Not every man or woman who finds himself or herself sexually attracted to someone of the same sex is happy with that attraction. Parents of adolescents who show such tendencies may consider it best for the happiness of their child to seek counseling or other professional help for them. And such help is available.
However, the assumption that homosexual attraction, and, in some cases at least, more established orientation, can change, runs into a wall of opposition from gay rights campaigners and professional bodies. These assert that it is harmful to try and change something they believe is not even a problem, but a naturally occurring phenomenon.
In April this year the White House threw its weight behind this anti-therapy campaign, which had already seen three US states ban sexual orientation change therapy for minors (New Jersey, California and Washington, D.C.). In May the openly lesbian Governor of Oregon, Kate Brown, signed another such law. At the same time Representative Ted W. Lieu introduced a bill into the US Congress that would ban so-called “conversion therapy” throughout the United States.
MercatorNet believes this is a very one-sided culture war. Where is there space given to professional therapists who work in this area to explain what they do and to defend it? Well, right here. We emailed some questions to Dr Christopher Rosik, a practising psychologist and director of research at Link Care Center in Fresno, California, as well as a clinical faculty member of Fresno Pacific University. Here are his responses.
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Q. Earlier this year President Obama endorsed a ban on “gay conversion therapy” for minors. What would this mean for the kinds of young people you see in your practice?
A. In my opinion, this topic is above our President’s pay grade. What the ban in California has meant for me is that I immediately added language to my advanced consent forms, which parents and adolescents read at the outset of therapy, indicating that the law is in effect and therefore I can no longer engage in any intervention that could be construed as promoting change in unwanted same-sex attractions and behaviors.
The California law is very nebulous, as I am still allowed to share information, talk about change, or provide support to a minor, but not say anything that could be viewed as promoting change. Given that costly ethics complaints are made by patients, whose perceptions may vary wildly, such distinctions are of little practical value, and I suspect these laws will hinder the provision of any type of professional psychological care to these minors that is not overtly gay-affirmative in nature.
Q.The White House defined “conversion therapy” as “any practices by mental health providers that seek to change an individual’s sexual orientation or gender identity.” – Does this term and its definition describe what you do?
A. The progressive left has done a superb job of demonizing terms such as “conversion therapy” or “reparative therapy” beyond recognition. These terms have been repeatedly and widely associated with abusive aversive techniques that have not been used within the psychological professions for over three decades, and this includes licensed therapists who do such work.
We are further characterized as coercing minors into treatment and telling such patients they must have been sexually abused.
However, my colleagues and I always follow the lead of the client in goal setting because we understand that there is no genuine therapeutic process without client self-determination. Nor do we assume every client has a history of childhood sexual abuse, although there is reason from the literature to believe such abuse can be an important influence on the development of sexual orientation for some people (Beard et al. 2013; Bickham et al. 2007; O’Keefe et al. 2014; Roberts, Glymour, & Koenen, 2013; Wells, McGee, & Beautrais, 2011; Wilson & Widom, 2009).
Such poor practices, were they actually being used by licensed therapists, would surely risk ethical censure or even loss of licensure without the aid of such bans. Yet I am not aware of a single therapist who has had to deal with an ethics complaint on such a basis. Indeed the lack of any ethics complaints against such therapists at the state level suggests that their professional conduct is not the problem but rather their willingness to entertain the possibility of change for some patients.
Recent legislation in Washington State further disclosed ban supporters motives as seeking to suppress the free speech rights of therapists. A bill with bipartisan support to prohibit harmful aversive techniques with minors (e.g., electrical shocks, chemically induced nausea, ice baths) eventually died after ban advocates protested that the bill still allowed for therapist speech in the potential facilitation of change.
In point of fact, there is no one special kind of therapy for such patients. I am not a reparative therapist, but I do see insights from this paradigm as being applicable to some patients. Therapists like me who work in this area typically utilize a number of mainstream interventions that address relevant emotional and cognitive processes as well as certain relational dynamics. While many of these therapists operate from a psychodynamic and developmental perspective, they often incorporate insights from the cognitive, interpersonal, narrative, and psychodrama traditions as well, to name just a few (Hamilton & Henry, 2009).
