3:13-cv-06629 #1 - Complaint

IN THE UNITED STATES DISTRICT COURT FOR THE
DISTRICT OF NEW JERSEY

CAMDEN DIVISION

JOHN DOE, by and through JACK )
DOE and JANE DOE, JACK DOE, )
individually and on behalf of his son, )
JOHN DOE, JANE DOE, individually )
and on behalf of her son JOHN DOE )
) Case No. ________________
Plaintiffs, )
v. )
)
CHRISTOPHER J. CHRISTIE, )
Governor of the State of New Jersey, in )
his official capacity, )
)
Defendants. )

COMPLAINT FOR DECLARATORY AND INJUNCTIVE RELIEF AND DAMAGES

COME NOW Plaintiffs, JOHN DOE, by and through his parents, JACK and JANE DOE,
JACK DOE, individually and on behalf of JOHN DOE, and JANE DOE, individually and on
behalf of JOHN DOE (collectively Plaintiffs), by and through counsel, and file this civil action
to respectfully request this Court to issue Injunctive and Declaratory Relief and Nominal
Damages for the constitutional violations described below. In support, Plaintiffs aver as follows:
INTRODUCTION
1. Plaintiffs bring this civil action to challenge the constitutionality of New Jersey Assembly
Bill Number 3371, An Act concerning the protection of minors from attempts to change sexual
orientation, (A3371), and to prevent A3371 from violating their federal constitutional
guarantees of Freedom of Speech, Free Exercise of Religion, and parental rights. This law went
into full effect immediately, upon being signed by Governor Christie on August 19, 2013,
and thus time is of the essence to obtain judicial relief because Plaintiffs are currently
Case 3:13-cv-06629-FLW-LHG Document 1 Filed 11/01/13 Page 1 of 28 PageID: 1
Complaint for Injunctive and Declaratory Relief - 2
suffering immediate and irreparable injury to their constitutional liberties and will
continue to suffer irreparably injury until this unconstitutional law is enjoined.
2. Plaintiffs Jack and Jane Doe have the fundamental right, as parents, to direct the
upbringing and education of their child, Plaintiff John Doe, and to do so free from
unconstitutional government interference. They also have the First Amendment rights as parents
to religious freedom and free speech, including the right to receive information and to provide
information to their children.
3. Plaintiff John Doe also has First Amendment rights to engage in constitutionally
protected speech and religious freedom, and the right not only to speak, but also to receive
information.
4. A3371 denies Plaintiff John Doe, as well as all other minors in New Jersey their right to
self-determination in the exercise of their religious and moral values, and their right to receive
counseling consistent with those values, by preventing them from obtaining counseling from
licensed mental health professionals to address the conflict and confusion about or questions
concerning their unwanted same-sex sexual attractions, behaviors, or identity and to reduce or
eliminate those unwanted same-sex sexual attractions, behaviors, and identity, including but not
limited to sexual orientation change efforts (SOCE) counseling.
5. By denying John Doe and all New Jersey minors access to counseling from licensed
professionals (i.e., talk therapy) that can help those minors who so desire to reduce or
eliminate their unwanted same-sex attractions, behaviors, or identity, A3371 infringes on the
fundamental rights of Jack and Jane Doe to direct the upbringing and education of their child,
which includes the right to meet each childs individual counseling, developmental, and spiritual
needs.
6. Despite the value and benefit that Plaintiffs have experienced by receiving SOCE
counseling and their sincere desire to continue to receive such counseling from a licensed mental
health counselor in New Jersey, Defendant is enforcing A3371 against all licensed mental health
counselors in New Jersey who could provide SOCE counseling to John Doe and is causing
immediate and irreparable harm to Plaintiffs.
7. A3371 is currently harming and will continue to harm Plaintiffs by preventing them from
