Conversion therapy

Conversion therapy (also known as reparative therapy) is a range of pseudo-scientific treatments that aim to change sexual orientation from homosexual to heterosexual. Conversion therapy has been a source of intense controversy in the United States and other countries. The American Psychiatric Association has condemned "psychiatric treatment, such as reparative or conversion therapy which is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his/her sexual homosexual orientation." It states that, "Ethical practitioners refrain from attempts to change individuals' sexual orientation." It also states that political and moral debates over the integration of gays and lesbians into the mainstream of American society have obscured scientific data about changing sexual orientation "by calling into question the motives and even the character of individuals on both sides of the issue."

The highest-profile contemporary advocates of conversion therapy tend to be fundamentalist Christian groups and other right-wing religious organizations. The main organization advocating secular forms of conversion therapy is the National Association for Research & Therapy of Homosexuality (NARTH), which often partners with religious groups. Psychologist Douglas Haldeman writes that conversion therapy comprises efforts by mental health professionals and pastoral care providers to convert lesbians and gay men to heterosexuality by techniques including aversive treatments, such as "the application of electric shock to the hands and/or genitals," and "nausea-inducing drugs...administered simultaneously with the presentation of homoerotic stimuli," masturbatory reconditioning, visualization, social skills training, psychoanalytic therapy, and spiritual interventions, such as "prayer and group support and pressure."

American medical and scientific organizations have expressed concern over conversion therapy and consider it potentially harmful. The advancement of conversion therapy may cause social harm by disseminating inaccurate views about sexual orientation.

The ethics guidelines of major mental health organizations in the United States vary from cautionary statements to recommendations that ethical practitioners refrain from practicing conversion therapy (American Psychiatric Association) or from referring patients to those who do (American Counseling Association). In a letter dated February 23, 2011 to the Speaker of the U.S. House of Representatives, the Attorney General of the United States stated "while sexual orientation carries no visible badge, a growing scientific consensus accepts that sexual orientation is a characteristic that is immutable".

In 2012, the Pan American Health Organization (the North and South American branch of the World Health Organization) released a statement cautioning against services that purport to "cure" people with non-heterosexual sexual orientations as they lack medical justification and represent a serious threat to the health and well-being of affected people, and noted that the global scientific and professional consensus is that homosexuality is a normal and natural variation of human sexuality and cannot be regarded as a pathological condition. The Pan American Health Organization further called on governments, academic institutions, professional associations and the media to expose these practices and to promote respect for diversity. The World Health Organization affiliate further noted that gay minors have sometimes been forced to attend these "therapies" involuntarily, being deprived of their liberty and sometimes kept in isolation for several months, and that these findings were reported by several United Nations bodies. Additionally, the Pan American Health Organization recommended that such malpractices be denounced and subject to sanctions and penalties under national legislation, as they constitute a violation of the ethical principles of health care and violate human rights that are protected by international and regional agreements.

History
Legal scholar Kenji Yoshino argues that the history of conversion therapy can be divided broadly into three phases: an early Freudian period, a period of mainstream approval of conversion therapy during a time when the mental health establishment became the "primary superintendent" of sexuality, and a post-Stonewall period wherein the mainstream medical profession disavowed conversion therapy.

During the earliest parts of psychoanalytic history, analysts granted that homosexuality was non-pathological in certain cases, and the ethical question of whether it ought to be changed was discussed. By the 1920s psychoanalysts assumed that homosexuality was pathological and that attempts to treat it were appropriate, although psychoanalytic opinion about changing homosexuality was largely pessimistic. Those forms of homosexuality that were considered perversions were usually held to be uncurable. Psychoanalysts‘ tolerant statements about homosexuality arose from recognition of the difficulty of achieving change. Beginning in the 1930s and continuing for roughly twenty years, major changes occurred in how psychoanalysts viewed homosexuality, which involved a shift in the rhetoric of psychoanalysts, some of whom felt free to ridicule and abuse their gay patients.

Sigmund Freud


Sigmund Freud was a physician and the founder of psychoanalysis. Freud stated that homosexuality could sometimes be removed through hypnotic suggestion, and was influenced by Eugen Steinach, a Viennese endocrinologist who transplanted testicles from straight men into gay men in attempts to change their sexual orientation, stating that his research had “thrown a strong light on the organic determinants of homo-eroticism”. Freud cautioned that Steinach's operations would not necessarily make possible a therapy that could be generally applied, arguing that such transplant procedures would be effective in changing homosexuality in men only in cases in which it was strongly associated with physical characteristics typical of women, and that probably no similar therapy could be applied to lesbianism. In fact Steinach’s method was doomed to failure because the immune system rejects transplanted glands, and was eventually exposed as ineffective and often harmful.

Freud‘s main discussion of female homosexuality was the 1920 paper “The Psychogenesis of a Case of Homosexuality in a Woman“, which described his analysis of a young woman who had entered therapy because her parents were concerned that she was a lesbian. Her father wanted this condition changed. In Freud‘s view, the prognosis was unfavourable because of the circumstances under which she entered therapy, and because homosexuality was not an illness or neurotic conflict. Freud wrote that changing homosexuality was difficult and possible only under unusually favourable conditions, observing that “in general to undertake to convert a fully developed homosexual into a heterosexual does not offer much more prospect of success than the reverse.” Success meant making heterosexual feeling possible, not eliminating homosexual feelings.

Gay people could seldom be convinced that heterosexual sex would provide them with the same pleasure they derived from homosexual sex. Patients often wanted to become heterosexual for reasons Freud considered superficial, including fear of social disapproval, an insufficient motive for change. Some might have no real desire to become heterosexual, seeking treatment only to convince themselves that they had done everything possible to change, leaving them free to return to homosexuality after the failure they expected. Freud therefore told the parents only that he was prepared to study their daughter to determine what effects therapy might have. He eventually broke off the treatment entirely because of what he saw as her hostility to men.

