The vocation of medicine has regarded itself as an ethical discipline
ever since Hippocrates in the fifth century B.C.E. The ethical
principles of beneficence (promoting good), nonmalificence (do no
harm), and justice were likely implicitly behind the work of the above
scientists. However, experts in biomedical ethics were shocked when it
became apparent in the Nuremberg trials that many of those who carried
out cruel biomedical experiments on Holocaust inmates had been
respected physicians who justified their actions on various ethical
principles. Medicine and science had played crucial roles in the
fostering both the Nazi ideology and in implementing the Final
Solution. Most of of those involved were not madmen. One of the most
frequently invoked defenses of their actions was the morality of
sacrificing the interests of the few in order to benefit the majority.
By such rationales, Jews, Gypsies, Slavs, the congenitally handicapped,
and homosexuals were all regarded as threats to the existence and
health of the nation. [1]
This heinous biomedical reality occurred in a context of some
governmental policies whose origins were in church traditions, and
against which the influences of both past church teachings and
contemporary organizations seemed impotent. This example makes it easy
to understand why medical ethics manuals make it clear that although
physicians are both legally and morally accountable, the two may not
always be concordant and ethical obligations typically exceed legal
obligations. Because slavery was once legal, and in some countries
torture still is, neither are or were morally defensible. [2] It seems
fair to say that American biomedical ethics has for historical reasons
seen fit to develop its own ethical values and standards which are set
at arm's length from ethnic, national, and religious traditions. All
such systems may vary over time and with each other, depending on
context and differing interpretations of data and texts. The evolving
medical ethics regarding homosexuality should be understood in this
context.
The Kinsey "reports" marked the beginning of the move away from the
view of homosexuality as pathology toward the understanding of
homosexuality as a normal variant of sexual desire. Ford and Beach
published studies demonstrating that same-sex activity was common
across cultures and occurred in almost all non-human primate species
(1951). This suggested that homosexuality was both natural and
widespread. Evelyn Hooker published a groundbreaking study of matched
groups of homosexual and heterosexual men who were given a series of
projective psychological tests (1957). Experienced experts could not
distinguish between the two groups. Others later substantiated her
studies. These studies established the concept that homosexuality was
not associated with mental illness.
In the past 100 years many medical attempts have been directed at
trying to change sexual orientation. Physiological methods - many
unethical - included castration, transplanting testicles from a
heterosexual male to a homosexual male, brain surgery, hormonal
therapy, and caustic aversion (electric shock, drug induced nausea)
therapy. At the same time therapists were trying psychological
techniques. Underlying these various methods (psychoanalytic,
behaviorist, etc.) was the premise that human behavior and sexual
orientation are potentially malleable. Treatment failures implied the
homosexual person was a failure, and he or she was to be blamed for not
being sufficiently motivated. The efficacy of such treatments was
rarely the criterion governing their use. "Never did they (the
researchers) seriously consider the possibility that sexual orientation
unfolds naturally like the buds of a flower, rather than as the result
of subterranean psychic forces." [3]
Judd Marmor, a psychoanalyst, researcher, and president of the American
Psychiatric Association (APA) published a series of papers and books
that, with the help of academic medicine, psychiatry and pediatrics,
moved the psychiatric profession away from the position that
homosexuality was a type of mental illness. Marmor and others
(especially Davison) recognized that much of the presumed
psychopathology that had been observed by clinicians in so many
homosexual persons was a symptom of internalized homophobia from
societal stigmatization and not of homosexuality itself. The body
politic feared homosexual behavior and did everything possible to
prevent homosexuality, control it, and when nothing else worked, punish
it.
By pathologizing homosexuality, the APA recognized that it had been
causing a degrading psychological distress in homosexuals rather than
helping them. It was soon recognized by many practicing psychiatrists
that homosexuals became better adjusted and more capable when not
treated as morally degenerate or mentally diseased. Not surprisingly,
there were many who disagreed at first. Vigorous discussion on the
issue increased in the APA in the late 1960s and 1970s as
recommendations began to work their way through several committees to
the Board of Trustees of the APA.
