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Running Head: REPARATIVE THERAPY AND ETHICS
Ethical Considerations for Reparative Therapy for Christians Experiencing Same Sex Attraction
Aaron L. Norton
University of South Florida
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Abstract
This is a research review on ethical considerations related to reparative therapy (RT) for
Christians who experience same sex attraction. Thirty-two studies, research reviews, ethical
codes, and other professional sources published within the last 13 years were reviewed. Relevant
findings were summarized and conceptually organized under 4 of the 5 ethical principles in the
counseling field: (1) autonomy; (2) nonmalificience; (3) beneficience; and (4) fidelity. A brief
sample of positions taken by major counseling associations on ethical considerations for RT was
provided. The author concluded that RT proponents emphasize respect for the client’s autonomy
and the belief that RT benefits many clients psychologically and spiritually, whereas RT
opponents contend that RT is ineffective and causes harm to clients. The author further
concluded that research on potential benefit and harm is flawed due to biased sampling and
subjective measurement, suggesting the need for further research using randomized sampling and
objective forms of measurement.
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Introduction
Although Christian fundamentalism and, to a lesser extent, Christian orthodoxy tend to be
associated with negative attitudes towards homosexuality, there are a number of individuals who
identify themselves both as practicing Christians and as individuals attracted primarily to the
same or both sexes (Laythe et. al, 2002; Rowett et. al, 2006; Rodriguez & Ouellette, 2006; Yip,
2002). Although some Christian groups accept and embrace the sexual orientation of these
individuals (e.g. Soulforce, Evangelicals Concerned, Goodsoil, Dignity USA, Lutherans
Concerned, American Baptists Concerned, United Church of Christ General Synod, National
Council of the Churches of Christ), others do not accept the concept of homosexual orientation
(e.g. Focus on the Family, Evangelical Theological Society, American Family Association,
Human Life International, Southern Baptist Convention, Concerned Women for America,
Family Research Council). Some such Christian groups promote reparative, conversion, or
reorientation psychotherapy as an intervention for non-heterosexual orientation. Spitzer (2003)
defines reparative therapy (RT) as “therapy with the goal of helping their clients change their
sexual orientation from homosexual to heterosexual…Reparative therapists believe that samesex attractions reflect a developmental disorder and can be significantly diminished through
development of stronger and more confident gender identification” (p. 404). Throckmorton
(1998) defines conversion therapy as “therapy designed to effect a shift in sexual orientation” (p.
286). For purposes of this paper, RT will be used to describe therapy approaches aimed at
changing sexual orientation.
In the last 10 years, RT has emerged as a controversial form of therapy in the counseling
field. The primary concerns among counseling professionals center around ethical
considerations. Welfel (2001) identifies five fundamental ethical principles in counseling;
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respect for autonomy, nonmalificence, beneficience, justice, and fidelity. These five ethical
principles are incorporated into the ethical codes of several major counseling and psychological
associations, such as the American Counseling Association (ACA), American Psychological
Association (APA), National Association of Social Workers (NASW), and the Commission on
Rehabilitation Counselor Certification (CRCC) (American Psychological Association, 2002,
Commission on Rehabilitation Counselor Certification, 2001, American Counseling Association,
2005, National Association of Social Workers, 1999). Ethical considerations for RT can be
explored by examining its practice within the context of these five principles. This paper will
explore RT research and its implications for four of these five ethical principles; respect for
autonomy, nonmalificience, beneficience, and fidelity.
Respect for Autonomy
The APA incorporates self determination under Principle E, Respect for Peoples’ Rights
and Dignity, which stresses the elimination of work biases related to individual differences based
on age, gender, gender identity, race ethnicity, culture, national origin, religion, sexual
orientation, disability, language, and socioeconomic status. The CRCC ethical code requires
counselors to “honor the right to make individual choices” (CRCC, 2001; p. 4). Proponents of
RT often defend their counseling methods by citing this ethical principle (e.g. Yarhouse &
Throckmorton, 2002, Rosik, 2001, Rosik, 2003, Tozer & Hayes, 2004). If, they contend, a client
makes an informed decision to pursue a change in sexual orientation, then it may be unethical for
a counselor to prevent the client from pursuing that course. Of course, informed decision
requires that the client has the capacity to understand, has been informed of significant
information related to procedures, has consented freely and without undue influence, and that
consent has been appropriately documented (Welfel, 2001). Therefore, it behooves the
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counselor to provide a client with information on the potential harm and effectiveness associated
with RT prior to client consent.