Often these therapists are not focusing on same-sex attractions at all, but rather on the broader issues of identity and specifically gender identity in an attempt to resolve various factors that may contribute to the patient’s difficulties.
For those patients who prioritize their traditional religious and/or cultural values above acting upon their same-sex attractions, chastity/celibacy, behavioral management, and the modification of same-sex attractions and behaviors are all valid options that should be embraced by their faith communities.
Having said all this, it has to be acknowledged that conservative hyperbole on these issues (e.g., Ben Carson’s recent statements on people choosing to be gay; mean-spirited and scientifically uninformed comments by some leaders of the religious right) also does damage to how this work is seen by the public and makes a reasoned discussion around these issues more difficult.
Q. Are there any questionable practices in this field, in your opinion?
A. Among licensed therapists working in this area I believe questionable practices are kept to a minimum by accountability to a professional code of ethical conduct, including full informed consent and careful assessment of client motivation. I spearheaded a related effort to provide practice guidelines for clinicians who affirm the right of patients to pursue change of unwanted same-sex attractions and behavior. Therapists doing work in this area should be familiar with this document.
There is much greater variability regarding questionable practices among unregulated and unaccountable religiously oriented counselors and life coaches. It is a great irony that legal bans that prevent licensed therapists from assisting a patient’s free choice to pursue change actually increase the risk of harm by causing some of these individuals to seek out such non-licensed counselors.
Any sort of “therapeutic” nudity, which has apparently been offered by some ministries, is an invitation to (so to speak) get one’s pants sued off.
Less egregious but very important concerns arise when the counselor wanders too far from what current science says (or does not say) about sexual orientation.
Examples of this include the counselor overselling the likelihood and degree of change, not sufficiently exploring the role of outside pressure on the client’s motivation to pursue change, offering reductionistic explanations for homosexuality, overstating the co-occurrence of psychopathology in homosexuality, and ignoring or minimizing the potential impact of stigmatization and discrimination, both as a cause for the symptomology of a client or possibly resulting out of their pursuit of change.
Q. Do many of these patients drop out of therapy or decide to embrace a gay identity after all?
A. Psychotherapy patients in general do drop out of therapy with some regularity. In itself, this is not a clear indicator of harm. Some may drop out because of dissatisfaction, but others may drop out because they are doing better and no longer feel a need to continue in therapy. Some patients do decide to adopt a gay identity, and that is their right. As a psychologist, I am obligated to honor that decision as well.
Q. Do you see many minors? Under what conditions would they come to you – on their parents’ initiative? Their own initiative? The advice of a pastor? … Is it easier to resolve sexual orientation issues when a person is young than when they older?
A. I see minors with some regularity, although they are by no means the bulk of my caseload. Typically, they are accompanied by distressed parents. A professionally conducted therapy in such situations must first involve a careful assessment of the adolescent’s motivation and suitability for therapy.
It may interest your readers that, contrary to how ban advocates would portray me, the majority of adolescent patients I have evaluated were not deemed candidates to pursue change. In these instances, my main focus becomes working with the parents and encouraging them to love their child and keep the lines of communication open, even where they are having to manage value and/or theological differences.
Another rather heinous aspect of these bans is that research seems to indicate that change of same-sex attractions and behaviors is especially common in adolescence and young adulthood. While research directly addressing therapeutically assisted change in same-sex attractions and behaviors is limited, there is a growing research literature on sexual orientation fluidity that must inform this discussion (Diamond, 2008; Dickson, Paul, & Herbison, 2003; Dickson, van Roode, Cameron, Paul, 2013; Far, Diamond, & Boker, 2014; Moch & Eiback, 2010; Savin-Williams & Ream, 2007).
Large numbers of young non-heterosexual women and (to a slightly lesser extent) non-heterosexual men report fluidity in their sexual attractions and identities (Katz-Wise, 2014; Katz-Wise & Hyde, 2014), which typically first begin before the age of 18. I find it especially of interest that men who had experienced fluidity believed sexuality was changeable much more than men who did not experience fluidity, who tended to believe that sexuality was something a person is born with.
