized homosexuality and urged psychologists to affirm all LGB individuals. To be sure, the addition in 1980 of ego dystonic homosexuality to the DSM-III represented a momentary setback, as it labeled individuals who were distressed regarding same-sex attractions as abnormal. The removal of this diagnosis from DSM-III-R in 1987, however, served to re-affirm the broader mental health community’s commitment to de-pathologizing homosexuality (Eubanks-Carter et al., 2005). Nevertheless, views of homosexuality as pathological continued to be embraced by a subgroup of professionals and religious conservatives (e.g., Nicolosi, 1991; Socarides, 1979; see Krajeski, 1996, for a review). Individuals and institutions espousing these views began to aggressively market heterosexuality through increased promotion of conversion therapy approaches (Drescher, 2002; Haldeman, 2002).
Today, there are numerous professional and religious-based organizations that are dedicated to treating homosexuality. One of the most prominent, the National Association for Research and Therapy of Homosexuality (NARTH), states that its primary objective is “to make effective psychological therapy available to all homosexual men and women who seek change,” and describes the goal of sexual re-orientation as “a worthy one” (NARTH, 2005). NARTH and other organizations provide a wide range of resources to consumers, including educational materials promoting conversion therapy and referral services for individuals who wish to change their sexual orientation. Indeed, this information is easily accessible via the Internet and is likely to encourage distressed and vulnerable LGB individuals to seek out conversion therapists in their community.
Theoretical Explanations and Clinical Approaches
Many conversion therapies are rooted in psychoanalytic theory, and explain homosexual feelings as resulting from factors such as dysfunctional early attachment patterns, arrested psychosexual development, and/or an unconscious fear of the opposite sex (Bieber et al., 1962, p. 303; Haldeman, 1994). For example, Nicolosi (1991) developed a specific treatment for gay men that links homosexuality to disrupted father-son bonds and an impaired sense of masculinity, as well as poor identification with one’s same sex peers. The goal of treatment is to help the individual strengthen relationships with same sex peers as a means of increasing one’s masculine identity and sense of belonging with other men. Spitzer (2003) summarizes this approach: “samesex attractions . . . can be significantly diminished through development of stronger and more confident gender identification . . . When therapy succeeds in demystifying males and maleness, their romantic and erotic attractions to men diminish and oppositesex attractions may gradually develop” (p.404). There is a strong emphasis on a change in lifestyle, and clients are encouraged to inhibit any homosexual behavior in the service of trying to lead a heterosexual lifestyle. Other conversion therapy approaches include: behavior therapy (e.g., aversive conditioning or systematic desensitization, based on the premise that homosexuality is a learned behavior), group therapy, religious programs, and biological methods (e.g., surgery, drug/hormone therapy) (see Haldeman, 1994; Silverstein, 1996; Yarhouse, 1998, for further explanation and discussion of these techniques).
Efficacy and Safety Concerns
Overall, there is little empirical evidence supporting the efficacy of conversion therapy approaches (Brown, 1996; Haldeman, 1991, 1994, 2002; Shidlo & Schroeder, 2002; Tozer & McClanahan, 1999). In fact, the American Psychiatric Association (1999) claims that “there is no published scientific evidence supporting the efficacy of ‘reparative therapy’ as a treatment to change one’s sexual orientation.” While numerous researchers and clinicians have claimed to achieve success at re-orienting LGB individuals (e.g., Nicolosi, Byrd, & Potts, 2000a; see Throckmorton, 1998, for a review), the majority of these studies have been plagued by significant methodological problems, casting much doubt on the validity of their conclusions. Indeed, critical reviews of the literature have revealed serious limitations and/or study design flaws, including: sampling biases (e.g., reliance on convenience samples of individuals with strong anti-LGB views and/or motivation to change their sexual orientation, thereby highly invested in overreporting success and underreporting failure), no comparison groups, exclusive reliance on self-report or therapist-report outcome data (without more objective behavioral or physiological measures of change), low success rates (particularly after methodological flaws are accounted for), varying definitions of success (e.g., elimination of same-sex fantasies vs. suppression of samesex fantasies vs. celibacy), and limited follow-up data (Haldeman, 1994, 2002; Morrow & Beckstead, 2004; Stein, 1996; Tozer & McClanahan, 1999).