Nonmalificience
The Hippocratic oath primum non nocere, or “first, do no harm,” is regarded by many
counseling professionals as the single most important ethical principle (Welfel, 2001). Many
opponents of RT base their objections on this ethical principle. Haldeman (1994) proposed that
RT reinforces an unjustifiable, prejudicial view of homosexuality that can contribute to
internalized shame. Subsequent research has produced evidence supporting Haldeman’s
proposition. Over a period of 5 years, Shidlo & Schroeder (2002) interviewed 202 individuals
who had engaged in RT. Eighty-seven percent of the participants reported perceptions that they
had failed to change their sexual orientation, while 13% reported that they had been successful.
Of those who reported success, nearly half of them were categorized as “successful but
struggling,” meaning they were still experiencing homosexual fantasies or engaged in
homosexual behaviors. Many participants reported symptoms of depression and anxiety and
suicidal ideations and attempts that they associated with their RT experiences. Their experiences
were often organized around themes of loneliness, social isolation, relationship deterioration,
loss of social supports, and developmental delays. Many participants recalled that RT therapists
tended to attribute homosexuality with pervasive dysfunction. Despite these findings, the study
can be criticized in 3 ways: (1) little description is given to how the participant sample was
selected; (2) due to the design of the study, the researchers were unable to report the number of
participants for many of the response themes; (3) proponents of RT can argue that difficulties
experienced by these participants were akin to difficulties experienced by alcoholics or drug
addicts in early recovery, complete with relapse, guilt, shame, and feelings of failure.
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Beckstead & Morrow (2004) interviewed 42 Mormon individuals recruited from
conversion and RT clinics and offices. Roughly half of the participants identified themselves as
proponents of RT and the other half as opponents of RT. Participants discussed both positive
experiences (i.e. feeling hope, getting answers, finding a place to fit in, enhanced non-sexual
same-sex relationships, assimilating sexuality into one’s value system, enhanced gender identity
and self-exploration) and negative experiences (false hopes and disappointments, increased selfhatred, decreased self-esteem, increased denial and emotional distress, dehumanization and being
untrue to self, increased depression and suicidality, lost loves and friendships, wasted time and
resources, a slowing down of the “coming-out” process, decreased capacity for same-sex
intimacy, lost faith and spirituality, increased anger towards family members, increased sexual
confusion, increased marital and family conflict connected to disappointments). Both opponent
and proponent participants discussed increased suicidality after therapy because of self hatred
linked to perceived failure in changing sexual orientation. (Interestingly, two nonparticipant
Mormon youth committed suicide during the interview process of the study.) RT opponents
discussed feelings of self hatred, guilt, and shame associated with the notion that
nonheterosexuality was wrong, deviant, unnatural, and abnormal, a core assumption of RT
proponents. Notably, the researchers utilized a qualitative rather than quantitative design,
thereby decreasing the predictive validity of their findings.
Rosik (2001) provided a counterargument, inferring that acceptance and promotion of
homosexual identity can potentially cause harm. Rosik summarized research suggesting an
association between homosexuality and psychological maladjustment. He then referenced some
studies suggesting potential for change in sexual orientation. For example, Nicolosi, Byrd, &
Potts (2000) interviewed 882 dissatisfied homosexual men and women, 726 of whom reported
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participation in RT. Participants from this study tended to report indicators of higher
psychological, spiritual, and interpersonal well-being. Therefore, Rosik reasoned, a ban on RT
could result in harm for some clients. However, the study’s participants were dissatisfied with
their orientation and were referred through RT and ex-gay groups, thus elevating the risk of
sampling and volunteer bias. Given the subjective nature of evaluation methods (i.e. participant
self-report), there is no guarantee that the participants were fully honest with themselves or the
researchers.