Because of its control over diagnostic nomenclature, the APA became the
focus of both gay activists and religious lobbyists. However, there
were larger issues at stake, which included establishing objective
scientific criteria for what constituted a mental disorder. The APA had
a number of different groups and disciplines go to work on the problem.
As a result of the findings of this initiative, in 1973, the Board of
Trustees of the APA voted to delete homosexuality as a disorder
(disease, pathology) from the Diagnostic and Statistical
Manual of Mental Disorders (DSM-II). This decision has been
characterized by some critics as a hasty vote by a minority of the
membership at an annual meeting that amounted to caving in to the "gay
lobby." The factual history, however, is that the initiative to
declassify homosexuality as a mental disorder started from regional
sections of the APA and moved up through several committees before it
was approved by the APA board. The issue was debated in committees and
small groups, but there was no debate in plenary session and no vote
was taken at that meeting. The first 58% affirmative vote by the APA
was a written mail-in vote of 10,000 members in a referendum that
followed the 1973 meeting. Because of the minority opposition, the 1973
– 74 decision was a compromise which retained "sexual
orientation disturbance," as a diagnosis for a limited type of
distressed homosexual patients. A second revision in 1977 changed this
to "ego-dystonic homosexuality," but the most significant change in
both cases was deletion of the word disorder from the manual of mental
disorders in reference to homosexuality. [5]
As the discussion about how homosexuality should be categorized
progressed through the 1970s and 1980s, those opposing the change
became a smaller and smaller minority. This was largely for two
reasons. The first reason was that many who originally opposed the
change did so not because they thought homosexuality should continue to
be called a mental disorder, but because of a related concern that this
change would undermine the legitimacy of psychoanalysis. As time went
on, this became a moot point so they dropped their opposition.
The second reason the group opposing the diagnostic change became
smaller is that their argument to retain homosexuality as a disorder
was increasingly linked to attempts to retain the legitimacy of
reorientation therapy. However, continued reorientation therapy was
strongly opposed by the majority because the small group of proponents
did not define a diagnostic category where therapy was indicated,
develop criteria for this category of who would be appropriate
candidates, or outline what the recommended pre-therapy psychological
evaluation should be. The persistent unanswered question was, "Why
should we continue to provide a cure for that which has been judged not
to be an illness?" In addition, the argument by proponents of
reorientation became more and more identified with specific church
groups, and some of these proponents shifted more and more toward
biblical justifications. [6]
As time went on the opposition minority within the APA seemed less and
less grounded in scientific integrity, which distanced them and their
arguments from the view of the majority. It was this minority group
that coined the term "reparation" therapy (Moberly) and names such as
Socarides and Nicolosi became more and more identified with religious
faith-based groups. In 1986 the last vestiges of the word "homosexual"
were removed from the diagnostic manual of mental disorders in favor of
the single description of "normal variant of sexual desire and
expression." The diagnostic category of "ego dystonic" was used only
five times in ten years. Homosexual persons could, of course, still
have thought, mood, and anxiety disorders, just as heterosexuals do. A
primary concern of the majority in the APA on this issue was the
fundamental rule of medicine, "First, do no harm." This concern was not
to be limited to biological or psychological harm, but also respect for
religious beliefs such that medical encounters do not harm a patient's
faith. Intuitively, treatments that increase depression risk
undermining religious faith.
Those who opposed the APA change in the early 1970s had many
opportunities to make their case for going back to classifying
homosexuality either as a mental disorder or some other diagnostic
category that would meet legitimate scientific criteria. But positive
clinical experience and more studies moved the membership steadily
toward defining homosexuality solely as a normal variant of sexual
desire and expression. This decision was a momentous event because for
the first time in modern history homosexuality was not classified as a
type of illness or pathology.
The 1973 - 1987 APA decisions were not sudden, superficial decisions by
a small committee or a political response to a pressure group but the
result of changes of a 100-year gestation, which the majority came to
view as long overdue. With this action the profession had moved past
the moral and religious arguments against homosexuality in the 19th
century. At the same time it needs to be noted that many sexuality
disorders are still classified as mental disorders (e.g. fixated
pedophilia, incest, sexual sadism, etc.) because they meet the
necessary criteria (see definitions).