This raises the possibility many non-heterosexual male activists who fight against a client’s right to pursue professional care for unwanted same-sex attractions are men who have not experienced change and who assume that this is the case for all non-heterosexuals. Therefore they may erroneously assume that all claims of change must either be lies or self-deception.
Although this research is addressing spontaneous changes in same-sex attractions and behaviors rather than change facilitated by professional therapy, the discovery of sexual orientation fluidity to such an extent certainly makes more plausible claims that professional psychological care has contributed to such change for some people. To quote one research group, “People with changing sexual attractions may be reassured to know that these are common rather than atypical” (Dickson et al., 2013, p. 762).
With such changes in same-sex attractions and behaviors occurring all around us, is it reasonable to maintain that the only place where such change can never happen is in the therapist’s office?
The professional bodies: “It doesn’t fit into our world view”
Q.What is the position of the American Psychiatric Association, the American Counseling Association and other professional groups on this issue? What are their grounds?
A. The major professional associations are generally in lock step agreement on the subject. Their formal pronouncements typically claim that there is no good evidence that such therapies are effective and that they have the potential to be harmful. This unanimity of perspective does look like a kind of trump card, which is why opponents typically pile on the references to statements by professional associations against such therapies in their arguments. But by looking a little deeper, it’s evident things are not that simple.
The fact of the matter is that there is little to no ideological diversity in the leadership of these organizations, leading to a left-of-center groupthink process when addressing contentious social issues, including those involving sexual orientation (Duarte et al., in press; Redding, 2001; 2012; 2013; Wright & Cummings, 2005). This has an inhibitory influence on the production of diverse scholarship in areas such as same-sex attraction change that might run counter to preferred worldviews and advocacy interests.
Keep in mind that the case against change oriented therapy with minors is typically based on four sets of data: anecdotal accounts of harm (mostly from adults), a very few quantitative studies (compilations of anecdotal accounts from adults with severe methodological limitations), inferences from other research domains of questionable relatedness to this therapy (e.g., harms from family rejection of gay youth), and citations of the pronouncements on these therapies from professional mental health and medical associations. These various sources tend to cite one another in an almost symbiotic manner that provides little if any new information relevant to answering important questions about therapies that may facilitate change in unwanted same-sex attractions and behavior.
There is no need to manufacture some sort of conspiracy here. This is just what naturally occurs when the leaders of mental health associations all share the same basic values and worldview. Just a few of a multitude of examples should be sufficient to underscore my contention.
Although many qualified conservative psychologists were nominated to serve on the highly influential American Psychological Association’s (APA) Task Force (2009) concerning “Appropriate Therapeutic Responses to Sexual Orientation,” all of them were rejected. This fact was noted in a book co-edited by a past-president of the APA (Yarhouse, 2009). The director of the APA’s Lesbian, Gay and Bisexual Concerns Office, Clinton Anderson, offered the following defense: “We cannot take into account what are fundamentally negative religious perceptions of homosexuality—they don’t fit into our world view” (Carey, 2007).
To no one’s surprise, only psychologists unsympathetic to sexual orientation change efforts (SOCE) were appointed—and at least 5 of the 6 Task Force members were LGB identified. It appears that the APA operated with a litmus test when considering Task Force membership—the only views of homosexuality that were tolerated were those the APA deemed acceptable. Of course the APA has every right to stack the deck however they wish on such matters, but they should at least publicly acknowledge that they represent a firmly and consistently left-of-center take on the science and politics of sexual orientation.
This was made even clearer in 2011 when the APA’s leadership body—the Council of Representatives—voted 157-0 to support same-sex marriage (Jayson, 2011). Likewise, the leadership of the National Association of Social Workers endorsed a total of 169 federal candidates in the 2014 elections—all of whom were affiliated with the Democratic Party (Pace, 2014)—and thus functioned like an arm of the Democratic National Committee. These figures undoubtedly represent a “statistically impossible lack of diversity” (Tierney, 2011). Even the esteemed American Medical Association has been hemorrhaging membership due to supporting left-of-center programs like Obamacare and now represents less than 20% of physicians in America (Pipes, 2011). With statistics such as these, sensible people will take the pronouncements of these associations regarding therapy assisted change in same-sex attractions with a huge grain of salt.