Spitzer (2003) recently completed a much-publicized study evaluating the effectiveness of conversion therapy in 200 individuals who claimed to have undergone such a treatment. He stated that most participants in the study reported that they had changed from a primarily homosexual orientation to a primarily heterosexual orientation, and that these changes were reflected in both overt sexual behavior and core sexual identity. Thus, Spitzer concluded that “change in sexual orientation following some kind of therapy does occur in some gay men and lesbians” (p. 413). Not surprisingly, this study has ignited much debate in the field and has generated an abundance of critical responses from the mental health community. Consistent with general limitations of the conversion therapy literature discussed above, key critiques of this study include: significant sampling bias (i.e., sample consisted predominantly of members of religious or political organizations supporting conversion therapy; individuals who claimed failure/no change in sexual attraction from conversion therapy were largely excluded), exclusive reliance on self-report, and lack of a comparison group (Bancroft et al., 2003).
In addition to skepticism over efficacy, there has also been great concern regarding the safety of conversion therapy. Many of the major U.S. mental health associations (i.e., American Counseling Association, 1998; American Psychiatric Association, 2000; APA, 1997; National Association of Social Work, 1997), as well as the U.S. Surgeon General (2001) and American Academy of Pediatrics (1983), have issued statements warning of possible harm and the potential of serious safety risks resulting from participation in conversion therapies. For example, the American Psychiatric Association (1999) stated that “the potential risks of ‘reparative therapy’ are great, including depression, anxiety, and self-destructive behavior” (p. 1131). Indeed, Shidlo and Schroeder (2002) recently interviewed more than 200 consumers of conversion therapies, and reported that treatment frequently resulted in the following negative consequences: depression, suicidal ideation and behavior, increased self-hatred, increased internalized homophobia, sexual dysfunction, and impaired interpersonal relationships. It should be noted that these findings are based on a non-representative sample of conversion therapy clients (i.e., individuals who responded to advertisements soliciting general feedback about conversion therapy experiences), and thus need to be interpreted with caution. Nevertheless, Shidlo and Schroeder’s data raise serious concerns about the potential pernicious consequences of conversion therapy for many clients. Further, consistent with efficacy concerns raised above, 87% of this sample self-identified as treatment failures, and, of the 13% who self-identified as treatment successes, many reported ongoing distress over same-sex desire and repeated slips (e.g., anonymous homosexual sex, disturbing same-sex fantasies).
The Current Debate
Proponents of conversion therapy argue that individuals have the right to choose this type of treatment if they so desire, and are strong supporters of client autonomy (e.g., Yarhouse, 1998). Davison (1991) has countered this argument by emphasizing that client requests alone are never sufficient justification for any form of therapy. Halpert (2000) illustrates this point with the example of an “abusive partner [who] may request a counselor’s assistance in order to control the victimized partner without the use of violence” (p. 26). Halpert adds that such requests would “likely be denied on ethical grounds without implying the professional’s infringement on client autonomy” (p. 25). Another argument made by conversion therapy supporters is that this treatment aims to reduce the societal stigma experienced by LGB individuals, by converting them to the social norm (Nicolosi, 1991). Davison (2005) challenged this argument by stating that attempts to reorient LGB individuals send the message that homosexuality is pathological and problematic, and this in turn only serves to reinforce intolerance and stigma experienced by the LGB community. Finally, Drescher (2002) notes that proponents of conversion therapies often support their stance with religious ideology condemning homosexuality, and tend to view homosexuality as a behavior that can be changed, not an identity that is more fixed and stable. Indeed, many LGB individuals seeking conversion therapy have done so because of conflicts between their sexual orientation and their religious beliefs (Haldeman, 2002; Morrow and Beckstead, 2004; Tozer & Hayes, 2004).
There are many arguments against the practice of conversion therapy. First and foremost, as discussed above, there have been powerful reports of serious negative side effects associated with conversion therapy, accompanied by a lack of methodologically-sound research supporting its efficacy. Second, homosexuality is not viewed as pathological or problematic by the contemporary mental health community (and thus is not defined as a condition worthy of treatment). Third, as stated above, it has been argued that the practice of conversion therapies only serves to reinforce societal prejudice and discrimination against LGB individuals. Related to the foregoing arguments, conversion therapy is associated with numerous ethical problems.