In 1935, a mother asked Freud to treat her son. Freud replied in a letter that later became famous:

""I gather from your letter that your son is a homosexual...it is nothing to be ashamed of, no vice, no degradation; it cannot be classified as an illness; we consider it to be a variation of the sexual function, produced by a certain arrest of sexual development. By asking me if I can help [your son], you mean, I suppose, if I can abolish homosexuality and make normal heterosexuality take its place. The answer is, in a general way we cannot promise to achieve it. In a certain number of cases we succeed in developing the blighted germs of heterosexual tendencies, which are present in every homosexual; in the majority of cases it is no more possible. It is a question of the quality and the age of the individual. The result of treatment cannot be predicted.""

Isidor Sadger
Isidor Sadger published “Fragment der Psychoanalyse eines Homosexuellen” in the Jahrbuch fuer sexuellen Zwischenstufen in 1908. It described his analysis of a melancholy Danish count who was homosexual. The analysis lasted for only thirteen days before being terminated by the patient, whose sexual orientation was not changed. Later in 1908, Sadger published “Ist der Kontraere sexual Empfindung heilbar?”, which assessed the value of psychoanalysis as a treatment for “contrary sexual feeling“, in the Zeitschrift fuer Sexualwissenschaft. He answered the question of whether it could be cured in patients who were moral and determined “mit einem runden Ja!“ (“with a round Yes!“). Sadger believed that it was not enough to establish a spurious kind of heterosexual functioning or “masturbatio per vaginam”, wanting instead to change a patient’s “Sexualideal”, the internal image of his sexual object.“

Sadger supported his claim that homosexuality could be cured entirely by describing a four month analysis of a patient whose crucial memories “had been wholly unconscious and first had to be unearthed very laboriously through a month-long analysis.“ Making striking claims about homosexuality on the basis of brief analyses appears to have been typical for psychoanalysts in the early 20th century. The material Sadger’s patients produced appears to have been influenced by his expectations. Sadger permitted his patients to engage in homosexual activity during treatment because of his belief that "behind it, a heterosexual can again be found."

Magnus Hirschfeld, a physician and the leader of the gay rights movement in Germany in the early 20th century, argued that the purpose of therapy should be to permit clients to accept their homosexuality, but accepted that gay men had the right to attempt to change their sexual orientation if they wished and therefore sometimes recommended them to Sadger. Hirschfeld believed that the failure of attempts to change homosexuality through psychoanalysis proved that it was biologically innate.

Felix Boehm
German psychoanalysts who wrote about homosexuality included Felix Boehm. He accepted Freud’s earlier theory of homosexuality involving boys’ identification with their mothers and consequent narcissistic object choice. His major work was a four-part series on homosexuality published in the Internationale Zeitschrift fuer Psychoanalyse between 1920 and 1933. It attempted to present and illustrate the most up to date psychoanalytic thinking on homosexuality. In Boehm’s view, curing homosexuality meant making enjoyable heterosexual functioning possible rather than eliminating homosexual behavior. Boehm claimed to have cured gay people in the fourth part of his series on homosexuality, but presented as proof a case in which “the homosexuality never became conscious for the patient and had never expressed itself in manifest activity.” This patient does not appear to have been homosexual. Boehm claimed that manifest homosexuals regularly abandoned treatment out of hatred for their analysts just at the point when they were close to achieving heterosexual functioning. Boehm criticised Sadger’s Die Lehre von den Geschlechtsverwirrugen ... auf psychoanalytischer Grundlage for its brief analyses, many of which lasted only weeks or months.

Sándor Ferenczi
Sándor Ferenczi was an influential psychoanalyst. Native to Hungary, he wrote many of his works in German.

Ferenczi denied the importance of inherited factors on homosexuality, claiming that it was caused by “excessively powerful heterosexuality (intolerable to the ego)“. Ferenczi tried to distinguish between several different types of homosexuality, basing his distinctions on an unspecified number of patients whose analyses had sometimes lasted for a short period and sometimes “a whole year and even longer.” Ferenczi hoped to cure some kinds of homosexuality completely, but was content in practice with reducing what he considered gay men's hostility to women, along with the urgency of their homosexual desires, and with helping them to become attracted to and potent with women. In his view, a gay man who was confused about his sexual identity and felt himself to be “a woman with the wish to be loved by a man” was not a promising candidate for cure. Ferenczi believed that complete cures of homosexuality might become possible in the future when psychoanalytic technique had been improved. Sándor Radó and Melanie Klein were pupils of Ferenczi.

Anna Freud
Daughter of Sigmund Freud, Anna Freud became an influential psychoanalytic theorist in the UK after she left Austria in 1938 to escape the Nazis.

Anna Freud reported the successful treatment of homosexuals as neurotics in a series of unpublished lectures. In 1949 she published “Some Clinical Remarks Concerning the Treatment of Cases of Male Homosexuality” in the International Journal of Psychoanalysis. In her view, it was important to pay attention to the interaction of passive and active homosexual fantasies and strivings, the original interplay of which prevented adequate identification with the father. The patient should be told that his choice of a passive partner allows him to enjoy a passive or receptive mode, while his choice of an active partner allows him to recapture his lost masculinity. She claimed that these interpretations would reactivate repressed castration anxieties, and childhood narcissistic grandiosity and its complementary fear of dissolving into nothing during heterosexual intercourse would come with the renewal of heterosexual potency.

Anna Freud in 1951 published “Clinical Observations on the Treatment of Male Homosexuality” in Psychoanalytic Quarterly and “Homosexuality” in the American Psychoanalytic Association Bulletin. These articles insisted on the attainment of full object-love of the opposite sex as a requirement for cure of homosexuality. In 1951 she gave a lecture about treatment of homosexuality which was criticised by Edmund Bergler, who emphasised the oral fears of patients and minimized the importance of the phallic castration fears she had discussed.