No research means there is no scientific evidence of harm
Q. Opponents of therapy cite “harm” done by trying to change the sexual orientation or preferred identity of young people – the suicide of the “transgender” teenager known as Leelah Alcorn last December sparked the campaign to extend legal bans. What’s the hard evidence of harm – for any age group?
A. While every suicide of a young person is a real tragedy, these cases have been utilized with a complete loss of objectivity and instead are framed for maximum partisan political leverage.
Firstly, there is virtually no research on harm to minors from professional therapy that accepts the possibility of change in same-sex attractions and behaviors. The APA (2009) has acknowledged this in its Task Force Report. Second, the vast majority of anecdotal accounts of harm involve unlicensed religious counselors or ministries that are not even under the jurisdiction of these bans. Third, without good quality outcome research, of which none exists, we have no way of disentangling preexisting suicidality and distress from that which is allegedly caused by the therapy. Fourth, there is plenty of evidence of the “potential for harm” for psychotherapy in general, with 5-10% of adults and 15-24% of minors getting worse from their treatments (Lambert, 2013; Lambert & Ogles, 2004).
So claims of potential harm simply cannot be offered as an indictment of such therapies unless opponents can marshal evidence that the prevalence of harm specific to professionally assisted change efforts is greater than it is for all forms of psychotherapy, and no such data currently exist.
I think the most striking display the lack of science behind these bans occurred a few months after then California State Senator Ted Lieu (D) introduced the law to ban therapies allowing for change. Just before he seemed to stop making public comments on the bill while it was being debated, he made the following comparison: “The attack on parental rights is exactly the whole point of the bill because we don’t want to let parents harm their children,” he said. “For example, the government will not allow parents to let their kids smoke cigarettes. We also won’t have parents let their children consume alcohol at a bar or restaurant.”(quoted by the Orange County Register, August 2, 2012).
This prompted me to put Sen. Lieu’s harm equivalency statement to the test. I conducted a search of the PsycARTICLES and MEDLINE databases. PsycARTICLES is a definitive source of full text, peer-reviewed scholarly and scientific articles in psychology, including the nearly 80 journals published by the American Psychological Association. MEDLINE provides authoritative medical information on medicine, nursing, and other related fields covering more than 1,470 journals. I searched all abstracts from these databases using combinations of key words best suited to identify studies related to the question of harm to youth from alcohol, cigarettes, and change oriented therapy. You can check the specifics of the results here: http://www.therapeuticchoice.com/#!analysis-of-anti-soce-legislation/cwgr.
What I discovered was that, in stark contrast to the thousands of articles related to alcohol and cigarette usage by youth, my search of the scientific literature for references that would back up Sen. Lieu’s claims yielded a total of four articles. Interestingly, three of these articles were not research-oriented (one of them actually appeared supportive of change efforts) and the only empirical article identified had well known methodological flaws. Consequently, I had to conclude from this investigation that Sen. Lieu’s comparison lacked merit scientifically and therefore attempts to legally prohibit therapies facilitating change on the basis of harms to minors lacks a clear scientific justification. This is a conclusion I hold just as firmly today as I did in 2012.
Ex-ex-gays and gay ministries
Q. There have been some high-profile defections from the ranks of ex-gays, and the dramatic shut-down of Exodus International by its president, Alan Chambers, after he repudiated its mission, as The Atlantic noted back in April. He told the magazine:“99.9 percent of people I met through Exodus’ ministries had not experienced a change in orientation.” What’s the hard evidence of success for this kind of therapy?