Ethical Concerns Regarding Conversion Therapy: 2002 APA Ethics Code
It can be argued that the principles and practice of conversion therapy may stand in direct opposition to many of the general principles and enforceable standards outlined in the Ethical Principles of Psychologists and Code of Conduct (APA, 2002). The following discussion draws upon a variety of sources to support claims of ethical problems, including expert commentary, literature reviews, and empirical data examining real-world practice among conversion therapists. Indeed, Schroeder and Shidlo’s (2001) qualitative study of conversion therapy effectiveness has shed much light on the types of ethical violations that occur in the practice of sexual re-orientation therapies (see also, Shidlo & Schroeder, 2002). As stated above, the fact that these findings are based on retrospective self-reports of a self-selected sample of consumers limits the extent to which the results can be generalized to all conversion therapy experiences. However, the sample did include individuals who reported some degree of treatment success, in addition to those reporting treatment failure. Moreover, this is one of the few published attempts to document real-world practices among conversion therapists, and thus these data will be drawn upon frequently to illustrate a variety of ethical breaches in this regard.
Overall, key problems associated with conversion therapies fall into the following general categories: competence and nonmaleficence, prejudice and unfair discrimination, informed consent, false or deceptive statements, termination of therapy, and confidentiality.
Competence and Nonmaleficence
Standard 2.01(a) states that psychologists only provide services “within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience” (p. 1063). In addition, standard 2.01(b) states:
Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with. . .sexual orientation. . .is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services (pp. 1063-1064).
Due to limited exposure to LGB-specific issues in most graduate training programs, it can be argued that many therapists working with LGB clients may not be optimally effective, and that increased awareness of these key issues is critical if one is to be truly competent, according to these ethical guidelines (Eubanks-Carter et al., 2005, Sue & Sue, 2003). More specifically, many therapists working with LGB clients who desire to change their sexual orientation often neglect to address the underlying factors that commonly drive individuals to seek conversion therapy in the first place, such as societal discrimination and heterosexism, as well as internalized homophobia, a construct that has been directly linked to the desire to change one’s sexual orientation (Halpert, 2000; Safren, 2005; Stein, 1996; Tozer & McClanahan, 1999). For example, in a sample of more than 200 LGB individuals, Tozer and Hayes (2004) found that internalized homophobia fully mediated the relationship between religiosity and desire to seek conversion therapy.
Therapists working with LGB clients also need to be sensitive to the dynamic, unfolding process of sexual identity development. Indeed, various developmental models of sexual identity describe a phase of identity confusion, in which individuals may present with significant distress and uncertainty regarding same-sex attractions (Cass, 1996; Troiden, 1988). Competent and sensitive therapists need to provide a supportive environment in which clients can explore these feelings, in order to facilitate healthy growth and identity development (Haldeman, 2004). By misallocating therapeutic resources toward re-orientation rather than the exploration of internal conflicts and the personal effects of societal stigma, therapists practicing conversion therapy may be viewed as lacking an understanding of the core issues facing LGB clients and are thus failing to recognize the boundaries of their competence.
Standard 2.04 (Bases for Scientific and Professional Judgments) states that “psychologists’ work is based upon established scientific and professional knowledge of the discipline” (p. 1064). In light of the paucity of credible evidence supporting the efficacy of conversion therapy techniques, it has been argued that practitioners supporting conversion therapy approaches may be operating unethically by providing treatments shown to be largely ineffective (e.g., Haldeman, 1991, 1994; Tozer & McClanahan, 1999). In addition, conversion therapy techniques often carry with them the underlying assumption that homosexuality is pathological and needs to be treated. There is no scientific evidence supporting this claim; this was a primary impetus for the 1973 decision to remove homosexuality from the DSM-II (Gonsiorek, 1991). Nevertheless, recent survey data indicate that most conversion therapists still espouse a pathological view of homosexuality (Nicolosi, Byrd, & Potts, 2000b). Further, based on the retrospective accounts of consumers, Schroeder and Shidlo (2001) reported that the majority of conversion therapists did not base their claims to clients on current scientific knowledge, but rather on unsupported theories, anti-gay propaganda, and extremist religious ideology.