obtaining the counseling services they choose to resolve or reduce unwanted same-sex sexual
attractions, behaviors, or identity.
8. By denying minors the opportunity to pursue a particular course of action that can help
them address the conflicts between their religious and moral values and same-sex attractions,
behaviors, or identity, A3371 has caused, is causing, and will continue to cause those minors,
including Plaintiff John Doe, confusion and anxiety over same-sex sexual attractions, behaviors,
or identity that the minors must balance, resolve, and/or eliminate with respect to their religious
and moral values, and therefore infringes on their free speech and religious liberty rights.
9. Consequently, Plaintiffs seek Preliminary and Permanent Injunctive Relief enjoining
Defendant from enforcing A3371 because it violates (1) Plaintiffs rights to freedom of speech
and free exercise of religion, guaranteed by the First and Fourteenth Amendments to the United
States Constitution, and (2) Plaintiffs Jack and Jane Does fundamental rights to direct the
upbringing of their child guaranteed by the Fourteenth Amendment.
10. Plaintiffs also seek Declaratory Relief from this Court declaring that A3371 is
unconstitutional on its face and as applied, as well as nominal damages for the past violation of
their rights.
JURISDICTION AND VENUE
11. This action arises under the First and Fourteenth Amendments to the United States
Constitution and 42 U.S.C. 1983.
12. This Court has jurisdiction of this action under 28 U.S.C. 1331, and 1343.
13. This Court is authorized to grant the Plaintiffs prayer for relief regarding costs, including
reasonable attorneys fees, pursuant to 42 U.S.C. 1988.
14. This Court is authorized to grant declaratory judgment pursuant to the Declaratory
Judgment Act, 28 U.S.C. 2201-02, implemented through Federal Rule of Civil Procedure 57,
and to issue the preliminary and permanent injunctive relief pursuant to Federal Rule of Civil
Procedure 65.
15. Venue is proper under 28 U.S.C. 1391(b). Each and all of the acts alleged herein were
done and are to be done by Defendant and/or his agents, and each of them, not as an individual,
but under the color and pretense of statutes, ordinances, regulations, customs, and uses of the
United States of America and of the State of New Jersey.
PARTIES
16. Plaintiff John Doe is a 15 year old minor and resident of New Jersey who is seeking
SOCE counseling from a licensed mental health counselor in New Jersey, but is currently being
prevented from doing so by A3371 and Defendants enforcement of A3371.
17. Plaintiffs Jack and Jane Doe, both individually and on behalf of John Doe, are residents
of the State of New Jersey and are the parents of John Doe. They are seeking to provide their
son, John Doe with the opportunity to receive SOCE counseling from a licensed mental health
counselor in New Jersey but are currently being prevented from doing so by A3371 and
Defendants enforcement of A3371.
18. Defendant Christopher J. Christie is the Governor of the State of New York and is
responsible for executing the laws of New Jersey. He is sued in his official capacity.
STATEMENT OF FACTS
19. Following the New Jersey Legislatures passage of A3371, Defendant Governor Christie
signed A3371 on Monday, August 19, 2013, which amended Title 45 of the Revised Statutes of
New Jersey, and the law went into effect immediately. A3371 is attached hereto as Exhibit A
and incorporated herein by reference.
20. Section 2(a) of A3371 states:
A person who is licensed to provide professional counseling under Title 45 of
the Revised Statutes, including, but not limited to, a psychiatrist, licensed
practicing psychologist, certified social worker, licensed clinical social worker,
licensed social worker, licensed marriage and family therapist, certified
psychoanalyst, or a person who performs counseling as part of the persons
professional training for any of these professions, shall not engage in sexual
orientation change efforts with a person under 18 years of age.