Of equal importance to the APA decision about diagnostic declassification of homosexuality was the following resolution approved in 1974 by the membership:
II. Current Understanding
A. Cause of homosexuality
The cause of differences in sexual orientation is obscure and probably
multifaceted, but homosexuality has many characteristics that suggest
at least a partial and significant genetic basis. Evidence for this
includes things such as the lack of evidence for much variation in
prevalence in many different countries and many ethnic and
socioeconomic groups over different historical periods. Identical twin
studies which show up to a 50% concordance rate of homosexuality in
twins indicate there is not a "single gene" type of causation. However,
an incidence five to ten times the expected rate in twins is consistent
with a significant genetic factor (such as a combination of recessive
genes).
At least one benefit of such a theory is that a parent's love for a
homosexual child recognizes her or his self biologically in the child
in a more positive sense than regarding homosexuality as some serious
accident of nature, a chosen behavior, or some special manifestation of
original sin that corrupted their normal child. One of the most common
situations where there is a sudden change from a negative towards a
more positive attitude toward a homosexual person is when an adolescent
or young adult son or daughter "comes out" to parents who have always
loved and respected them. Sibling relationships have a similar effect.
Here love is at its most genuine.
Continued research into the cause of homosexuality could lead to
something which could change sexual orientation in adults, but this is
unlikely. Furthermore, the lack of knowledge of the precise
before-birth vs. after-birth mechanisms which cause homosexuality are
irrelevant if the result is equally irreversible. No analogy is
perfect, but if one child is born destined to be left-handed and
another had an accident at an early age such that he or she had to
learn to do most things with the the left arm and hand, both would have
a minority trait which neither they nor their parents intended. One can
say "I was born this way" and the other could not, but both would have
an irreversible condition with no memory of cause or choice and for
which neither should be held morally culpable. Like everyone else, they
must strive to do the best with what they "have" when they come to full
realization of how they differ from the majority.
Although basic science evidence of the cause or causes of homosexuality
are inconclusive, it is important to note that the original and current
medical stance about the nature of homosexuality is not based on
extrapolation from inconclusive basic biological research. The change
that started over thirty years ago was based on a combination of the
clinical experience of thousands of psychiatrists, outcome
psychological studies, and ethical concerns.
B. Experiencing (discovering) homosexuality
The experience of most homosexual persons in becoming aware that they
are homosexual has been extensively studied. Most first go through an
initial phase in adolescence when they are disturbed about being
homosexual ("ego-dystonic") in which the origin of their reaction lies
in an internalization of negative societal views about homosexuality or
internalized homophobia. In other words, the internal stress is from
external sources of societal opprobrium, not in the homosexuality per
se. This may express itself in young people through denial of being
homosexual, attempts to pass as heterosexual, including attempts at
heterosexual intercourse, and attempts to eliminate homosexuality.
These efforts can be psychologically damaging. This begins a maturing
process that determines how well the homosexual person may end up as a
psychologically healthy and otherwise stable and productive member of
society. For some persons the process is relatively easy, but for
others it can be very difficult.
The experience of discovering one's homosexuality is usually very
private because of the negative views of society and religion, so most
adolescents do not reveal their distress to anyone for several years.
[9] Unlike stigmatized racial minorities, they usually have no family
or friends to offer support. It is during this period that they are
particularly vulnerable to make unwise decisions, ironically
facilitated by church and family members who present homosexuality as
uniquely bad.
It is not unusual for professional therapists to see young people who
felt driven out of home, church, and even communities because of
messages of negativism that pastors and teachers promulgate but did not
realize had this effect. [10] To be lonely and depressed and feel
driven out into unhealthy parts of society looking for understanding
because of discrimination is not healthy. One study concluded:
"Society, by permitting active discrimination and blocking the pursuit
of happiness in homosexual men may be actively contributing to the
spread of HIV and other STD diseases." [11] Two other studies showed
that decriminalization laws led to an improvement in psychological
adjustment, a decrease in sexual promiscuity and a decrease in sexually
transmitted diseases in homosexual men. [12, 13] These same coercive
discriminatory influences have made many homosexual persons hide their
identity in opposite-sex marriages doomed to failure. Suicides and
suicidal ideation are significantly higher in homosexual persons than
in comparable heterosexual populations for various reasons, including
stigma.