General Principle A (Beneficence and Nonmaleficence) states that psychologists should take all steps to do no harm to those with whom they work. Standard 2.01(e) states:
In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm. (p. 1064)
Further, standard 3.04 (avoiding harm) states that “psychologists take reasonable steps to avoid harming their clients/patients. . .” (p. 1065). As discussed above, there is empirical evidence that conversion therapy brings the potential for serious harm to clients (Shidlo & Schroeder, 2002), and it is opposed by all major mental health organizations; thus, it should not be endorsed by psychologists or other mental health professionals. Indeed, Brown (1996) asserts that conversion therapy techniques represent “clear violations of the ethic of doing no harm (p. 905),” and the American Psychiatric Association’s Commission on Psychotherapy by Psychiatrists has formally recommended that “ethical practitioners refrain from attempts to change individuals’ s sexual orientation, keeping in mind the medical dictum to ‘First, dono harm’” (American Psychiatric Association, 2000, p. 1719).
Prejudice and Unfair Discrimination
General Principle E (Respect for People’s Rights and Dignity) states that “Psychologists are aware of and respect cultural, individual, and role differences, including those based on . . . sexual orientation. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices” (p. 1063).
Further, standard 3.01 (unfair discrimination) states that “psychologists do not engage in unfair discrimination based on . . . sexual orientation . . .”(p. 1064). It has been argued that conversion therapy perpetuates societal discrimination against homosexuality by deeming it pathological (Davison, 1991, 2005); thus, psychologists endorsing this treatment may in fact be showing a lack of respect for their LGB clients by reinforcing the view that their sexual orientation is problematic and needs to be changed. Indeed, it has been suggested by several authors that psychologists practicing conversion therapy display significant bias in their work, and possess heterosexist and homophobic attitudes (Brown, 1996; Haldeman, 1994; Halpert, 2000).
It should be noted that respecting religious diversity is also subsumed under the foregoing ethical standards. As stated above, many clients seek conversion therapy because of conflicts between their sexual orientation and their religious beliefs (Morrow & Beckstead, 2004; Tozer & Hayes, 2004). Many proponents of conversion therapy correctly point out the importance of respecting clients’ religious beliefs and values, and argue for the potential utility of conversion therapy in helping some individuals to address these conflicts (Throckmorton, 1998). Indeed, respecting the religious diversity of clients is equally as important as respecting the diverse sexual identities and orientations of clients. The challenge for the ethical and competent clinician, therefore, is to place equal emphasis on, and to help clients to integrate, all aspects of their identity (Haldeman, 2002). In other words, religion should not be accorded higher importance than sexual orientation, or vice versa. Haldeman (2004) states that the ideal “treatment philosophy is antidogma; rather than encourage either ‘coming out,’ repressing sexuality in the service of religious belief, or advocating for any particular outcome at all, a treatment framework is offered that enables the client to make decisions for himself” (p. 712). (For an excellent discussion of the clinical implications of working with same-sex attracted clients experiencing conflict between religiosity and sexual orientation, the reader is referred to Haldeman, 2004).
Standard 3.10 (informed consent) states that psychologists obtain the informed consent of all clients prior to any professional activities. Similar to standard 3.10, standard 10.01 (informed consent to therapy) states that psychologists need to obtain the informed consent of all clients prior to beginning therapy. This should involve not only a full disclosure of the nature of the therapeutic relationship and appropriate logistical concerns, but, as stated in 10.01(b), “the potential risks involved [due to the specified treatment], [and] alternative treatments that may be available” (p. 1072). The APA Ethics Code makes this stipulation for treatment techniques that have not yet been fully established or shown to be efficacious (e.g., conversion therapy).
Full informed consent procedures should always accurately and completely outline the expected benefits and risks of the experience that individuals are about to enter into. Drescher (2002) notes that a lack of disclosure of the negative consequences of conversion therapies is rampant in research touting its success. Consistent with competence concerns raised above, it is therefore possible that many conversion therapists are themselves unaware of the high failure rates and strong potential for negative consequences that is often associated with this therapy. Indeed, Drescher has stated that “It is not clear . . . if reparative therapists ever provide informed consent to explain these substantial risks to the patients they treat, or even if they are fully aware of the costs to the unrepaired” (Ontario Consultants on Religious Tolerance, 2003). More importantly, there is empirical support for the foregoing claims. Based on their interviews with consumers of conversion therapy, Schroeder and Shidlo (2001) reported numerous violations of informed consent requirements, including misrepresentations of the efficacy of conversion therapies, no mention of possible deleterious side-effects or consequences, failure to discuss alternative treatment options (e.g., gay-affirmative therapy), and, in several cases, coercion into therapy by therapists or religious institutions.