A. As I noted previously, there is evidence to suggest that same-sex attractions and behaviors can change, and therapeutic work may facilitate these shifts (Karten &Wade, 2010; Phelan, Whitehead, & Sutton, 2009; Santero, Whitehead, & Ballesteros, 2015).This research is not above critique, of course, as is the case with all research, but critics of this literature seem to view the presence of any study limitations as justification for complete dismissal of the findings.
You will notice that opponents have a much higher standard for methodological rigor when it comes to efficacy of change interventions than they do when addressing the potential for harm, as was the case with the APA (2009) Task Force Report (Jones, Rosik, Williams, & Byrd, 2010).They demand randomized, controlled research designs to prove efficacy and reject case studies of success, but are quick to tout anecdotal accounts of harm in the absence of any controlled, representative research showing harm. This is in spite of the APA’s (2009) conclusion that, “Recent SOCE (sexual orientation change efforts) research cannot provide conclusions regarding efficacy or safety” (p. 3).
It’s been years now since I and some colleagues have challenged anyone in the APA to do collaborative work with us to address the issues of efficacy and harm (Rosik, Jones, & Byrd, 2012), but we have not had a single hint of interest. This makes me question the sincerity of opponents’ demands for us to conduct the most methodologically rigorous forms of research, especially when many of these same folks are working to create a professional and legal environment completely hostile to the conducting of such studies. One can’t be faulted for wondering why anybody would want to conduct any sort of research on a subject that is caught in the legal and ethical crosshairs of politicians and the mental health associations.
Regarding some ex-gay leaders who have shifted their thinking about the possibility of change for anyone with unwanted same-sex attractions and behaviors, what you need to know is that most of these leaders operated in religious contexts, which sometimes contributed to unrealistic expectations for complete change and to feeling pressure to portray such change when this was not their experience.
Equally critical to recognize is that many of these “ex-ex-gays” never received any professional therapy with a licensed therapist knowledgeable about change in unwanted same-sex attractions and behavior. The implosion of some ex-gay ministries serves as a very useful warning that these religious organizations need to operate with a high ethical standard that is fully informed about the science pertaining to sexual orientation and same-sex attraction change.
At the same time, I would caution those who believe change can never occur against relying too much on overgeneralizations from the experience of certain ex-gay leaders. This approach could backfire. I would find it contemptible if someone inferred from the fact that some very influential gay rights leaders have been recently charged with felony sodomy and sexual abuse with teenage boys (Manning, 2014) and felony possession of child pornography (Ho, 2014) that therefore this must be the case for all such leaders. In a similar vein, one cannot possibly be an expert on everyone’s experience of same-sex attraction change. It just makes people look desperate to win a point when they leave the scientific record and engage in such ill advised generalizations.
Working under a ban
Q. What is the effect of the bans which are already in place?
A. The effect of the current ban on “sexual orientation change efforts” (SOCE) for minors is to make it impossible for these patients to pursue any treatment goal that involves the possibility of change, no matter how mainstream the interventions may be. I imagine that if such bans were ever extended to adult patients, the language and objectives would be the same.
In the short term, obviously, therapists like me should continue to operate with strict fidelity to our professional ethics codes and to what the science of sexual orientation change can say and cannot say. Perhaps we will need to reframe what we do somewhat away from changing sexual orientation, language which plays into impressions that only categorical change from all same-sex attractions to all opposite-sex attractions is successful change. I have for some time preferred to speak of change in unwanted same-sex attractions and behaviors as occurring on a continuum of change, since I think this makes for more realistic expectations for most people who pursue change.
As for the long term, since these laws are so vague, I do not think anyone can really predict the actual effect of such bans until we have a test case against a therapist. No one wants to be this person, of course, but it will take a real case against a real therapist to find out how actionable practices will be defined, if they can be. But I have no doubt that such a day is coming, given the fundamentalist-like zeal that groups such as the Southern Poverty Law Center have for restricting client and therapist liberty in this area.
Q. Finally, given the prejudice and opposition, why do you bother with this work?
A. In my work as a psychologist, I have been privileged to meet many religious leaders and others who sincerely desired to pursue the degree of change that might be possible for them and who wish to make professional therapy one aspect of their journey. It is to these individuals that I have dedicated my efforts in this area. It would be a great tragedy if the psychological professions abandoned these people, and for some time I have felt an obligation to represent their interests and aspirations in the professional arena.