21. Section 2(b) of A3371 states:

[S]exual orientation change efforts means the practice of seeking to change a
persons sexual orientation, including, but not limited to, efforts to change
behaviors, gender identity, or gender expressions, or to reduce or eliminate sexual
or romantic attractions or feelings toward a person of the same gender; except that
sexual orientation change efforts shall not include counseling for a person seeking
to transition from one gender to another, or counseling that:

(1) provides acceptance, support, and understanding of a person or facilitates a
persons coping, social support, and identity exploration and development,
including sexual orientation-neutral interventions to prevent or address unlawful
conduct or unsafe sexual practices; and

(2) does not seek to change sexual orientation.

22. Section 3 of A3371 states that [t]his act shall take effect immediately.
THE APA TASK FORCE REPORT
23. The New Jersey Legislature primarily relied on the Report of the American Psychological
Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. A Copy of
the APA Report is attached hereto as Exhibit C and incorporated herein.
24. The APA Task Force was charged with reporting on the appropriate application of
affirmative therapeutic interventions for adults who present a desire to change their sexual
orientation or their behavioral expression of their sexual orientation. APA Report at 4.
25. The APA Report states that recent SOCE research cannot provide conclusions regarding
efficacy or effectiveness. Id. at ix.
26. The APA Report noted that people had reported varying degrees of satisfaction and
varying perceptions of success, had altered their sexual orientation; participants had multiple
endpoints, including LGB identity, ex-gay identity, no sexual orientation identity, and a unique
self-identity, and had reported a range of effects from their efforts to change their sexual
orientation, including both benefits and harm. Id. at 45, 50, 53.
27. The APA Report states that it performed a systematic review of the peer-reviewed
literature and found some evidence of both harm and benefits produced by SOCE (for
adults). Id. at 2-3, 42, 49-50.
28. The APA Report noted that [t] o date, the research has not fully addressed age, gender,
gender identity, race, ethnicity, culture, national origin, disability, language, and socioeconomic
status in the population of distressed individuals. Id. at 120.
29. The APA Report highlighted that sexual minority adolescents are underrepresented in
research on evidence-based approaches, and sexual orientation issues in children are virtually
unexamined. Id. at 91 (emphasis added).
30. It stated that [n]one of the recent research (1999-2007) meets methodological standards
that permit conclusions regarding efficacy or safety. Id. at 2.
31. The APA Report concluded that that there is a dearth of scientifically sound research
on the safety of SOCE. Early and recent research studies provide no clear indication of the
prevalence of harmful outcomes . . . because no study to date of scientific rigor has been
explicitly designed to do so. Id. at 42 (emphasis added).
32. It also noted that [t]here is no research demonstrating that providing SOCE to children
or adolescents has an impact on adult sexual orientation. Id. at 4 (emphasis added).
33. Given these limitations, the Task Force concluded that research on SOCE
(psychotherapy, mutual self-help groups, religious techniques) has not answered basic questions
of whether it is safe or effective and for whom. . . . [R]esearch into harm and safety is
essential. Id. at 90 (emphasis added).
34. Indeed, the only evidence of harm the Task Force discovered was some anecdotal
testimony of some individuals [who] reported being harmed by SOCE. Id. at 120.
JOHN DOE
35. John Doe is currently 15 years old, lives in New Jersey, and desires to continue
counseling for his unwanted gender identity disorder and unwanted same-sex attractions with a
licensed mental health provider in New Jersey, but is currently prohibited from obtaining such
counseling because of A3371 and Defendants application of it.
36. John Doe began experiencing gender identity disorder when he was around nine years
old, and he remembers having a bias against the male gender and thinking that boys were stupid
because his mother talked negatively about his father.
37. When John Doe was ten years old, he began developing a suicidal ideation and frequently
thought of killing himself because he did not like himself and was significantly confused about
his own personal identity.
38. He began to think he would like himself much better if he was a girl. In an effort to begin
to look more feminine, he began to secretly shave his armpits and pubic hair.
39. John Doe also attempted to cover up other gender expressions and mannerisms typically
associated with an adolescent male, and he would attempt to display female mannerisms and
expressions.
40. During this period, John Doe hated everything masculine about himself, and sincerely
thought he would be happy with himself and his life if he could be feminine.
41. John Doe began to develop feelings of same-sex attractions when he was around 12 or 13
years old, and he remembers secretly having attractions and desires for some of the male
celebrity figures.
42. John Doe did not understand why he had these feelings, did not want them, and began to
experience the most intense feelings of hopelessness and frequently thought of killing himself.
43. Because of those thoughts of hopelessness and despair, John Doe also began to hate
himself for the impression he had that he was not as good as the men he would see in magazines,
who were muscular and athletic, and that he was never going to be like those ,men.
44. John Doe began to think that if he were a girl, then his hatred and despair would
disappear because he would not have to compete with these other boys anymore. He experienced
feelings of despair because he believed that he would never be good enough if he remained a
boy.
45. John Doe continued to feel hatred toward himself, and this began to cause psychological
distress, which manifested in feelings of intense anxiety, panic, and obsessive-compulsive traits.
46. During these years, John Does hatred of himself was the worst it had ever been, and he
was having frequent panic attacks during the day and trouble sleeping at night.