Yarhouse (1998) argues for the use of advanced informed consent procedures for therapists who choose to offer conversion therapy to their clients. He advocates that, given the current controversy surrounding these techniques, advanced informed consent to treatment should include the following information: etiological hypotheses for clients’ current distress, a full description of available treatments and corresponding success rates, alternatives to professional treatment including mention of the lack of strong empirical support for conversion therapy, and full disclosure of the benefits and risks of conversion therapy, including a discussion of potential outcomes with and without treatment.
False and Deceptive Statements
General Principle C (Integrity) states that psychologists should strive to promote “accuracy, honesty, and truthfulness” in their work (p. 1062). Standard 5.01(a) states that “psychologists do not knowingly make public statements that are false, deceptive, or fraudulent concerning their research, practice, or other work activities or those of persons or organizations with which they are affiliated” (APA, 2002, p. 1067). Similarly, standard 5.01(b) states “psychologists do not make false, deceptive, or fraudulent statements concerning . . . their training, experience, or competence. . . their services . . . [and] the scientific or clinical basis for, or results or degree of success, of their services . . .” (p. 1067).
Given the limited empirical support for the efficacy of conversion therapy (e.g., Haldeman, 1991, 1994), any psychologist advertising conversion therapy as an efficacious treatment option may be viewed as being in breach of this section of the Ethics Code for making false, deceptive, or fraudulent claims about the benefits of this treatment approach. Further, by its very nature, conversion therapy is based on inaccurate information regarding homosexuality- specifically, that it is a pathological condition, necessitating treatment. This lies in direct opposition to the current beliefs of the entire field of professional mental health (e.g., Drescher, 2002; Haldeman, 1994; Stein, 1996). It is especially concerning that the majority of conversion therapists in Schroeder and Shidlo’s (2001) study actively misled clients about the nature of homosexuality and about the basis for the 1973 decision to remove it as a diagnosis from the DSM-II. Indeed, according to the clients interviewed, most therapists claimed that this decision was based solely on political pressure from the gay community and was not based on empirical research, and insisted that homosexuality is a mental illness. In fact, many therapists denied the existence of a homosexual orientation altogether.
Standard 5.04 (media presentations) states “when psychologists provide public advice or comment via print, Internet, or other electronic transmission, they take precautions to ensure that statements . . . are based on their professional knowledge, training, or experience in accord with appropriate psychological literature and practice . . .” (p. 1067). Haldeman (2002) described a recent advertising campaign that promoted conversion therapies with the theme, “The truth can set you free.” The advertisements featured people who claimed to have changed their sexual orientation through engaging in conversion therapies, and were designed to convince the general public that homosexuality was pathological, changeable, and amenable to therapeutic interventions. As discussed above and elsewhere (e.g., Gonsiorek, 1991; Haldeman, 1994), these claims are, at worst, false and misleading, and, at best, supported by flawed and scientifically-unsound research. One can therefore argue that psychologists who participate in public deception through the use of advertising such as the kind described above are in violation of the Ethics Code.
Termination of Therapy
Standard 10.10(a) states that “psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service” (p. 1073). In addition, 10.10(c) states “. . . prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate” (p. 1073). Both anecdotal and empirical evidence suggests that conversion therapists are unlikely to voluntarily terminate therapy prior to a successful conversion, even if clients are reporting lack of progress, a change of heart, or personal harm. Indeed, Drescher (2002) states that most conversion therapists simply demand that a client work harder and often claim that a client’s lack of motivation is the primary obstacle to successful conversion. In their study of conversion therapy consumers, Schroeder and Shidlo (2001) reported that many clients were pressured to remain in therapy, despite their wishes to terminate. In addition, among clients that did terminate therapy (i.e., as conversion failures), a majority were reportedly not provided adequate pretermination counseling by their therapists, and were unprepared for life post-conversion therapy. Interviews with these individuals reveal that they were left alone to deal with feelings of shame, guilt, failure, anger, and increased internalized homophobia following their unsuccessful attempts at conversion. According to their reports, their therapists did not help to provide them with the tools to cope with these feelings, nor did they provide appropriate referrals following termination; rather, they blamed the clients for their lack of success (Schroeder & Shidlo, 2001).
