Curing Gays

Today we're going to point the skeptical eye at therapies designed to convert homosexuals into heterosexuals. Such programs make headlines pretty frequently for their controversial nature, with proponents positioning it as an important spiritual or psychological healing, and opponents charging it with being misguided, unscientific, insulting, ineffective, and completely unnecessary. Some of the answers depend on your point of view, but others can be answered for certain with sound science.

This is one of those issues that has all sorts of philosophical, moral, and religious facets. Those are all valid debates, but here on Skeptoid, we leave those to others. Today we're going to focus on just the science. Is homosexuality truly a psychological condition that requires treatment? Can any of the existing treatments actually change sexual orientation? Has there been any meaningful success? There is actual science here, though it may be buried deep under a layer of ideological propaganda and misinformation; and understanding the true science is the best first step in forming opinions or policy.

The formal name of all such programs are Sexual Orientation Change Efforts (SOCE), and they include all kinds of different methods. There are psychological approaches including behavior therapy, hypnosis, conversion therapy, and support groups. There are religious approaches involving prayer or atonement. In the past, change efforts have included electroshock therapy, lobotomy, and a variety of surgical procedures to remove various parts of the genitalia on both men and women, including complete castration. Only relatively recently has homosexuality become legal, and even today it remains illegal in some countries. Punishment has been severe, ranging from execution, to chemical castration as was given to the father of computer science Alan Turing, to years of imprisonment and hard labor as was suffered by the poet Oscar Wilde.

Today, some groups still consider homosexuality to be a psychological illness, and others consider it to be a religious sin. So there are two basic directions from which change effort proponents come. The first, that homosexuality is an actual mental illness, was almost universally accepted, in nearly all countries, until quite recently. It was principally codified as such in Richard von Krafft-Ebing's 1886 book Psychopathia Sexualis, which influenced the psychological profession of the time to consider homosexuality a disease. It could either be acquired or innate. Von Krafft-Ebing found only limited treatment options, of limited effectiveness. As a Roman Catholic, von Krafft-Ebing's work was largely inspired by religious beliefs which held that any sexual activity leading to pregnancy was generally normal and healthy (even including rape), while any activity not leading to pregnancy (including homosexual sex, masturbation, or any recreational non-penetrating activity) was generally deviant and perverted.

This was the prevailing view until Sigmund Freud presented a differing opinion in the first half of the 20th century. Freud believed that everyone was naturally bisexual, with some tendencies toward both heterosexuality and homosexuality, one or the other usually dominating. He did not consider either to be an illness by itself, and most of his work with patients focused not on trying to change this cause but on helping patients deal with the resulting effects: confusion, self esteem, rejection, inhibitions, or unhappiness.

It wasn't until 1973 that the American Psychological Association (APA) voted to remove homosexuality from the DSM-II (Diagnostic and Statistical Manual of Mental Disorders). The DSM-III was given a section on ego-dystonic homosexuality, which is an inner conflict between one's attractions and one's own idealized self-image, and by 1986 even this was removed completely. Patients who have particular stress about their sexual orientation are now treated the same as any other patients who are under stress about something. This is now the standard in virtually all Western countries.

According to nearly all surveys, the vast majority of people who voluntarily seek sexual orientation change are white male Christians in the United States. The principal face of Christian change efforts is Exodus International, founded in the 1970s, with nearly 300 Protestant and evangelical ministries in some eighteen countries. When it began, its mission was to convert homosexuals into heterosexuals. Over the years they realized that this was a virtual impossibility (more on that in a moment), and so today they concentrate mainly on changing behavior; in other words, getting gays to simply act straight. They advocate celibacy for homosexuals, and heterosexual sex only for bisexuals. The Exodus mission statement is:

Mobilizing the body of Christ to minister grace and truth to a world impacted by homosexuality.

Exodus' primary method for changing behavior is something they call reparative therapy. According to their website, they believe that homosexuality is the result of the individual's unconscious attempts to restore a damaged relationship with his same-sex parent (97% of Exodus patients are men). Reparative therapy consists of forcing oneself to participate in manly activities, such as playing sports and hanging out with heterosexual men; flirting with and dating women in an assertive way, and avoiding them otherwise; and avoiding activities that Exodus considers to appeal to homosexuals, such as going to the opera or museums. In addition, joining a men's group at a Christian church is a fundamental of reparative therapy. One of Exodus' closest partners is the American Christian evangelical nonprofit Focus on the Family.