Anna Freud recommended in 1956 to a journalist who was preparing an article about psychoanalysis for the London Observer that she not quote Freud‘s letter to the American mother, on the grounds that “...nowadays we can cure many more homosexuals than was thought possible in the beginning. The other reason is that readers may take this as a confirmation that all analysis can do is to convince patients that their defects or ‘immoralities‘ do not matter and that they should be happy with them. That would be unfortunate.”

Melanie Klein
The Austrian-born psychoanalyst Melanie Klein moved to London in 1926. Her seminal book The Psycho-Analysis of Children, based on lectures given to the British Psychoanalytic Society in the 1920s, was published in 1932. Klein claimed that entry into the Oedipus Complex is based on mastery of primitive anxiety from the oral and anal stages. If these tasks are not performed properly, developments in the Oedipal stage will be unstable. Complete analysis of patients with such unstable developments would require uncovering these early concerns. The analysis of homosexuality required dealing with paranoid trends based on the oral stage. The Psycho-Analysis of Children ends with the analysis of Mr. B., a gay man. Klein claimed that he illustrated pathologies that enter into all forms of homosexuality: a gay man idealizes “the good penis” of his partner to allay the fear of attack he feels due to having projected his paranoid hatred onto the imagined “bad penis“ of his mother as an infant. She stated that Mr. B.’s homosexual behaviour diminished after he overcame his need to adore the “good penis” of an idealized man. This was made possible by his recovering his belief in the good mother and his ability to sexually gratify her with his good penis and plentiful semen.

Edmund Bergler
Edmund Bergler’s first contribution to the psychoanalytic theory of homosexuality was “Der Mammakomplex des Mannes“, an article co-authored with L. Eidelberg and published in the Internationale Zeitschrift fuer Psychoanalyse in 1933. It described a “breast complex“ found in both normal and pathological conditions, among which Eidelberg and Bergler included “a type of homosexuality.” The male child reacts violently to weaning, making unsuccessful attempts to inhibit his frustrated aggression that only heighten it. This causes ambivalent identifications, object choices, and narcissistic compensations. Cathexes are displaced from the breast onto the penis, and the infant substitutes urine for milk, attempting to make active what was once passive. He unsuccessfully tries to transfer hatred of the mother onto the father, but the Oedipus complex does not reach normal intensity because of the unresolved ambivalence of the oral period. The unstable organization achieved at the Oedipal period regresses to an earlier stage involving fixation on the oral mother, whose vagina is conflated with the infant‘s own cannibalistic mouth, transmuting it into the vagina dentata. This oral fixation leads to character traits such as spite and libido charged with aggression.

J. Vinchon and Sacha Nacht
J. Vinchon and Sacha Nacht in 1929 published "Considerations sur la cure psychoanalytique d’une nevrose homosexuelle" in Revue francaise de psychoanalyse. This article divided gay people into three categories: those with glandular abnormalities, sexual perverts, and neurotics. Vinchon and Nacht believed that gay people in the second category (who were "comfortably settled in [their] vice") were incurable.

Daniel Lagache
Daniel Lagache in 1950 published “Homosexuality and Jealousy” in the International Journal of Psychoanalysis. It described the analysis of a gay man, illustrating the relation of active and passive forms of homosexuality and the defensive maneuvers that mediate between them. The patient shifted from homosexual to heterosexual interests, and experienced a stage of intense jealousy that Lagache regarded as both a sign of progress and a resistance. The heterosexual interest was a new defense against passive homosexuality, while active homosexuality had been his old defense. Passive homosexuality was intolerable to the patient because it was associated with castration, but it was deeply rooted in his psychology because “submission and obedience to the father [had] as their aim the right to take his place.”

20th century
Psychoanalysis started to receive recognition in the United States in 1909, when Sigmund Freud delivered a series of lectures at Clark University in Massachusetts at the invitation of G. Stanley Hall.

Abraham Brill in 1913 wrote “The Conception of Homosexuality”, which he published in the Journal of the American Medical Association and read before the American Medical Association’s annual meeting, where it was criticised by several doctors. Brill declared that after long study he had slowly overcome his disgust for homosexuality. He denied that homosexuality was influenced by inherited factors or necessarily related to emotional disturbance. Brill observed that it was impossible to use the term homosexuality diagnostically, since it could refer to several different entities. Brill asserted that the development of sexual attraction to the same sex was always related to narcissism, which he incorrectly defined as love for one‘s self. Brill criticised physical treatments for homosexuality such as bladder washing, rectal massage, and castration, along with hypnosis, but referred approvingly to Freud and Sadger's use of psychoanalysis, calling its results “very gratifying.“ Since Brill understood curing homosexuality as restoring heterosexual potency, he claimed that he had cured his patients in several cases, even though many remained homosexual.

Dr. Wilhelm Stekel, an Austrian, published his views on treatment of homosexuality, which he considered a disease, in the American Psychoanalytic Review in 1930. Stekel believed that “success was fairly certain“ in changing homosexuality through psychoanalysis provided that it was performed correctly and the patient wanted to be treated. In 1932, the Psychoanalytic Quarterly published a translation of Dr. Helene Deutsch's paper “On Female Homosexuality“. Deutsch reported her analysis of a lesbian, who did not become heterosexual as a result of treatment, but who managed to achieve a "positive libidinal relationship" with another woman. Deutsch indicated that she would have considered heterosexuality a better outcome.

Dr. La Forest Potter of New York City published Strange Loves: A Study in Sexual Abnormalities, which focused on homosexuality, in 1933, probably to exploit the interest in the subject generated by the American publication of Radclyffe Hall’s novel The Well of Loneliness and Blair Niles’s Strange Brother. He believed that homosexuality was caused by psychological and hormonal disturbances, and that it could be cured if the patient wanted to change. Potter advocated a mixture of psychoanalysis and hormone treatment. He believed that marriage might help to alter lesbianism in cases in which it was not hereditary. Potter described his treatment of two lesbians, stating that it was unsuccessful in one case but successful in the other. He stated that he had successfully cured a young man of homosexuality.