Standards 4.01-4.07 of the 2002 Ethics Code all emphasize the importance of maintaining the confidentiality of those with whom psychologists work, in therapy or other professional settings. In particular, 4.01 states that “psychologists have a primary obligation and take reasonable precautions to protect confidential information obtained through or stored in any medium . . .” (p.1066), and 4.05(b) states that “psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose...” (p. 1066). Examples of these valid purposes include protecting clients or others from harm, or operating within the HIPAA frame work (i.e., allowing release of information without prior consent for treatment, payment, and healthcare operations) (U.S. Dept. of Health and Human Services, 2005). However, Schroeder and Shidlo (2001) found many violations of confidentiality when interviewing former consumers of conversion therapy. These ethical breaches most often occurred in the context of a religious university or related setting, but also occurred in private practice settings. It was revealed that, without prior consent, many therapists disclosed confidential information about clients’ sexual orientation and practices to school officials and/or family members, resulting in students being expelled from school and/or experiencing disrupted family dynamics and uncomfortable confrontations. These occurrences certainly constitute significant ethical violations, and are likely to result in a chilling effect among individuals seeking counseling for sexuality-related concerns if they cannot feel assured that their disclosures in therapy will be kept confidential by their therapist.
APA Guidelines for Therapy with LGB Clients
In 2000, the APA released their Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients (Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force, 2000) to specifically address the needs of this population. These guidelines include aspirational principles meant to supplement the Ethics Code, and offer a framework that should be followed by psychologists working with LGB clients. It can be argued that the principles and practice of conversion therapy may also lie in direct opposition to many of these guidelines, several of which are explained in more detail below.
Interviews with these individuals reveal that they were left alone to deal with feelings of shame, guilt, failure, anger, and increased internalized homophobia following their unsuccessful attempts at conversion.
Guideline 1 states that “psychologists understand that homosexuality and bisexuality are not indicative of mental illness” (p.1441). Survey data suggest that most therapists practicing conversion therapy do view a homosexual (or bisexual) orientation as being pathological (Nicolosi, Byrd, & Potts, 2000b), despite empirical evidence refuting this claim (Gonsiorek, 1991). As described above, it has been documented that many conversion therapists insist upon telling their clients that homosexuality is a psychiatric disorder and that LGB individuals are unhealthy (Schroeder & Shidlo, 2001). These therapists are displaying a blatant disregard for the prevailing views of the contemporary mental health and medical communities, and are violating this fundamental therapeutic guideline.
Guideline 2 states that “psychologists are encouraged to recognize how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated” (p. 1441). Many researchers and clinicians have argued that most therapists practicing conversion therapy are inherently heterosexist and homophobic, and are demonstrating an insensitivity to the true needs and concerns of the LGB population (Brown, 1996; Haldeman, 1994; Halpert, 2000; Tozer & McClanahan, 1999). In the spirit of cultural competence, a lack of awareness of, or disregard for, personal biases and negative attitudes toward LGB clients should preclude therapists practicing conversion therapy from doing so (Sue & Sue, 2003). In general, Brown (1996) emphasizes the need for any therapist working with LGB individuals to continue to engage in ongoing professional development, and to take special care to receive advanced education regarding this, or any other, minority population. Indeed, psychologists need to recognize the limits of their own knowledge base, and, when appropriate, refer clients to other therapists in clinical situations beyond the scope of their competence. Empirical evidence suggests that many conversion therapists are, in large part, ignoring these practice guidelines in their work (Schroeder & Shidlo, 2001).
Guideline 3 states that “psychologists strive to understand the ways in which social stigmatization (i.e., prejudice, discrimination, and violence) poses risks to the mental health and well-being of lesbian, gay, and bisexual clients” (p. 1442).
Guideline 4 states that “psychologists strive to understand how inaccurate or prejudicial views of homosexuality or bisexuality may affect the [client]...” (p.1443). In addition, the guidelines advise psychologists to “[provide] clients with accurate information about the social stressors that may lead to discomfort with sexual orientation... [in order to] help neutralize the effects of prejudice and inoculate clients against further harm” (Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force, 2000, p. 1443). Many authors have argued that therapists practicing conversion therapy are themselves espousing prejudicial views of homosexuality, and are not displaying a genuine concern for the impact of inaccurate views of sexuality on their clients (Tozer & McClanahan, 1999). Indeed, their encouragement of sexual orientation conversion is likely to reinforce societal stigmatization of homosexuality (e.g., Davison, 1991, 2005), and can ultimately prove quite damaging to clients over the long-term.