The reporting of the negative experience of the coming to a realization
of one’s homosexuality in the majority of homosexual persons
is the polar opposite of the improbable notion of choosing to be
homosexual rather than heterosexual because the former is an attractive
choice. Nevertheless, a minority in the mental health professions and
many religious groups still promote the idea that homosexuality is a
choice or learned behavior that can be reversed, which is in turn used
by many groups as a reason to justify discriminatory laws against
homosexual persons. Studies such as those cited above support the
conclusion that discrimination harms more than helps the health of gays
and lesbians.
C. Spirituality and homosexuality
Many homosexual persons begin this journey of discovery in a context of
a significant personal religious faith (up to two thirds in some
studies). This experience has been described by some homosexual persons
in terms of the soul - "the foundation for spiritual, affective, and
moral experience, where inspiration germinates and from which vitality
grows." This view of the soul could be understood in the same way by
heterosexual persons. But what is different about the soul of gays and
lesbians is that more than most other persons, it is forged out of pain
and struggle, usually the results of societal stigmatization. The wound
leads to a confrontation with all of its elements: shame, terror of
abandonment, rage, and self-loathing. [14]
For those who cope successfully, the emotional and spiritual elements
mature together in a mystical journey that purifies the soul through
which the psychic wounds become healed. [15] However, where sexuality
and religious teachings conflict, most homosexual persons totally
reject their religious backgrounds in an anti-religious backlash
detrimental to their faith. [16, 17, 18] Gay and lesbian persons may
make this entire journey without professional help, may "come out," or
seek counseling at various places along the way. Standard psychiatry
textbooks recognize the importance of understanding where the
homosexual person is in this sort of self-realization experience, and
dealing positively with the individual's religious faith in any
counseling. [18, 19]
The ideal for most lesbians and gays is to integrate sexual orientation
and spirituality into the overall concept of identity by resolving
anti-gay stigma internalized from negative societal or religious
experiences. However, for some gays and lesbians, the experience of
religion or spiritual identity is as deeply felt, and as highly valued,
as the experience of sexual orientation. For such persons, it may be
more conceivable and less emotionally disruptive to contemplate
changing or sacrificing sexual orientation than to disengage from a
religious way of life that is seen as central to their sense of self
and purpose.
Both the APA and the American Psychological Association recognize this
spiritual reality and the right of some homosexual persons to resolve
the conflicting emotions involved by an integrative acceptance of their
sexual and spiritual realities or a rejection of one. However, in
offering advisory policies, both APA organizations consider it
important to also recognize other complicating realities of this
conflict. One of these realities is the psychologically devastating
effect anti-gay religious doctrine from organized religion can have
because of the considerable power religious institutions hold over
their congregants, including lesbians and gay men. For some, this can
cause an anti religion backlash detrimental to their faith.
In the United States,
two particularly prominent influences fostering anti homosexual
attitudes have been religious fundamentalism and heterosexism...