At least one prominent group promotes itself as a science-based professional organization of psychiatrists and psychologists who disagree with the APA's finding that homosexuality is not a mental disorder. NARTH, the National Association for Research & Therapy of Homosexuality, charges the APA with politicking and creating a hostile environment that discourages research into homosexuality as a disease. NARTH acts as a referral service for more than 1,000 member counselors, mostly church groups. NARTH does not require that its members be licensed therapists or doctors. NARTH also works closely with Focus on the Family. From these facts, and from a keyword search of their website and published biographies of their directors, it's hard to argue that NARTH is not a religiously motivated group, despite their omission of any overtly Christian objectives in their mission statement.

The overwhelming majority of psychological studies show that change efforts have never worked; however, both Exodus and NARTH link to a few cherrypicked studies in an effort to show that change efforts are successful. Chief among these is one by Dr. Robert Spitzer in 2001. It's a perfect example of how poorly conducted these studies are, and that it's one of the Exodus and NARTH favorites shows what a sparse field they have to work with. The main criticism is with Spitzer's methodology, a telephone survey of only 202 subjects, provided by Exodus. In fact, fully a fifth of the subjects were directors of Exodus International ministries. 100% of them were religious, nearly all Christian. The selection criteria was that all had undergone reparative therapy after self identifying as being previously gay — in other words, the only subjects chosen for the survey were those who already shown the effect the experimenter hoped to prove! If that's not enough, more than three quarters of the subjects had spoken in public in favor of sexual orientation change efforts. Among the questions was to self-report their own sexual orientation on a scale of to 1 to 7, 1 being fully heterosexual, 7 being fully homosexual. But amazingly, of the 202 subjects, only eight stated that their Exodus therapy took them from 5 or more to 3 or less, the only range that could reasonably be called a successful conversion. Of those eight, seven were Exodus ministry directors, and the eighth refused a followup interview. Yet Spitzer concluded from all of this that reparative therapy was effective. Spitzer's methodology and conclusions were roundly criticized, including directly by the APA itself. When it was finally published in 2003 by the Archives of Sexual Behavior, one of the journal's sponsoring associations, the International Academy of Sex Research, resigned because of the decision to publish.

Interestingly, there has been a tendency for some leaders of the major "gay cure" organizations to engage in homosexuality themselves. Two of Exodus International's founders, Michael Bussee and Gary Cooper, left the organization in 1979 to divorce their wives, and became a couple in a 1982 commitment ceremony. In 2010, a director of NARTH, Dr. George Reker, resigned after having been caught touring Europe with a hired male escort. Incidents like these show that at least some of the leadership of the organizations have been men with personal internal conflicts between Christianity and their own sexuality. We often consider former drug addicts to be well conditioned to be drug counselors, and it's perhaps equally appropriate for these men who have had their own issues to counsel other gay Christians. These incidents shouldn't surprise anyone; in fact, they probably shouldn't even be considered incidents. Relapsing is an expected consequence of many forms of counseling. It doesn't necessarily mean that the counseling itself is fundamentally flawed.

Neither does the religious nature of "gay cures" say anything about their effectiveness, and it's not a relevant line of investigation. Whether gays should seek change efforts, or whether homosexuality is sinful, are not science questions. To find out whether the change efforts work, we review the scientific research. And fortunately, that's already been done, in about as comprehensive a way as possible.

In 2007, under pressure from a growing evangelical movement promoting change efforts, the American Psychological Association announced the formation of a "Task Force on Appropriate Therapeutic Responses to Sexual Orientation" charged with assessing how best to deal with patients who express a desire to change their sexual orientation, and to evaluate the effectiveness of existing interventions. Their report was published in August of 2009. The abstract summarizes their conclusions:

...Efforts to change sexual orientation are unlikely to be successful and involve some risk of harm, contrary to the claims of SOCE practitioners and advocates. Even though the research and clinical literature demonstrate that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality, regardless of sexual orientation identity, the task force concluded that the population that undergoes SOCE tends to have strongly conservative religious views that lead them to seek to change their sexual orientation. Thus, the appropriate application of affirmative therapeutic interventions for those who seek SOCE involves therapist acceptance, support, and understanding of clients and the facilitation of clients' active coping, social support, and identity exploration and development, without imposing a specific sexual orientation identity outcome.

As anyone who lives and breathes has learned, trying to change people is nearly always destined for failure. There is no upside in changing from one person with one set of problems into a different person with a whole new set of problems; it usually just compounds all those problems together. Sexual orientation change efforts are no different. Recognizing their failure is neither pro-gay nor anti-gay, and it's neither pro-religion nor anti-religion. They simply don't work, and from the psychological data, they are both ill-advised and unnecessary. Many people face genuine problems and seek genuine interventions. For such people, we do have genuine psychological solutions that are proven to work. Trying to change who you are is not one of them.

Update: Exodus International has since shut down and apologized for its actions.

By Brian Dunning
Follow @BrianDunning