47. John Doe developed feelings that his life was spinning out of control and became
severely depressed, and his depression was so intense that he began to have thoughts of killing
himself nearly all day long, every single day.
48. When John Does suicidal thoughts reached this alarming frequency, his parents wanted
to get him help, and John Doe wanted help as well.
49. John Doe has a sincerely held religious belief and conviction that homosexuality is wrong
and immoral, and he wanted to address that value conflict because his unwanted same-sex
attractions and gender confusion are contrary to the fundamental religious values that he holds.
50. John Doe has a sincere desire to to live out his religious values and does not want to act
out on unwanted same-sex attractions that violate his sincerely held religious beliefs.
51. John Doe has a sincere desire to resolve his unwanted same-sex sexual attractions and
gender identity so that he can act in conformity with his religious beliefs.
52. Because of those sincerely held religious beliefs and because he did not want to
experience these same-sex attractions or gender confusion, John Doe talked with his parents
about having a counselor help him.
53. John Doe and his parents agreed to seek help from a licensed professional counselor who
provided counseling for young men and women desiring to reduce or eliminate their unwanted
same-sex sexual attractions, behaviors, or identity.
54. After John Does parents contacted his counselor and prior to the beginning of John
Does SOCE counseling, the counselor and the Doe family discussed the nature of the SOCE
counseling that the counselor provides, the theories behind the types of feelings John Doe was
having, the causes behind such feelings and why John Doe was feeling so distressed about them.
55. John Does counselor explained to him when he began the SOCE counseling that much
of his psychological confusion and distress surrounding his unwanted same-sex attractions and
gender confusion was likely rooted in developmental needs that went unfulfilled during his
childhood, many of which arose from a father who did not provide sufficient positive male
attention.
56. John Doe started SOCE counseling in May 2011, and he has shown tremendous
improvement in his psychological distress about his unwanted same-sex sexual attractions and
his confusion concerning his gender identity as a result.
57. John Doe no longer tries to speak in higher tones, like a girl, as he used to do; he does not
shave his body hair anymore; and his relationship with his father has improved tremendously as
a result of the counseling he has received.
58. Most significantly, John Doe no longer has thoughts of suicide as a result of his
counseling.
59. John Doe enjoys the counseling sessions with his counselor and sincerely desires to
continue to advance further in overcoming his unwanted same-sex attractions.
60. John Doe has experienced a significant reduction in his unwanted same-sex attractions,
and has described it as only about a 3 out of 10 today, when it used to be 8 out of 10.
61. Every day would get a little better for John Doe as he continued to receive counseling,
and he desperately wants to be able to continue to receive counseling. However, John Doe also
wants to progress in his counseling by engaging the services of a licensed psychotherapist,
because such additional counseling would be beneficial to him.
62. There are still a lot of conversations that John Doe would like to have with a counselor to
help him reach his goal of eliminating his unwanted same-sex attractions altogether and
resolving the underlying issues that once caused his gender confusion.
63. John Does discussions with his current counselor, who is a licensed social worker in
New York, have helped him tremendously, and sometimes talking to a counselor makes all of the
difference in the world for him.
64. John Does current counselor focuses primarily on current feelings and anxieties with a
forward-perspective. He does not focus much on the introspective root cause or background
issues that many licensed psychologists provide in this area.
65. Because he thought that John Doe might benefit significantly from the discussion
concerning the background, causes, and other introspective counseling, John Does current
counselor recommended that he seek a licensed psychologist who engages in that type of
counseling.
66. John Doe requested that his parents help him find a counselor who could help him with
the types of discussions his counselor recommended, and the Does contacted Dr. Ronald
Newman, a licensed psychologist in New Jersey.
67. Dr. Newman informed the Does that because of A3371, there were no licensed
psychologists in New Jersey who could provide such counseling or any counseling to reduce or
eliminate unwanted same-sex attractions, behaviors, or identity.
68. John Does conversation with his counselor have really helped him reduce his unwanted
feelings and attractions.
69. John Doe has made significant progress, but his struggle is not over and he will continue
to need to have conversations with licensed mental health counselors who are professionals in
this area of counseling.
70. Because no licensed mental health professional in New Jersey can provide him with
SOCE counseling, John Doe will substantially regress in the significant progress he has made
with his current counselor.
71. Because he cannot receive any SOCE counseling from a licensed mental health
professional in New Jersey, John Doe may begin to experience the same feelings of confusion,
awkwardness, and unwanted same-sex attractions that he has worked so hard to reduce and
eliminate.
72. Absent SOCE counseling from licensed professionals, John Doe may even begin to have
thoughts of suicide again.
73. John Doe may also begin to have an enormous struggle and temptations that will make it
difficult for him to continue to live consistently with his sincerely held religious beliefs and that
this will only further add to the significant stress, anxiety, and suicidal ideation that he suffered
through prior to being able to receive SOCE counseling.
74. A3371 has jeopardized the significant healing and restoration that John Does SOCE
counseling has brought to his family, especially the relationship between his parents and him,