Studies of anti homosexual (or homophobic) people indicate that they
are likely to be authoritarian, conservative, and religious. [20]
The historical invisibility of positive adult openly gay, lesbian, and
bisexual role models and the failure of schools, churches, and other
institutions to address variant forms of sexuality leave most young
people who become aware of being homosexual feeling isolated, ignored,
and often distressed .... Coping strategies include attempts to become
heterosexual and to self-hatred of one’s homosexuality
leading to self-fulfilling negativism by attributing everything
negative to being homosexual. [such as depression and suicidal
tendencies]. [21]
Organized religion has contributed significantly to the wounding of gay
men and lesbians, through a long history of negative bias that has been
extensively documented (Blumfeld and Raymond 1988,; Goss 1993; Scanzoni
and Mollenkott 1978) . . . The "Letter to the Catholic Bishops on the
Pastoral Care of Homosexual Persons" . . . by Cardinal Ratzinger
states, in part, " . . . the particular inclination of the homosexual
person . . . is more or less a strong tendency ordered toward an
intrinsic moral evil . . . when they engage in homosexual activity they
confirm within themselves a disordered sexual inclination . . . " [or
an - "objective disorder."] [22]
Given these three realities -- sexuality, spirituality, and the
complicating risk of religious doctrine on mental health -- the
difficult challenge for both scientific professionals and organized
religion is to formulate the best stance and the best approach for
enabling the realization of the best physical, mental and spiritual
health for all gays and lesbians. The primary medical stance is: "To
work with the young person struggling with his or her homosexuality, it
is essential for the clinician to be non-judgmental, informed, and
willing to be educated, supportive, and neutral in terms of outcome of
sexual orientation." [23]
Such an approach is acceptable to some churches but rejected by many
others in favor of a presumptive judgment that homosexual orientation
is bad and any intimate same-sex relationship is an egregious moral
lapse. Therefore this stance holds that homosexual orientation should
either be suppressed or changed with a goal of either celibacy or
opposite-sex marriage with no other options recommended. These two
fundamentally opposing stances are the basis for two opposing views of
reparation therapy.
D. Reparation or reorientation therapies
Whether same-sex relationships were viewed as immoral or a medical
abnormality, throughout history it was natural to attempt to change
sexual orientation. This would be reasonable if sexual orientation
could be easily changed without adverse effects in those in whom it
failed. But as noted previously, throughout the past century there have
been many attempts to change sexual orientation without significant
success and with clinical evidence of significant psychological harm to
those in whom it failed. [24, 25] However, a small minority, "primarily
psychologists, social workers, mental health counselors, and pastoral
ministers, continue to provide therapy with the goal of helping their
clients change their sexual orientation from homosexual to
heterosexual." [26]
1. Professional, political and ethical factors in
reparation therapy
The professional and personal implications of reparation therapy became
political in 1998 when a blitz of advertisements promoting reparation
therapy appeared in the media. The promoter of the campaign stated that
its purpose was to "strike at the assumption that homosexuality is an
immutable trait." [27] Some civil rights advocates asserted that "the
Christian Right aims to foster development of a restrictive legal
environment in which only heterosexuals have legal rights." [27] In
this context, the APA felt obliged to take the unusual action of
publishing a position statement on reparative therapy which has been
since updated (available with 46 references at www.psych.org). The
statement includes the following:
The
validity, efficacy and ethics of clinical attempts to change an
individual's sexual orientation have been challenged. To date, there
are no scientifically rigorous outcome studies to determine either the
actual efficacy or harm or "reparative" treatments . . . The theories
of "reparative" therapists define homosexuality as either a
developmental arrest, a severe form of psychopathology, or some
combination of both. In recent years, noted practitioners of
"reparative" therapy have integrated older psychoanalytic theories that
pathologize homosexuality with religious beliefs condemning
homosexuality.
Recent publicized efforts to repathologize homosexuality by claiming
that it can be cured are often guided . . . by religious and political
forces . . . APA recommends that the APA respond quickly and
appropriately as a scientific organization . . . In the last four
decades. "reparative" therapists have not produced any rigorous
scientific research to substantiate their claims of cure. Until there
is such research available, APA recommends that ethical practitioners
refrain from attempts to change individual’s sexual
orientation, keeping in mind the medical dictum to first, do no harm.
The reparative therapy literature . . . not only ignores the impact of
social stigma in motivating efforts to cure homosexuality; it is a
literature that actively stigmatizes homosexuality as well.
'Reparative' therapy literature also tends to overstate the treatment's
accomplishments while neglecting any potential risks to patients. APA
encourages and supports research in the NIMH and the academic research
community to further determine 'reparative' therapy's risks vs. its
benefits.