Edmund Bergler moved to the USA after vacating his post as psychoanalyst in Vienna in 1937. He published “Preliminary Phases of the Masculine Beating Fantasy“, a response to Freud‘s “A Child Is Being Beaten“, in Psychoanalytic Quarterly in 1938. Bergler claimed to have detected the early phase of a beating fantasy in boys. This phase began with the weaning shock, which mobilizes enormous sadistic rage against the breasts of the depriving phallic mother, which is an attempt at narcissistic restitution for the lost breasts of the mother. Due to guilt, this rage is transmuted into a masochistic fantasy of being beaten by the father, substituting the boy’s own buttocks for the mother’s breasts and idealizing the father out of hatred of the mother, thereby substituting a homosexual for a heterosexual bond. The paper shifted the important stage in the development of homosexual perversion back from the Oedipus complex to the oral stage, minimized the importance of object libido and emphasised more primitive narcissistic oral rage, and established that homosexual perversion could not be based on a primary homosexual attachment to the father, since there was always an earlier heterosexual attachment to the mother. The implication was that all outcomes of the Oedipus complex involving a passive homosexual stance toward the father are perverse.

Bergler was the most important psychoanalytic theorist of homosexuality in the 1950s. He was vociferous in his opposition to Alfred Kinsey, who argued that homosexuality was normal human variation. Bergler argued that Kinsey's statistical research overestimated the incidence of homosexuality because it was conducted in cities where perversion thrived. Bergler based his theories partly on analysis of the novels of literary figures known to be gay. Kinsey's work, and its reception, led Bergler to develop his own theories for treatment, which were essentially to 'blame the victim'.

Bergler claimed that if gay people wanted to change, and the right therapeutic approach was taken, then they could be cured in 90% of cases. Bergler used confrontational therapy in which gay people were punished in order to make them aware of their masochism. Bergler openly violated professional ethics to achieve this, breaking patient confidentiality in discussing the cases of patients with other patients, bullying them, calling them liars and telling them they were worthless. He insisted that gay people could be cured, and that if they believed they should be accepted, they were asking for punishment, which confirmed their pathological immaturity. Bergler initially blamed those who mistreated gay people, because it provided a rationale for the masochistic view of the world; but, from the 1950s, and following the emergence of gay rights organisations, he began to blame homosexuals for their own oppression. Bergler confronted Kinsey because Kinsey thwarted the possibility of cure by presenting homosexuality as an acceptable way of life, which was the basis of the homosexual rights activism of the time. Bergler popularised his views on homosexuality and its cure in the USA in the 1950s using magazine articles and books aimed at non-specialists.

In 1951, the mother who wrote to Freud asking him to treat her son sent Freud's response to the American Journal of Psychiatry, in which it was published. The 1952 first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-I) classified homosexuality as a mental disorder.

During the three decades between Freud's death in 1939 and the Stonewall riots in 1969, conversion therapy received approval from most of the psychiatric establishment in the United States. Sandor Rado in 1940 criticized Freud's theory of innate bisexuality in his article "A Critical Examination of the Concept of Bisexuality". Rado concluded that pursuing the genital organs of the opposite sex is the standard form of achieving genital stimulation and that the main cause of homosexuality is anxiety, although he granted that "constitutional factors may have an influence on morbid sex developments." Rado‘s article appears to have been partly motivated by the desire to combat homosexuality.

The homosexuality as sickness theory started to come under criticism in the 1950s. Evelyn Hooker in 1957 published “The Adjustment of the Male Overt Homosexual”, which found that "homosexuals were not inherently abnormal and that there was no difference between homosexual and heterosexual men in terms of pathology." This paper subsequently became influential. Irving Bieber and his colleagues in 1962 published Homosexuality: A Psychoanalytic Study of Male Homosexuals, which concluded that "although this change may be more easily accomplished by some than by others, in our judgment a heterosexual shift is a possibility for all homosexuals who are strongly motivated to change." The same year, Albert Ellis published Reason and Emotion in Psychotherapy, which claimed that "fixed homosexuals in our society are almost invariably neurotic or psychotic:... therefore, no so-called normal group of homosexuals is to be found anywhere." Ellis published his main work on homosexuality, Homosexuality: Its Causes and Cure, in 1965.



Charles Socarides’s first book, The Overt Homosexual, was published in 1968. Socarides regarded homosexuality as an illness arising from a conflict between the id and the ego usually arising from an early age in "a female-dominated environment wherein the father was absent, weak, detached or sadistic". He credited the earlier work of Irving Bieber with clarifying progress in therapeutic knowledge and effectivenes.

There was a riot in 1969 at the Stonewall Bar in New York after a police raid. The Stonewall riot acquired symbolic significance for the gay rights movement and came to be seen as the opening of a new phase in the struggle for gay liberation. Following these events, conversion therapy came under increasing attack. Activism against conversion therapy increasingly focused on the DSM's designation of homosexuality as a psychopathology.

Lawrence Hatterer in 1970 published Changing Homosexuality in the Male, which advocated a therapy based on simplified psychoanalytic ideas and behavior modification techniques.

In 1973, after years of criticism from gay activists and bitter dispute among psychiatrists, the American Psychiatric Association removed homosexuality as a mental disorder from the Diagnostic and Statistical Manual of Mental Disorders. Supporters of the change used evidence from researchers such as Alfred Kinsey and Evelyn Hooker. Psychiatrst Robert Spitzer, a member of the APA's Committee on Nomenclature, played an important role in the events that lead to this decision. Critics argued that it was a result of pressure from gay activists, and demanded a referendum among voting members of the Association. The referendum was held in 1974 and the APA’s decision was upheld by a 58% majority.