and that only though additional counseling can their relationship continue to heal and strengthen.
JACK AND JANE DOE
75. Jack Doe is the father of John Doe, and Jane Doe is the mother of John Doe.
76. When John Doe was young, Jack and Jane Doe were very argumentative and would have
significant arguments right in front of John Doe, and Jane Doe would sometimes accuse Jack
Doe of things or call him names that were negative towards men in general.
77. Jack Doe often saw his role as the provider and doer and thought his love was manifested
by always being on the go to provide for his family.
78. Because of his efforts and view of his role as the provider, Jack Doe often had raging
arguments with Jane Doe for hours well into the night, which hurt Jane Doe emotionally and
resulted in significantly negative statements from her concerning men in general.
79. John Doe witnessed many of these arguments and was always very sensitive and artistic,
which is probably why Jane Does negative statements about men in general and her husband in
particular had a negative impact on John Does overall perception of men.
80. When John Doe was around five years old, Jack and Jane Doe noticed that he had started
to play with female dolls or toys, and Jane Doe noticed that he was particularly obsessed with
Ariel from The Little Mermaid.
81. Jack and Jane Doe frequently noticed that John Doe would sketch pictures of Ariel on
any scrap piece of paper he could find, and Jane Doe noticed that he spent many long hours
drawing, which her husband did not like.
82. On numerous occasions, Jane Doe witnessed her husband become frustrated with John
Doe because he was not behaving like a typical male, and she had a number of arguments with
Jack Doe because of his statements to John Doe criticizing him for exhibiting female
characteristics, expressions, and mannerisms.
83. When John Doe was 10 years old, the Doe family was visiting a friends house and Jane
Doe witnessed her son removing all of his clothes and trying to to dress up in princess clothes.
84. Jack and Jane Doe were very concerned by this incident because they knew this behavior
appeared to be quite disordered, and because they knew that their son was experiencing
confusion and distress over his gender identity.
85. On several occasions, Jack and Jane Doe were extremely fearful about their sons
behavior because the significant psychological distress and anxiety that John Does gender
confusion had created for him was manifesting itself in life threatening ways.
86. On several occasions, Jack and Jane Doe witnessed John Doe take sharp knives into the
bathroom threatening to commit suicide because of his psychological distress about his gender
identity and confusion.
87. Because they knew that John Does behavior was of grave concern to his safety and well-
being, Jack and Jane Doe began to seek counseling for their son to help him understand and
reduce or resolve the significant psychological confusion over his gender identity and his
unwanted same-sex attractions.
88. Jack and Jane Doe searched for a Catholic counselor believing that as long as the
counselor shared the Does sincerely held religious beliefs (they are Roman Catholic), he would
be able to help their son regardless of his professional training and licensure in this type of
counseling.
89. Jane Doe has a fairly extensive understanding of the theories relating to gender
confusion, same-sex attractions, and SOCE counseling, which she obtained in part from self-
study and in part through her Masters in Systematic Theology from Seton Hall Universitys
Immaculate Conception Seminary School of Theology.
90. Because of her education and understanding of this type of counseling, Jane Doe was
surprised and concerned when the unlicensed Catholic counselor they had retained did not seem
to share the same scholarly view of the issues surrounding SOCE counseling as the many experts
in the field.
91. Because this unlicensed counselor did not share the same views as many of the experts in
this area and because he was not sufficiently trained or educated in the specific counseling
techniques that studies have shown are effective with minors struggling with unwanted same-sex
attractions, behaviors, or identity, he was not able to help her son with his significant confusion
and distress about his unwanted same-sex attractions.
92. In fact, John Doe actually seemed only to have more distress and more confusion as a
result of this unlicensed counselor being unable to provide specialized and experienced SOCE
counseling.
93. Jack and Jane Does concern over the psychological and physical well-being of John Doe
reached its peak when the Does took a trip to Myrtle Beach two years ago..
94. On that trip, Jack and Jane Doe discovered that their son had shaved his body hair,
including his armpits, they witnessed him flush his underwear down the toilet, and witnessed
their son try to commit suicide by jumping off of the balcony of their hotel room.
95. When the Does returned home, Jack and Jane Doe found various pornographic pictures
and illustrations of men in graphic sexual positions under his mattress, and they realized that
their son was having significant psychological and emotional distress over his gender confusion
and unwanted same-sex attractions.
96. Because of their fear and concern over John Does psychological distress and suicidal
behaviors and because John Doe had approached his parents desperately seeking their help with
his psychological distress over his confusion and unwanted same-sex attractions, Jack and Jane
Doe contacted the National Association for the Research and Therapy of Homosexuality
(NARTH), which is an organization that provides referrals to individuals seeking SOCE
counseling from a licensed mental health professional.
97. The counselor recommended by NARTH was a licensed clinical social worker, and his
offices are located in New York.
98. Based on their previous experienced with the unlicensed counselor, which only seemed to
make their sons psychological distress and confusion worse, Jack and Jane Doe sought only the
help of a licensed mental health professional who understood and specialized in this type of
counseling.
99. Jack and Jane Doe contacted the licensed counselor that NARTH had recommended, and
the Does all visited his office together.