Beneficience and Fidelity
Beneficience refers to the responsibility of counselors to do good for their clients, and
fidelity, often equated with loyalty, refers to faithfulness to promises made and to the truth
(Welfel, 2001). RT proponents cite research defending the effectiveness and benefit of RT,
suggesting that RT therapists are faithful to their claims and their clients while also doing “good”
for their clientele by enhancing their sexual, psychological, and spiritual well-being. Nicolosi,
Byrd, & Potts (2000) found that 35% of participants who had engaged in RT reported a primarily
heterosexual attraction post-RT. At the surface, this finding may suggest a 35% success rate for
RT. However, only 89.7% of participants reported a primarily homosexual attraction prior to
RT, begging the question of whether or not the other 10.3% of respondents were part of the 35%
who reported a primarily heterosexual attraction post-RT. In addition, sampling methods were
suggestive of volunteer and sampling bias and the subjective self-report interview methods
present a concern for predictive validity.
Spitzer (2003) interviewed 200 participants reporting a sustained shift from primarily
homosexual attraction to primarily heterosexual attraction. However, reports of “complete
change” were uncommon. Spitzer concluded that either some gay men and lesbian women
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experience significant change in sexual orientation, “some gay men and women construct
elaborate self-deceptive narratives (or even lie) in which they claim to have changed their sexual
orientation” (p. 403), or some combination of the two exists. Unlike previous studies, Spitzer
employed a more thorough and structured interview process, used a relatively large sample size,
and measured interrater reliability, thus increasing face and content validity. However, the
majority of participants were referred to the study by The National Association for Research &
Therapy of Homosexuality (NARTH; the primary professional counseling organization that
promotes RT) and Exodus International (an ex gay ministry) and all participants were self
selected, suggesting sampling and volunteer bias. The study relied on subjective self report as an
assessment tool, resulting in potentially low predictive validity.
Opponents argue that RT is ineffective. Former RT clients who both oppose and support
RT have evaluated a variety of counseling methods as ineffective, such as chemical and
electroshock aversion therapies, behavioral management, orgasmic reconditioning, thought
stopping (i.e. snapping a rubber band on the wrist when experiencing homosexual or bisexual
fantasy), cognitive behavioral therapy techniques (i.e. thought mapping, disputation, reframing,
revising self talk), visual imagery, hypnosis, medicinal and hormonal treatments, marriage
counseling, rapid eye movement, obsessive compulsive disorder treatments, and chiropractic
treatments (Beckstead & Morrow, 2004). Spitzer’s 2003 study is cited with particular frequency
by RT proponents. However, Spitzer acknowledged that a number of misinterpretations have
been connected with his study in a videotaped documentary by Lutes (n.d.):
The individuals who went into my study were very motivated…If [change] were that
easy, there wouldn’t be many homosexuals left…It’s not something one chooses, and it’s
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something that’s very difficult to change. I’d imagine it’s relatively rare that they are
successful. (n.p.).
Spitzer also reported significant difficulty in locating 200 individuals who purported to have
changed as a result of RT and a belief that acceptance of homosexual identity is healthy.
Notably, the DVD was distributed by Soulforce, a pro-gay Christian advocacy organization.
Therefore, the source may be considered a biased one.
Consideration for Professional Consensus
Welfel (2001) presented a commonly practiced ethical decision-making model. Step
three of this model encourages counselors to refer to professional standards, and step five
encourages counselors to search out ethical scholarship. Exploration of ethical considerations
for RT may not be complete without a review of professional consensus on the issue. In general,
contemporary mental health professionals agree that sexual orientation is primarily biological
based, is relatively static, and resistant to change (e.g. American Psychiatric Association, n.d.;
Bem, 2000; Masters, Johnson, & Kolodyn, 1995; Quinsey, 2003, Santrock, 2001, United States
Department of Health and Human Services, 2001). If sexual orientation is an ingrained part of
the human psyche, then it follows that therapies aimed at altering sexual orientation risk
violation of ethical principles (Steigerwald & Janson, 2003). Consequentially, several
professional counseling organizations have aggressively criticized RT. The APA issued its
Resolution on Appropriate Therapeutic Responses to Sexual Orientation, affectively
discouraging RT:
Therefore be it further resolved that the American Psychological Association opposes
portrayals of lesbian, gay, and bisexual youth and adults as mentally ill due to their
sexual orientation and supports the dissemination of accurate information about sexual
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orientation, and mental health, and appropriate interventions in order to counteract bias
that is based in ignorance or unfounded beliefs about sexual orientation (APA, 1997).