Books promoting new forms of conversion therapy were published in the 1980s. Robert Kronemeyer in 1980 published Overcoming Homosexuality, while research psychologist Elizabeth Moberly in 1983 published Homosexuality: A New Christian Ethic.

The APA removed ego-dystonic homosexuality from the DSM-III-R in 1987 and opposes the diagnosis of either homosexuality or ego-dystonic homosexuality as any type of disorder.

Joseph Nicolosi began playing an important role in the development of conversion therapy in the early 1990s, publishing his first book Reparative Therapy of Male Homosexuality in 1991. In 1992, Joseph Nicolosi, Charles Socarides, and Benjamin Kaufman founded the National Association for Research & Therapy of Homosexuality (NARTH), a mental health organization that opposes the mainstream medical view of homosexuality and aims to "make effective psychological therapy available to all homosexual men and women who seek change." Former American Psychological Association President Dr. Nicholas Cummings was the Keynote Speaker at the 2011 NARTH Conference and said that he had a "high regard" for NARTH and considered it an honor to be invited to speak at NARTH's scientific gathering.

21st century
United States Surgeon General David Satcher in 2001 issued a report stating that "there is no valid scientific evidence that sexual orientation can be changed". The same year, a study by Robert Spitzer concluded that some highly motivated individuals whose orientation is predominantly homosexual can become predominantly heterosexual with some form of reparative therapy. Spitzer based his findings on structured interviews with 200 self-selected individuals (143 males, 57 females). He told The Washington Post that the study "shows some people can change from gay to straight, and we ought to acknowledge that." Spitzer's study caused controversy and attracted media attention. Spitzer recanted his study in 2012, and apologized to the gay community for making unproven claims of the efficacy of reparative therapy, calling it his only professional regret.  gIifMxPcRnI  The American Psychoanalytic Association (APsaA) spoke against NARTH in 2004, stating "that organization does not adhere to our policy of nondiscrimination and ... their activities are demeaning to our members who are gay and lesbian." NARTH believes that it is discriminatory and unethical to ignore the needs and goals of people who do not wish to be gay. In 2006, Focus on the Family and several other organizations announced that they would protest the American Psychological Association's convention in New Orleans. Mike Haley, the director of gender issues for Focus on the Family, commented that, "The APA's views on issues such as the immutability of homosexuality have caused real harm to real people and patients." The same year, a survey of members of the American Psychological Association rated reparative therapy as "certainly discredited", though the authors warn that the results should be interpreted carefully as an initial step, not a final word.

The American Psychological Association in 2007 convened a task force to evaluate its policies regarding reparative therapy; ex-gay organizations expressed concerns about the lack of representation of pro-reparative-therapy perspectives on the task force, while alleging that anti-reparative-therapy perspectives were amply represented.

In 2008, the organizers of an APA panel on the relationship between religion and homosexuality canceled the event after gay activists objected that "conversion therapists and their supporters on the religious right use these appearances as a public relations event to try and legitimize what they do."

In 2009, American Psychological Association stated that it "encourages mental health professionals to avoid misrepresenting the efficacy of sexual orientation change efforts by promoting or promising change in sexual orientation when providing assistance to individuals distressed by their own or others’ sexual orientation and concludes that the benefits reported by participants in sexual orientation change efforts can be gained through approaches that do not attempt to change sexual orientation".

Behavioral modification
Douglas Haldeman writes in "Sexual Orientation Conversion Therapy for Gay Men and Lesbians: A Scientific Examination" that early behavioral forms of conversion therapy mainly employed aversive conditioning techniques, involving electric shock and nausea-inducing drugs during presentation of same-sex erotic images. Cessation of the aversive stimuli was typically accompanied by the presentation of opposite-sex erotic images, with the objective of strengthening heterosexual feelings. Haldeman discusses the work of M. P. Feldman, who in "Aversion therapy for sexual deviation: a critical review", published in 1966, claimed a 58% cure rate. Haldeman is skeptical that such stressful methods permit feelings of sexual responsiveness, and notes that Feldman defined success as suppression of homosexuality and increased capacity for heterosexual behavior.

Haldeman also discusses the covert sensitization method, which involves instructing patients to imagine vomiting or receiving electric shocks, writing that only single case studies have been conducted, and that their results cannot be generalized. He writes that behavioral conditioning studies tend to decrease homosexual feelings, but do not increase heterosexual feelings, citing Rangaswami's "Difficulties in arousing and increasing heterosexual responsiveness in a homosexual: A case report", published in 1982, as typical in this respect.

Haldeman concludes that such methods applied to anyone except gay people would be called torture, writing, "Individuals undergoing such treatments do not emerge heterosexually inclined; rather they become shamed, conflicted, and fearful about their homosexual feelings."

Haldeman writes in "Gay Rights, Patient Rights: The Implications of Sexual Orientation Conversion Therapy" that aversive treatments sometimes involved the application of electric shock to the hands and/or genitals, or nausea-inducing drugs, administered simultaneously with the presentation of homoerotic stimuli, while less cruel methods included masturbatory reconditioning, visualization, and social skills training. All of these methods were based on the idea that homosexuality is a learned behavior that can be reconditioned.

Ex-gay ministry


Some sources describe ex-gay ministries as a form of conversion therapy, while others state that ex-gay organizations and conversion therapy are distinct methods of attempting to convert gay people to heterosexuality. Ex-gay ministries have also been called transformational ministries. Some state that they do not conduct clinical treatment of any kind. Exodus International once believed reparative therapy could be a beneficial tool, but ceased activities in June 2013, issuing a statement which repudiated its aims and apologized for the harm their pursuit has caused to LGBT people. Evergreen International states that it is unlikely therapy can erase all homosexual feelings, and does not advocate any particular form of therapy.