This current APA position on reparation therapy is
based primarily on 100 years of history and a half- century of
psychoanalytic, behavioral, and other reorientation methods by
thousands of psychiatrists. The clinical research supporting
reorientation in the sub-type of psychoanalysis by Socarides was an
embarrassment to most credentialed psychoanalysts. His patients who
failed were described by him as sociopathic and worse. Prominent
psychoanalyst and former APA president Judd Marmor in a sharply worded
statement said:
I consider the kind of evidence that Socarides
marshals from his clinical practice as essentially meaningless . . . If
our judgment about the mental health of heterosexuals were based only
on those whom we see in our clinical practices we would have to
conclude that all heterosexuals are also mentally ill. [28]
In contrast to such studies, Gerald C. Davison at SUNY at Stony Brook
did exemplary work in a series of behavioral therapy trials (1960's)
trying to alter homosexual orientation. The trials were not successful.
He concluded that dissatisfaction with homosexual orientation was
likely a function of internalized social (including religious and
medical) stigma causing him to shift his research to the social factors
and ethical issues involved in requests to change sexual orientation.
[29] Since the 1970s cognitive behavioral theory and practice of the
type advocated by Davison have become predominant in psychology and
psychiatry. In contrast, the older psychoanalytic theory of
homosexuality as arrested sexual development has generally declined but
has remained as the seeming dominant basis for religiousgroup related
reparation methods.
Most psychiatrists did not give up reparation
therapy because there was never any evidence of some change in a few
homosexual patients, but because of evidence of harmful psychological
effects on many as a price paid for some change in a few. Some
"ex-ex-gays" from current and former programs end up in psychiatrist's
and psychologist's offices. [30] Some psychiatrists and psychologists
have spoken of banning reparation therapy programs because the present
forms are not in keeping with the ethical dictum of first, do no harm.
However, the majority think that this would be premature because of the
complexity of the issue.
The psychologist’s role, regardless of
therapeutic orientation, is not to impose beliefs on clients but to
examine thoughtfully the client's experiences and motives. . . In the
absence of empirically based conversion therapy models, such treatments
are difficult to recommend. Nevertheless, we must respect the choices
of all who seek to live life in accordance with their own identities;
and if there are those who seek to resolve the conflict between
sexuality and spirituality with conversion therapy, they must not be
discouraged. [31]
The basis for medical and psychological groups officially rejecting
attempts to ban reparation therapy are ethical rights of both (a)
individual autonomy and (b) societal acceptance of biological and
spiritual diversity. [32] The medical stance recommends, however, that
any consideration of reparative therapy include careful assessment of
the motives of the client that distinguish between the effects of
hostile social-religious and authentic personal / spiritual incentives.
Ethical informed consent should also include a realistic assessment of
success as balanced against the risks of both failure to change and
possible complications of failures. These risks and the problems in
assessing them are the center of continuing controversy.
2. Problems in assessing risk vs. benefit of reparation therapy
Most positive results of conversion therapies are reported by the
groups doing the studies without independent verification or long-term
outcomes of those who dropped out or failed the therapy. There are only
a few reports of outcomes done independently of the groups providing
reparation therapy. Two such recent studies illustrate the problems in
evaluating reparation therapies.
In one study (Shidlo et al), convenience sampling (open voluntary
solicitation) by phone interview of 202 homosexual persons from
multiple therapy centers,13% reported the experience as positive, with
4% of the 13% indicating some shift toward heterosexual orientation. In
the remaining 87% who viewed the experience as negative, the most
common experiences were increased depression, suicidal ideation and
attempted suicide, distorted perception of homosexual orientation,
harmed relationships with parents, and increased social alienation.
Eleven of the participants reported suicide attempts during therapy and
another eleven after completion of therapy. For obvious reasons, actual
after the fact successful suicides could not be self-reported. [33]
Another study (Spitzer) solicited only persons who self-identified
themselves as having a significant change in sexual orientation which
lasted at least five years. [34] This "successful only" solicitation
phone interview study took 16 months to recruit the 200 eligible for
the study despite repeated notices sent to promoters of therapy to
therapists in every section of the US and Europe, including the almost
1500 members of the National Association for Research and Therapy of
Homosexuality (NARTH). This, according to the author, suggests "the
frequency of successful outcomes meeting the criteria of the study are
rare . . . obviously this study cannot address the question of how
often sexual reorientation actually results in the substantial changes
reported by most participants in this study."