The American Psychiatric Association, National Association of Social Workers, American
Counseling Association, American Academy of Pediatrics, American School Health Association,
and National Association of School Psychologists have issued similar resolutions and have
endorsed the statement, “…health and mental health professional organizations do not support
efforts to change young people's sexual orientation through ‘reparative therapy’ and have raised
serious concerns about its potential to do harm” (APA, n.d.; p. 6). To date, NARTH is the only
major professional counseling organization that endorses RT. NARTH’s first position statement
reads:
NARTH respects each client's dignity, autonomy and free agency. We believe that clients
have the right to claim a gay identity, or to diminish their homosexuality and to develop
their heterosexual potential. The right to seek therapy to change one's sexual adaptation
should be considered self-evident and inalienable (NARTH, 2006; n.p.).
Although professional consensus does not exclusively dictate ethical practices, it is a significant
factor to consider when assessing an ethical dilemma (Welfel, 2001).
Discussion
This paper focused on ethical criticisms of and justifications for RT based on 4 ethical
principles; respect for autonomy, nomalficience, beneficience, and fidelity. To more thoroughly
explore this issue, the reader is encouraged to research RT from the perspective of the ethical
principle of justice, a topic beyond the scope of this paper. In addition, exploration of this issue
should not be considered complete without considering the ethical implications for RT’s
counterparts; acceptance of personal sexual orientation and the “coming out” process. A
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comparison of ethical implications for both of these approaches should be considered when
assisting clients with an informed decision concerning RT, an exploration that is beyond the
scope of this paper.
Research on ethical considerations for RT has identified two schools of thought. RT
proponents support RT based on respect for the client’s autonomy, the belief that homosexual
identity is maladaptive and harmful for some people, and the belief that RT can improve
psychological and spiritual well-being. Opponents of RT argue that RT has been demonstrated
to be relatively ineffective and harmful and operates under a prejudicial and errant viewpoint that
homosexual orientation is maladaptive and psychologically unhealthy. A large number of
individuals who experience same sex attraction and engage in RT report significant harm or, at
the least, perceived failure. On the other hand, some individuals engaged in RT report
significant benefit.
Despite the recent increase in RT research, existing study designs have lacked controls,
sampling methods, and objective evaluation methods (e.g. penile plethysmograph, thermography,
positron emission tomography) needed to adequately assess sexual arousal and the efficacy of
RT. Ethical considerations (e.g. potential for causing harm to participants in an experimental RT
group), ambiguity about what constitutes change in sexual orientation, and suspicion,
defensiveness, and privacy concerns among RT proponents may be factors affecting this trend.
Researchers have focused on subjective and potentially biased and unreliable self-reports of RT
participants (Haldeman, 2002). Individuals who are dissatisfied with their sexual self
understanding and who are engaged in RT are typically religious Christians. Some incentives for
a heterosexual identity include relief from cognitive dissonance; reconciliation of sexual self
understanding and deeply rooted religious, philosophical, and moral beliefs and values; approval
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and support from the community, religious institutions, family, and friends; increased societal
acceptance and inclusion; internalized homophobia; and the promise of a more secure afterlife
(Tozer & Hayes, 2004, Haldeman, 1994, Haldeman, 2002, Morrow & Beckstead, 2004,
Rodriguez & Ouellette, 2000). In some studies, participants were essentially “hand-picked” by
RT and ex-gay proponents. It is therefore possible, if not probable, that sampling techniques
utilized in RT research have adversely affected validity of the findings. Given these flaws in
existing RT research, studies with more valid and reliable experimental designs may yield more
results more conducive to exploring RT from an ethical perspective.
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