Psychoanalysis
Douglas Haldeman writes that psychoanalytic treatment of homosexuality is exemplified by the work of Irving Bieber and his colleagues in Homosexuality: A Psychoanalytic Study of Male Homosexuals. They advocated long-term therapy aimed at resolving the unconscious childhood conflicts that they considered responsible for homosexuality. Haldeman notes that Bieber's methodology has been criticized because it relied upon a clinical sample, the description of the outcomes was based upon subjective therapist impression, and follow-up date were poorly presented. Bieber reported a 27% success rate from long-term therapy, but only 18% of the patients in whom Bieber considered the treatment successful had been exclusively homosexual to begin with, while 50% had been bisexual. In Haldeman's view, this makes even Bieber's unimpressive claims of success misleading.

Haldeman discusses other psychoanalytic studies of attempts to change homosexuality. Curran and Parr's "Homosexuality: An analysis of 100 male cases", published in 1957, reported no significant increase in heterosexual behavior. Mayerson and Lief's "Psychotherapy of homosexuals: A follow-up study of nineteen cases", published in 1965, reported that half of its 19 subjects were exclusively heterosexual in behavior four and a half years after treatment, but its outcomes were based on patient self-report and had no external validation. In Haldeman's view, those participants in the study who reported change were bisexual at the outset, and its authors wrongly interpreted capacity for heterosexual sex as change of sexual orientation.

Reparative therapy
Reparative therapy has been used as a synonym for conversion therapy generally, but Jack Drescher has argued that strictly speaking it refers to a specific kind of therapy associated with Elizabeth Moberly and Joseph Nicolosi. Joseph Nicolosi's Reparative Therapy of Male Homosexuality, published in 1991, introduced reparative therapy as a term for psychotherapeutic attempts to convert gay people to heterosexuality.

Douglas C. Haldeman writes that Nicolosi promotes psychoanalytic theories suggesting that homosexuality is a form of arrested psychosexual development, resulting from "an incomplete bond and resultant identification with the same-sex parent, which is then symbolically repaired in psychotherapy". Nicolosi’s intervention plans involve conditioning a man to a traditional masculine gender role. He should "(1) participate in sports activities, (2) avoid activities considered of interest to homosexuals, such [as] art museums, opera, symphonies, (3) avoid women unless it is for romantic contact, (4) increase time spent with heterosexual men in order to learn to mimic heterosexual male ways of walking, talking, and interacting with other heterosexual men, (5) Attend church and join a men’s church group, (6) attend reparative therapy group to discuss progress, or slips back into homosexuality, (7) become more assertive with women through flirting and dating, (8) begin heterosexual dating, (9) engage in heterosexual intercourse, (10) enter into heterosexual marriage, and (11) father children". Nicolosi's "A Parent's Guide to Preventing Homosexuality" clarifies that Haldeman's interpretation of his work, cited above, is inaccurate; Nicolosi explains that some males are temperamentally more sensitive and esthetically oriented and can never be expected to act in a way that is stereotypically masculine. As Nicolosi says, "A gender-nonconforming boy CAN be sensitive, kind, social, artistic, gentle--and heterosexual. He can be an artist, an actor, a dancer, a cook, a musician--and a heterosexual. These innate artistic skills are 'who he is,' part of the wonderful range of human abilities. No one should try to discourage those abilities and traits." Nicolosi adds, "With appropriate masculine affirmation and support, however, they can all be developed within the context of normal heterosexual manhood.".

Most mental health professionals consider reparative therapy discredited, but it is still practiced by some. In fact, former American Psychological Association presidents Robert Perloff and Nicholas Cummings have both been Keynote Speakers at recent NARTH conferences and have strongly decried the efforts of the major professional associations, in their opinion, to marginalize reparative therapists and allegedly promote gay activism instead of scientific impartiality.

Psychoanalysts critical of Nicolosi's theories have offered gay-affirmative approaches as an alternative to reparative therapy. Exodus International regarded reparative therapy as a useful tool to eliminate "unwanted same-sex attraction" but ceased activities in June 2013 and issued a statement repudiating its aims and apologizing for the harm the organization had caused to LGBT people.

Sex therapy
Douglas Haldeman has described William Masters' and Virginia Johnson's work on sexual orientation change as a form of conversion therapy.

In Homosexuality in Perspective, published in 1979, Masters and Johnson viewed homosexuality as the result of blocks that prevented the learning that facilitated heterosexual responsiveness, and described a study of 54 gay men who were dissatisfied with their sexual orientation. The original study did not describe the treatment methodology used, but this was published five years later. John C. Gonsiorek criticized their study on several grounds in 1981, pointing out that while Masters and Johnson stated that their patients were screened for major psychopathology or severe neurosis, they did not explain how this screening was performed, or how the motivation of the patients to change was assessed. Nineteen of their subjects were described as uncooperative during therapy and refused to participate in a follow-up assessment, but all of them were assumed without justification to have successfully changed.

Douglas Haldeman writes that Masters and Johnson's study was founded upon heterosexist bias, and that it would be tremendously difficult to replicate. In his view, the distinction Masters and Johnson made between "conversion" (helping gay men with no previous heterosexual experience to learn heterosexual sex) and "reversion" (directing men with some previous heterosexual experience back to heterosexuality) was not well founded. Many of the subjects Masters and Johnson labelled homosexual may not have been homosexual, since, of their participants, only 17% identified themselves as exclusively homosexual, while 83% were in the predominantly heterosexual to bisexual range. Haldeman observed that since 30% of the sample was lost to the follow-up, it is possible that the outcome sample did not include any people attracted mainly or exclusively to the same sex. Haldeman concludes that it is likely that, rather than converting or reverting gay people to heterosexuality, Masters and Johnson only strengthened heterosexual responsiveness in people who were already bisexual.