Notable facts in the Spitzer study are that 28% of the respondents said
they were having opposite sex intercourse at the time of
starting therapy, half of these rated its physical
satisfaction at least 8/10, and 20% of all respondents were in
opposite-sex marriages when starting therapy. This suggests that some
clients were toward the bisexual part of the sexual orientation
spectrum despite how they answered some questions. This is not likely a
representative cross section sample of the gay and lesbian population.
The respondents of the "successful only" study were given the benefit
of doubt, but the report acknowledged that exaggeration, elaborate
narratives of self-deception or even lying by the respondents could not
be excluded with the methodology used. These are strong qualifiers.
Spitzer's conclusion was: "There is evidence that change in sexual
orientation following some form of reparative therapy does occur in
some gay men and lesbians." "Evidence of change" is not the same as
"proof of change" and one of the conclusions is that research is needed
"to further determine reparative therapy’s risks vs.
benefits." Another conclusion was that if clients are properly informed
about the risk of failure, there was not enough evidence to ban such
therapies.
An important question is whether these two studies are contradictory or
complementary. These two studies can be judged as complementary if the
"successful only" clients in the Spitzer study are viewed as coming
from the 4% sector of the homosexual population in the "all comers"
Shidlo study represented by those who reported some change in sexual
orientation. If the ratio of successful change in sexual orientation to
the suicide attempts in the Shidlo study (1:3) were applied to the en
tire population from which the Spitzer study clients were recruited,
there would be over 500 unsuccessful suicide attempts as a by-product
of 200 successes. It follows that if it is conservatively estimated
that only one out of 10 (instead of one in five) suicide attempts is
successful, it would mean there is at least one successful suicide for
every four reports of some change in sexual orientation (a minority of
whom have a "complete" change). The fact is that because of the
methodology limitations in both studies (convenience sampling), no one
can accurately say what the suicide risk of these therapies is.
The glaring gap in all existing reparation therapy programs is their
failure to report detailed outcomes on significant series of all
consecutive clients, including good results, dropouts, failures and
complications (not just a generic segment of "failures"). Some
proponents of reparation therapy criticize the medical community for
not continuing research on reparation therapy. However, approval and
funding for research on therapies currently in use similar to previous
studies that showed more harm than benefit would require accurate
documentation selection criteria, methods, and outcomes of a
representative current group. Ethical institutional research review
boards (IRBs) of respected institutions have estimated ethical risk to
benefit criteria and other standards which must be met for approval of
research studies. [35]
Besides the APA, the following professional organizations also either
oppose or are critical of reparation (conversion, reorientation)
therapies: American Academy of Pediatrics, American Medical
Association, American Psychological Association, The American
Counseling Association, and the National Association of Social Workers.
To this list should be added the World health Organization (WHO) in
which all 37 member nations from the Americas also agreed to delete
homosexuality from the International Classification of
Diseases.
Dr. Simon Rosser of the University of Minnesota Medical School Human
Sexuality Studies Program suggests a "best case" fair conclusion for
reparation therapies: they may be successful enough to lead to
successful opposite marriage in 1-2% of those who try it (Wordalone
2004 conference on homosexuality). At the same time it is obvious that
reparation therapy does not enjoy a positive enough reputation in the
gay and lesbian community to have more than a small percentage try it.
From a public health and therefore a public policy perspective, this
translates into less than one per thousand of all homosexual persons
experiencing some measure of successful reorientation therapy as
defined and offered in the above two studies. But the serious risks of
these treatments on some of those in whom treatment fails have not been
accurately established.