Practice guidelines clearly state that therapists should “not impose their beliefs on clients but rather examine thoughtfully the clients’ experiences and motives” (APA, 1998). Stein and Cabaj (1996) emphasize the importance of considering the impact of negative societal attitudes on clients’ self-concepts. Indeed, they strongly encourage therapists to assess for the presence of internalized homophobia in their LGB clients and to make that a target of treatment. Other authors also stress the critical role that internalized homophobia and societal stigmatization play in the lives of LGB clients (Eubanks-Carter et al., 2005; Tozer & McClanahan, 1999). Conversion therapy, in contrast, only serves to reinforce these prejudicial and homophobic views, increasing the subjective distress of clients seeking help (Davison, 2005).
Finally, Guideline 5 states that “psychologists... respect the importance of lesbian, gay, and bisexual relationships” (p. 1443). One can argue that therapists practicing conversion therapy are not adhering to this important therapeutic guideline in their work with clients. Indeed, many conversion therapists actively display a fundamental lack of respect toward gay and lesbian relationships. For example, Nicolosi (1991) believes that individuals in homosexual relationships can never be truly happy or content with their lives, and has stated that “it is legitimate to place higher worth on heterosexuality within the framework of one’s value system” (p. xvii). Schroeder and Shidlo (2001) documented many instances of conversion therapists telling their clients that homosexual relationships are undesirable and unhealthy. Drescher (2002) points out that heterosexuality is idealized by reparative therapists, and notes that a core belief of these clinicians is that “any price is worth paying to become a heterosexual” (p. 83).
LGB individuals may present in treatment seeking to change their sexual orientation secondary to many factors, most notably societal prejudice, internalized homophobia, and/or religious beliefs. Consistent with this, many therapists will be faced with the dilemma of how best to treat these clients. Haldeman (2002) recommends that clinicians help clients to consider the psychological and social context in which their distress occurs, present clients with accurate information about the lives of LGB individuals, and ultimately assist clients to integrate all aspects of their identity, including sexual orientation and religious beliefs. Indeed, clinicians are encouraged to utilize a person-centered approach, in which they “provide not wisdom, advice, or direction but a safe holding environment in which the client is free to explore the many challenging questions associated with identity conflicts” (Haldeman, 2004, p. 713). (For excellent discussions of clinical guidelines with LGB populations, particularly in cases of distress over sexual orientation, the reader is referred to Haldeman, 2004; Lasser & Gottlieb, 2004; Stein & Cabaj, 1996; Sue & Sue, 2003).
To be sure, working with clients in conflict over their sexual identity can certainly be an enormous challenge for clinicians. It must be emphasized, however, that there are many sound arguments against the practice of sexual orientation conversion therapy. All of the major U.S. mental health associations have espoused an LGB- affirming stance, and have warned of the possible dangers of conversion therapies. Indeed, emerging empirical and anecdotal evidence strongly suggests that the risks of potentially serious negative side effects are quite real, and credible evidence of the efficacy of these therapies is lacking. In addition, many researchers and clinicians have claimed that conversion therapy merely serves to reinforce societal intolerance and discrimination. Davison (2005) emphasizes that the current debate over the efficacy of conversion therapies is irrelevant, and argues that therapists should not offer such treatments on political and moral grounds.
Consistent with the foregoing discussion, these treatment approaches raise a myriad of ethical concerns. It can be argued that the principles and practice of conversion therapy conflict with both general principles and ethical standards in the APA Ethics Code (APA, 2002), particularly in the areas of competence and nonmaleficence, prejudice and unfair discrimination, informed consent, avoidance of false or deceptive statements, termination of therapy, and confidentiality. The practice of conversion therapy also lies in opposition to many of the APA’s guidelines for therapy with LGB clients (Division 44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task Force, 2000). In conclusion, clinicians are strongly encouraged to heed these ethical considerations in their work with LGB clients distressed over their sexual orientation.
The author would like to thank Dr. Erica H. Wise for her invaluable consultation and assistance during the preparation of this paper.
Evan J. Waldheter, M.A. is a clinical psychology doctoral student at the University of North Carolina at Chapel Hill. Please address all correspondence regarding this article to: Evan J. Waldheter, University of North Carolina at Chapel Hill, Department of Psychology, Davie Hall, CB# 3270, Chapel Hill, NC 27599-3270 (email@example.com).
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