100. The counselor explained to the Does his theory of why John Doe was experiencing
unwanted same-sex attractions and the gender confusion, which he said were really the
manifestation of underlying emotional issues, explained that some of John Does emotional and
personal identity issues were the result of some childhood wounds that were caused by Jack and
Jane Does failure to meet some of the needs that John Doe had as a child, and explained that
Jack Does failure to provide positive male attention caused John Does desire to fit in with Jane
Doe and identify as a woman, which he said all combined to form what is likely the root cause of
John Does unwanted same-sex attractions and gender confusion.
101. Since the counseling with this licensed social worker began, Jack and Jane Doe have
noticed significant changes in John Doe, including the fact that he no longer struggles with the
significant psychological distress and anxiety over his gender confusion and unwanted same-sex
attractions and that he no longer struggles with the serious suicidal thoughts and attempted
suicides.
102. John Doe has frequently told Jack and Jane Doe that he no longer experiences unwanted
same-sex sexual attractions as frequently as he did prior to counseling.
103. The relationship between John Doe and Jack Doe has improved significantly, and their
relationship is continuing to improve.
104. The relationship between the Doe family as a whole has also improved significantly, and
John Does SOCE counseling has helped to restore the Does sense of family.
105. Jack and Jane Doe have spoken with John Doe about how he feels after receiving SOCE
counseling, and his reports are always positive, recognizing that he is now embracing his
masculinity, that he no longer feels the significant psychological distress resulting from his past
gender confusion, and that he no longer has frequent thoughts of committing suicide.
106. John Doe may need counseling for much of his life, but Jack and Jane Doe are committed
to making sure that he has the chance to lead a happy and healthy lifestyle without the significant
burden and overwhelming psychological distress that John Does gender confusion and
unwanted same-sex attractions caused him.
107. The Does desire that John Doe continue to receive the methods of counseling that will
continue to assist him in his progress towards achieving his goals of eliminating his unwanted
same-sex attractions.
108. If John Doe can continue to receive SOCE counseling from licensed mental health
professionals, then he will likely be able to continue to make progress toward his goal of
eliminating his unwanted same-sex attractions and resolving his confusion concerning his gender
identity.
109. However, if John Doe is unable to receive this SOCE counseling from licensed mental
health professionals, then he will likely regress from the significant progress he has made thus
far, will again likely suffer from the gender identity issues and unwanted same-sex attractions
that have been significantly reduced, and will likely begin to struggle again with suicidal
thoughts and attempts.
110. Jack and Jane Doe have affirmed John Does choice to seek SOCE counseling and never
pressured him to either start or continue the counseling. They have seen the counseling benefit
John Doe without any evidence of harm whatsoever resulting from the counseling.
111. John Doe is much happier and less withdrawn and depressed since he began counseling,
and Jack and Jane Doe have experienced a repairing and restoration of the family bonds because
of SOCE counseling.
112. Jack and Jane Doe did not just seek SOCE counseling for their son because of his sincere
desire to receive such counseling; they also sought such counseling for their son because they,
too, have sincerely held religious beliefs that homosexuality is a harmful, immoral, and sinful
lifestyle that is prohibited under the fundamental tenets of their faith and the faith of their son.
113. Jack and Jane Doe have a sincerely held religious belief that they should provide their
children the necessary education to understand Sacred Scripture, as well as the teachings of their
Catholic Church. They also believe that assisting him in receiving SOCE counseling will help
John Doe live consistently with and prioritize his religious beliefs and values above his gender
confusion and unwanted same-sex attractions is one aspect of educating him to live virtuously
through the fundamental tenets of their faith.
114. John Does current counselor is a licensed clinical social worker in New York, but his
counseling does not involve the in-depth analysis and discussion of the underlying causes and
background information that many licensed psychologists do in this area.
115. Because his counseling is more prospective oriented, John Does counselor informed
Plaintiffs that John Doe would likely benefit from the additional counseling of a person who
engages in conversations dealing with root causes, background information, and other
introspective analysis offered in other licensed professional counseling.
116. John Does counselor made his recommendation based on some of the recent discussions
he has had with John Doe, and the Does want to continue to make sure their son receives the best
counseling from the best counselors on all aspects of those problems that cause him distress.
117. It was because of that recommendation that Jack and Jane Doe contacted Dr. Ronald
Newman, a licensed psychologist in New Jersey, to attempt to engage him for John Doe. Dr.
Newman informed them, however, that A3371 prevented any New Jersey licensed psychologist
from providing any counseling to John Doe concerning his desire to reduce or eliminate his
unwanted same-sex attraactions..
118. Because of this prohibition, Jack and Jane Doe and their son, John Doe, have no options
for receiving SOCE counseling from a licensed professional in New Jersey who is educated and
trained in the area and has the ability of assisting John Doe with his objectives and goals for
counseling.
119. Because of their experience with the unlicensed counselor at the beginning of John
Does initial psychological struggle with unwanted same-sex attractions and gender confusion,
Jack, Jane, and John Doe all desperately seek to receive SOCE counseling from a licensed
mental health professional but are completely unable to do so in the State of New Jersey.