E. Medical Consensus
The introduction to this review stated that "the purpose is to present
what we regard as the standard medical-psychiatric science, ethics, and
practice as accepted by all but a small minority of physicians in
medical practice in the U.S. and Canada." It will conclude with some
clarification and support for the claim that the scientific
understanding and practice as described *represents a consensus of all
but a small minority of psychiatrists, psychologists, and other
physicians and mental health workers.
First, any question of whether or not the designation of the minority
view within the medical profession deserves to be called a "small"
minority should begin with the fact that there are about 38,000 members
of the APA and there are about 150,000 psychologists who are members of
the American Psychological Association. Not all psychiatrists and
psychologists are members of these organizations so the numbers of
these specialists are even greater. The largest organization advocating
the minority view that we are aware of is the National Association for
Research and Treatment of Homosexuality (NARTH). Their web site and
other sources claim a membership "approaching 1500." Publications by
ELCA authors break these 1500 members down into 1000 psychologists with
the other 500 made up of three groups: psychiatrists, other physicians,
and other mental health workers. Therefore, all categories of
membership in NARTH do not likely exceed 1% of either the total number
or of the individual groups. It is also worth noting that the World
Medical Association represents eight million physicians in eighty
countries and has an ethical statement on homosexuality similar to that
of the APA, ACP, and AMA.
Second, there is essentially no debate going on in the APA or AMA or
American College of Physicians (ACP) about the nature of homosexuality,
about whether committed unions between homosexual couples are to be
encouraged, or about the APA position on reparation therapy. The vast
majority of medical professionals are practicing an affirming and
nondiscriminatory stance toward gays and lesbians. Sexual promiscuity
is generally regarded as dangerous for the physical, mental, and
spiritual health of all persons no matter what their sex or the gender
mix. Essentially all the special medical problems of gays are
considered related to sexual promiscuity and the consequent sexually
transmitted diseases. Societal hostility to homosexuality and
objections to gay committed relationships are regarded as promoting
more than inhibiting gay promiscuity and the consequent adverse health
effects, partly because a committed relationship is considered the best
deterrent to promiscuity for most persons [36, 37]. A life of celibacy
or successful change in sexual orientation sufficient to make a
long-term opposite-sex committed relationship likely is regarded as a
realistic option for only a very small percentage of homosexual persons.
Third, a majority consensus does not mean all heterosexual physicians
have identical views about homosexuality. Some medical professionals
view homosexuality as something other than a normal variant. [38] But
these professionals, like all other physicians, cannot by policy
discriminate in major medical institutions or organizations against
other medical professionals or patients. There may be some different
individual views on homosexuality in the medical profession and some
covert discrimination in private offices but there are no prejudicial
policies. Medical school admission, specialty training eligibility,
hospital credentialing, and medical licensing policies make no
character or proficiency distinctions that treat homosexual and
heterosexual medical professionals differently [7]. If physicians are
found guilty by medical ethics boards of prejudicial actions against
homosexual patients, they are punished.
There may be a large minority or a majority in society and many
churches who view homosexuality as a condition that is something other
than a normal variant. However, in the medical and mental health
professions, available evidence indicates this difference is between a
large majority and a small minority (probably less than 5% in
individual theory and less than 1% in institutional practice).
The combined diagnostic declassification of homosexuality as a mental
disorder and the nondiscrimination resolution by the APA in 1974 were
based on sound clinical evidence and ethical concerns but still this
represented a bold and decisive advance in psychiatric thinking. This
change of judging homosexual persons as having no intrinsic impairments
as compared to heterosexuals has stood the test of time. For the past
25 years all major physician specialty organizations, hospitals, and
teaching institutions have had non-discrimination policies regarding
sexual orientation. Only a few in the medical profession seem to
question this policy or be disappointed by it. This attitude toward
homosexual persons has been adopted by other vocations and more and
more of U.S. society and culture.
This change in practice in the medical community has had a likely
significant impact on moving both other vocations and broader society
in the same direction of accepting homosexuality as a normal variant of
sexual desire and expression rather than a pathological disorder or a
unique sin. This reality, more than the present lack of definite proof
of a biological mechanism of the cause of homosexuality, is the best
proof that homosexuality is mostly inherent but not inherently bad.