Can Some Gay Men and Lesbians Change Their Sexual Orientation?
In May 2001, Robert Spitzer presented Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation", a study of attempts to change homosexual orientation through ex-gay ministries and conversion therapy, at the American Psychiatric Association's convention in New Orleans. The study was partly a response to the APA's 2000 statement cautioning against clinical attempts at changing homosexuality, and was aimed at determining whether such attempts were ever successful rather than how likely it was that change would occur for any given individual. Spitzer wrote that some earlier studies provided evidence for the effectiveness of therapy in changing sexual orientation, but that all of them suffered from methodological problems.

He reported that after intervention, 66% of the men and 44% of the women had achieved "Good Heterosexual Functioning", which he defined as requiring five criteria (being in a loving heterosexual relationship during the last year, overall satisfaction in emotional relationship with a partner, having heterosexual sex with the partner at least a few times a month, achieving physical satisfaction through heterosexual sex, and not thinking about having homosexual sex more than 15% of the time while having heterosexual sex). He found that the most common reasons for seeking change were lack of emotional satisfaction from gay life, conflict between same-sex feelings and behavior and religious beliefs, and desire to marry or remain married. This paper was widely reported in the international media and taken up by politicians in the United States, Germany, and Finland, and by conversion therapists.

In 2003, Spitzer published the paper in the Archives of Sexual Behavior. Spitzer's study has been criticized on numerous ethical and methodological grounds, and "press releases from both NGLTF and HRC sought to undermine Spitzer's credibility by connecting him politically to right-wing groups that had backed the ex-gay movement." The Advocate - Jun 19, 2001. Gay activists argued that the study would be used by conservatives to undermine gay rights. Spitzer acknowledged that the study sample consisted of people who sought treatment primarily because of their religious beliefs (93% of the sample), served in various church-related functions, and who publicly spoke in favor of changing homosexual orientation (78%), and thus were strongly motivated to overreport success. Critics felt he dismissed this source of bias, without even attempting to measure deception or self-deception (a standard practice in self-reporting psychological tests like MMPI-2). That participants had to rely upon their memories of what their feelings were before treatment may have distorted the findings. It was impossible to determine whether any change that occurred was due to the treatment because it was not clear what it involved and there was no control group. Spitzer's own data showed that claims of change were reflected mostly in changes in self-labelling and behavior, less in attractions, and least in the homoerotic content during the masturbatory fantasies; this particular finding was consistent with other studies in this area. Participants may have been bisexual before treatment. Follow-up studies were not conducted. Spitzer stressed the limitations of his study. Spitzer said that the number of gay people who could successfully become heterosexual was likely to be "pretty low", and conceded that his subjects were "unusually religious."

Spitzer renounced and retracted his own study in 2012, stating "I was quite wrong in the conclusions that I made from this study. The study does not provide evidence, really, that gays can change. And that’s quite an admission on my part." He also apologized to the gay community for making unproven claims of the efficacy of reparative therapy, calling it his only professional regret. Spitzer has requested that all "ex-gay" therapy organizations such as NARTH, PFOX, American College of Pediatricians, and Focus on the Family stop citing his study as evidence for conversion therapy.

Changing Sexual Orientation: A Consumer's Report
Ariel Shidlo and Michael Schroeder found in "Changing Sexual Orientation: A Consumer's Report", a peer-reviewed study of 202 respondents published in 2002, that 88% of participants failed to achieve a sustained change in their sexual behavior and 3% reported changing their orientation to heterosexual. The remainder reported either losing all sexual drive or attempting to remain celibate, with no change in attraction. Some of the participants who failed felt a sense of shame and had gone through conversion therapy programs for many years. Others who failed believed that therapy was worthwhile and valuable. Shidlo and Schroeder also reported that many respondents were harmed by the attempt to change, causing; depression, suicidal ideation and attempts, hypervigilance of gender-deviant mannerisms,social isolation, fear of being a child abuser and poor self-esteem. Of the 8 respondents (out of a sample of 202) who reported a change in sexual orientation, 7 worked as ex-gay counselors or group leaders. NARTH states that the Shidlo study has often been used by gay activists as "proof" that conversion therapy is on average harmful, but they advertised for study participants with an ad that said, "Help Us Document the Harm". The Shidlo-Schroeder recruitment poster is available at NARTH online, stating that the study's authors did not seek to measure the average outcome of conversion therapy, although their study has often been used by activists as if it had, in fact, sought a representative sample; the lack of a representative sample therefore means that the 80% failure rate, cited above in this same paragraph, should be taken with caution. The study does show however that qualitatively conversion therapy can cause significant harm.

Ethical Issues in Attempts to Ban Reorientation Therapies
Mark Yarhouse and Warren Throckmorton, of the private Christian school Grove City College, in 2002 published "Ethical Issues in Attempts to Ban Reorientation Therapies", which argues that conversion therapy should be available out of respect for a patient’s values system and because there is evidence that it can be effective. They state that studies from the 1950s–1980s generally reported rates of positive outcomes at about 30%, with more recent survey research generally consistent with the extant data. Their paper was partly a response to Jack Drescher's 2001 paper, "Ethical issues surrounding attempts to change sexual orientation", which used the principle of "Do no harm" to argue against conversion therapy.

United States
National health organizations in the United States find that conversion therapy is ineffective, risky and can be harmful, and that there has been no scientific demonstration of its efficacy in the last forty years. Anecdotal claims of cures are counterbalanced by assertions of harm, and the American Psychological Association, for example, cautions ethical practitioners under the Hippocratic oath to do no harm to refrain from attempts at conversion therapy. Mainstream medical bodies state that conversion therapy can be harmful because it may exploit guilt and anxiety, thereby damaging self-esteem and leading to depression and even suicide. There is also concern in the mental health community that the advancement of conversion therapy can cause social harm by disseminating inaccurate views about sexual orientation and the ability of gay and bisexual people to lead happy, healthy lives.

Mainstream health organizations critical of conversion therapy include the American Medical Association, American Psychiatric Association, the American Psychological Association, the American Association for Marriage and Family Therapy, the American Counseling Association, the National Association of Social Workers, the American Academy of Pediatrics, the National Association of School Psychologists, and the American Academy of Physician Assistants.