COUNT I VIOLATION OF PLAINTIFFS FIRST AMENDMENT RIGHT TO
RECEIVE INFORMATION

120. Plaintiffs reiterate and adopt each and every allegation in the preceding paragraphs
numbered 1 through 119.
121. The First Amendment, as applied to the states by the Fourteenth Amendment, protects an
individuals freedom of speech, and also protects the right to receive information, which is the
corollary to the right to freedom of speech.
122. A3371, on its face and as applied, discriminates against Plaintiffs First Amendment
rights to receive information by limiting the type of counseling Plaintiffs may receive solely on
the basis of the content and viewpoint of the message.
123. A3371s prohibition, on its face and as applied, on mental health providers and
counselors from offering or referring clients to someone who offers SOCE counseling as a part
of their counseling represents unconstitutional viewpoint discrimination.
124. A3371, on its face and as applied, authorizes only one viewpoint on SOCE and unwanted
same-sex sexual attractions, behaviors, or identity, by forcing the licensed counselors in New
Jersey to provide only one viewpoint, thereby prescribing what information and viewpoint
Plaintiffs may receive in the counselors office.
125. To withstand constitutional scrutiny, restrictions on the fundamental right of Plaintiffs to
receive information must be supported by a compelling state interest and must be narrowly
tailored to meet that end.
126. Plaintiffs have sincerely held religious beliefs that shape their desire to receive SOCE
counseling and the information that licensed mental health professionals can provide on reducing
or eliminating unwanted same-sex attractions, behaviors, and identity.
127. A3371 prevents Plaintiffs from receiving SOCE counseling from a licensed New Jersey
professional.
128. A3371 is not supported by a compelling state interest.
129. Even if A3371 were supported by a compelling state interest, it is not narrowly tailored to
achieve any compelling government purpose and therefore violates Plaintiffs fundamental rights
to receive information.
130. Informed consent provisions mandating what must be provided to Plaintiffs and other
seeking SOCE counseling would have sufficed to protect against the alleged harm the State is
seeking to avoid, and mental health counseling organizations have written letters in the past with
similar legislation urging that the legislature adopt informed consent provisions. A copy of the
California mental health organizations' letter to the California legislature concerning legislation
virtually identical to A3371 is attached as Exhibit B and incorporated herein.
131. A3371s violation of Plaintiffs fundamental rights has caused, is causing, and will
continue to cause undue and actual hardship and irreparably injury.
132. Plaintiffs have no adequate remedy at law to correct the continuing deprivation of their
most cherished constitutional liberties.
WHEREFORE, Plaintiffs pray for relief against Defendant as hereinafter set forth in their
prayer for relief.
COUNT II VIOLATION OF PLAINTIFFS RIGHT TO THE FREE EXERCISE OF
RELIGION

134. The Free Exercise Clause of the First Amendment to the United States Constitution, as
applied to the states by the Fourteenth Amendment, prohibits Defendants from abridging
Plaintiffs right to the free exercise of religion.
135. Plaintiffs have sincerely held religious beliefs that same-sex sexual attractions, behaviors,
or identity are wrong, and they seek to resolve these conflicts between their religious beliefs and
their attractions in favor of their religious beliefs.
136. Jack and Jane Doe also have sincerely held religious beliefs to train up a child in the way
he should go, including seeking counsel to help their minor child experiencing significant
psychological distress, anxiety, and suicidal thoughts on the subject matter of same-sex
attractions, behaviors, or identity from a religious viewpoint that aligns with their religious
beliefs and those of their son.
137. A3371, on its face and as applied, targets Plaintiffs beliefs and values regarding human
nature, gender, ethics, morality, and SOCE counseling, which are informed by the Bible and the
teachings of their church and constitute central components of their sincerely held religious
beliefs.
138. A3371 causes them a direct and immediate conflict with their religious beliefs by
prohibiting them from receiving counseling from a licensed professional that is consistent with
their religious beliefs.
139. A3371 placed Plaintiffs in an irresolvable conflict between their sincerely held religious
beliefs and compliance with the prohibition on SOCE counseling, and forces them to choose
between the requirements of their value system or the State-imposed value systems.
140. A3371 puts substantial pressure on Plaintiffs to violate their sincerely held religious
beliefs by ignoring the fundamental tenets of their faith concerning same-sex attractions,
behaviors, or identity.
141. A3371, on its face and as applied, has impermissibly burdened Plaintiffs sincerely held
religious beliefs and compels them to either change those religious beliefs or to act in
contradiction to them.
142. A3371s imposition on Plaintiffs, on its face and as applied, is neither neutral nor
generally applicable, but rather specifically and discriminatorily targets the religious speech,
beliefs, and viewpoint of Plaintiffs and those individuals who believe change is possible, and
thus expressly on its face and as applied constitutes a substantial burden on sincerely held
religious beliefs that are contrary to the state-approved viewpoint on same-sex attractions,
behavior, or identity.
143. The State of New Jerseys alleged interest in protecting minors from the so-called harm
of SOCE counseling is unsubstantiated and does not constitute a compelling state interest.
144. No compelling state interest justifies the burdens Defendant has imposed upon Plaintiffs
rights to the free exercise of religion.
145. Even if A3371s provisions were supported by a compelling state interest, they are not
the least restrictive means to accomplish any permissible government purpose A3371 seeks to
serve.
146. On its face and as applied, A3371s violation of Plaintiffs rights to the free exercise of
religion has caused, is causing, and will continue to cause Plaintiffs to suffer undue and actual
hardship and irreparable injury.
147. Plaintiffs have no adequate remedy at law to correct the continuing deprivation of their
most cherished constitutional liberties.
WHEREFORE, Plaintiffs respectfully pray for relief against Defendant as hereinafter set
forth in their prayer for relief.
COUNT III VIOLATION OF PLAINTIFFS HYBRID RIGHTS TO THE FREE
EXERCISE OF RELIGION AND THE FIRST AND FOURTEENTH AMENDMENT
RIGHT TO RECEIVE INFORMATION AND DIRECT THE UPBRINGING OF THEIR
CHILD