I agree that it is a David and Goliath like pursuit which takes a little bit of courage, but I hope my observations above have suggested to your readers that there are sound arguments from both reason and science that can support this kind of therapeutic work. There is a lot more to learn that might improve outcomes and further minimize harms with patients who seek change, but for now, the professional and political climate is making such research next to impossible.
Understanding the other’s moral worldview
Finally, regarding the prejudice and opposition, I have found great insights for understanding such responses in Moral Foundations Theory (Haidt, 2012). Haidt has compiled an impressive database and identified left-of-center ideology as animated primarily by a morality focusing on the individual and emphasizing care for perceived victims of oppression. The welfare of the individual is overwhelmingly the primary moral concern for these people. They tend to support the use of government programs or changing social institutions to extend individual rights as widely and equally as possible and oppose institutional practices seen as victimizing people. The language of rights, equality, and social justice tends to be dominant in the moral argumentation of those on the left.
For those right-of-center, the welfare of the community (e.g., family, society) and the welfare of individuals are of equal moral concern and these people therefore have the often challenging task of balancing the desire to lessen harms to individuals with the desire to preserve the institutions and traditions that sustain a moral community. They generally believe the institutions, norms, and traditions that have helped build civilizations contain the accumulated wisdom of human experience and should not be tinkered with apart from immense reflection and caution. They usually have the intuitive sense that damaging these institutions and traditions could in fact eventually result in greater harm to individuals as well.
Supporters of these bans place their emphasis on alleged widespread harms to minors from therapies that allow for change. Their sales pitch for such bans is generally focused on individuals and the potential for harm. They may not see group-enhancing moral concerns such as respect for authority, tradition, or religious values as moral issues at all. At the least, they are likely to place less emphasis on such concerns as parental authority or a desire to respect religious identities and values. In fact, these moral concerns may be viewed as immoral when they are perceived to interfere with the rights and welfare of individuals (Graham, Haidt, & Nosek, 2009; Haidt & Graham, 2007; Haidt, Graham, & Joseph, 2009).
This fuels both the passion of ban supporters and their zealous antagonism towards individuals and organizations that support professionally conducted therapies open to change. Opponents are animated by a strong moral sense but are essentially limited to intuitive moral concerns that focus on harm to the individual. Thus, their moral predisposition is to mock me or dismiss me as simply being a quack, hateful, and/or bigoted rather than comprehend me as a professional who is committed to both minimizing the risk of harm and respecting the equally important group-centered moral aspirations of these patients.
Moreover, since ban advocates typically do not recognize a community-centered morality as being a valid dimension of morality in this context, a client’s choice to pursue change in therapy when motivated by these group-enhancing moral concerns can only be comprehended by ban supporters as reflecting a response to social oppression rather than an autonomous exercise of self-determination. I am certain that readers who are able to step outside of their own moral lens and more objectively examine the comments sections following the three parts of this interview will see how the moral language of many commentators reinforces the truth of these realities.
Having some understanding of these moral dynamics is very helpful in maintaining humility and extending graciousness toward those who seem unwilling to reciprocate these attitudes. I have actually learned a great deal from opposing viewpoints and respect many of the concerns that emanate from those who may disagree with me. Hopefully, my thoughts here might help some readers not morally predisposed to my perspective realize there actually are good people doing this work and doing it with some real basis in the social science research literature.
Christopher Rosik is a Phi Beta Kappa graduate of the University of Oregon and earned his doctorate in clinical psychology from Fuller Graduate School of Psychology. He is currently a psychologist and director of research at Link Care Center in Fresno, California, as well as a clinical faculty member of Fresno Pacific University. He has published more than 45 articles in peer reviewed journals and has served as President of the Western Region of the Christian Association for Psychological Studies. He is currently Past-President of the Alliance for Therapeutic Choice and Scientific Integrity.
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