The American Psychological Association undertook a study of the peer-reviewed literature in the area of sexual orientation change efforts (SOCE) and found a myriad of issues with the procedures used in conducting the research. The taskforce did find that that some participants experienced a lessening of same sex attraction and arousal, but that these instances were "rare" and "uncommon." The taskforce concluded that, "given the limited amount of methodically sound research, claims that recent SOCE is effective are not supported. Two issues with SOCE claims are that conversion therapists falsely assume that homosexuality is a mental disorder and that their research focuses almost exclusively on gay men and rarely includes lesbians.

Self-determination
The American Psychological Association's code of conduct states: "Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination," but also: "Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making." The American Counseling Association says that "it is of primary importance to respect a client's autonomy to request a referral for a service not offered by a counselor." No one should be forced to attempt to change their sexual orientation against their will, including children being forced by their parents.

Supporters of SOCE focus on patient self-determination when discussing whether therapy should be available. Mark Yarhouse, of Pat Robertson's Regent University, wrote that "psychologists have an ethical responsibility to allow individuals to pursue treatment aimed at curbing experiences of same-sex attraction or modifying same-sex behaviors, not only because it affirms the client's rights to dignity, autonomy, and agency, as persons presumed capable of freely choosing among treatment modalities and behavior, but also because it demonstrates regard for diversity." Yarhouse and Throckmorton, of the private Christian school Grove City College, argue that the procedure should be available out of respect for a patient’s values system and because they find evidence that it can be effective. Douglas Haldeman similarly argues for a client's right to access to therapy if requested from a fully informed position: "For some, religious identity is so important that it is more realistic to consider changing sexual orientation than abandoning one's religion of origin... and if there are those who seek to resolve the conflict between sexual orientation and spirituality with conversion therapy, they must not be discouraged."

In response to Yarhouse's paper, Jack Drescher argued that "any putative ethical obligation to refer a patient for reparative therapy is outweighed by a stronger ethical obligation to keep patients away from mental health practitioners who engage in questionable clinical practices." Chuck Bright wrote that refusing to endorse a procedure that "has been deemed unethical and potentially harmful by most medical and nearly every professional psychotherapy regulating body cannot be justifiably identified as prohibiting client self-determination." Some commentators, recommending a hard stand against the practice, have found therapy inconsistent with a psychologist's ethical duties because "it is more ethical to let a client continue to struggle honestly with her or his identity than to collude, even peripherally, with a practice that is discriminatory, oppressive, and ultimately ineffective in its own stated ends." They argue that clients who request it do so out of social pressure and internalized homophobia, pointing to evidence that rates of depression, anxiety, alcohol and drug abuse and suicidal feelings are roughly doubled in those who undergo therapy.

Douglas Haldeman wrote: "However this distinction between religious identity and sexual orientation may be viewed, psychology does not have the right to interfere with individuals’ rights to seek the treatments they choose. This is why the mental health organizations have adopted advisory policies about conversion therapy that affirm the right of LGB clients to unbiased treatment in psychotherapy and that reject treatments based upon the premise that homosexuality is a treatable mental disorder. They do not, however, ban the practice of conversion therapy outright out of concern for the individual whose personal spiritual or religious concerns may assume priority over his sexual orientation."

Ethics guidelines
In 1998, the American Psychiatric Association issued a statement opposing any treatment which is based upon the assumption that homosexuality is a mental disorder or that a person should change their orientation, but did not have a formal position on other treatments that attempt to change a person's sexual orientation. In 2000, they augmented that statement by saying that as a general principle, a therapist should not determine the goal of treatment, but recommends that ethical practitioners refrain from attempts to change clients' sexual orientation until more research is available.

The American Counseling Association has stated that they do not condone any training to educate and prepare a counselor to practice conversion therapy. Counselors who do offer training in conversion therapy must inform students that the techniques are unproven. They suggest counselors do not refer clients to a conversion therapist or to proceed cautiously once they know the counselor fully informs clients of the unproven nature of the treatment and the potential risks. However, "it is of primary importance to respect a client's autonomy to request a referral for a service not offered by a counselor." A counselor performing conversion therapy must provide complete information about the treatment, offer referrals to gay-affirmative counselors, discuss the right of clients, understand the client's request within a cultural context, and only practice within their level of expertise.

NARTH states that refusing to offer therapy aimed at change to a client who requests it, and telling him that his only option is to claim a gay identity, could also be considered ethically unacceptable.

International medical views
The World Health Organization's ICD-10, which along with the DSM-IV is widely used internationally, states that "sexual orientation by itself is not to be regarded as a disorder". It lists ego-dystonic sexual orientation as a disorder instead, which it defines as occurring where "the gender identity or sexual preference (heterosexual, homosexual, bisexual, or prepubertal) is not in doubt, but the individual wishes it were different because of associated psychological and behavioural disorders, and may seek treatment in order to change it."

The development of theoretical models of sexual orientation in countries outside the United States that have established mental health professions often follows the history within the U.S. (although often at a slower pace), shifting from pathological to non-pathological conceptions of homosexuality.

Legal views
In a 1997 U.S. case, the Ninth Circuit addressed conversion therapy in the context of an asylum application. A Russian citizen "had been apprehended by the Russian militia, registered at a clinic as a 'suspected lesbian,' and forced to undergo treatment for lesbianism, such as 'sedative drugs' and hypnosis.... The Ninth Circuit held that the conversion treatments to which Pitcherskaia had been subjected constituted mental and physical torture. The court rejected the argument that the treatments to which Pitcherskaia had been subjected did not constitute persecution because they had been intended to help her, not harm her, and stated "human rights laws cannot be sidestepped by simply couching actions that torture mentally or physically in benevolent terms such as 'curing' or 'treating' the victims."