149. A3371 violates both Plaintiffs right to the free exercise of religion and their First
Amendment right to receive information, as guaranteed by the First and Fourteenth Amendments
to the United States Constitution.
150. A3371 also violates both the Plaintiffs Jack and Jane Does right to the free exercise of
religion and their fundamental parental rights, as guaranteed by the First and Fourteenth
Amendments to the United States Constitution.
151. A3371 is not neutral or generally applicable in that it specifically exempts certain forms
of SOCE counseling while prohibiting SOCE counseling for those minors who wish to reduce or
eliminate their unwanted same-sex attractions, behaviors, or identity.
152. Plaintiffs have sincerely held religious beliefs instructing them that homosexuality is a
sinful and harmful lifestyle that is not in accordance with the teachings of the Holy Bible.
153. A3371 substantially burdens John Does sincerely held religious beliefs by prohibiting
him from obtaining SOCE counseling from a licensed professional to assist him in conforming
his attractions and behaviors to his sincerely held religious beliefs.
154. A3371 substantially burdens Jack and Jane Does sincerely held religious beliefs by
preventing them from raising up their child in the way he should go according to Holy Scripture
and preventing them from helping him obtain SOCE counseling from a licensed mental health
provider who can assist him with his unwanted same-sex attractions.
155. There is no compelling government interest sufficient to justify A3371 or Defendants
enforcement of it against Plaintiffs.
156. There is no significant government interest sufficient to justify A3371 or Defendants
enforcement of it against Plaintiffs.
157. A3371 is not the least restrictive means to accomplish any permissible government
objective sought to be achieved by A3371 or Defendants enforcement of it.
158. A3371 is not a narrowly tailored restriction on Plaintiffs constitutional freedoms.
COUNT IV VIOLATION OF PLAINTIFFS JACK AND JANE DOES
FUNDAMENTAL PARENTAL RIGHTS UNDER THE FIRST AND FOURTEENTH
AMENDMENT

160. The First and Fourteenth Amendments to the United States Constitution protect the
fundamental rights of parents to direct the upbringing and education of their children according
to their sincerely held religious beliefs.
161. To withstand constitutional scrutiny, restrictions on fundamental parental rights must
be supported by a compelling state interest and must be narrowly tailored to meet that end.
162. Jack and Jane Doe desperately desire that their son receive SOCE counseling to assist
him in conforming him sexual attractions, behaviors, and identity to his and their sincerely held
religious beliefs.
163. A3371 prevents Jack and Jane Doe from seeking mental health counseling from a
licensed New Jersey professional for their sons unwanted same-sex attractions, behaviors, and
identity and gender confusion that conforms to their sincerely held religious beliefs.
164. A3371 is not supported by a compelling state interest.
165. Even if A3371 was supported by a compelling interest, it is not narrowly tailored to
achieve any compelling purpose and therefore violates Jack and Jane Does fundamental parental
rights.
166. A3371s violation of Jack and Jane Does fundamental parental rights has caused, is
causing, and will continue to cause them to suffer undue and actual hardship and irreparable
injury.
167. Plaintiffs have no adequate remedy at law to correct the continuing deprivation of
their most cherished constitutional liberties.
PRAYER FOR RELIEF
For all of the foregoing reasons, Plaintiffs pray:
A. That this Court issue a Preliminary Injunction enjoining Defendant, Defendants
officers, agents, employees, attorneys, and all other persons acting in active concert or
participation with him, from enforcing A3371.
B. That this Court issue a Permanent Injunction enjoining Defendant, Defendants
officers, agents, employees, attorneys, and all other persons acting in active concert or
participation with him, from enforcing A3371.
C. That this Court render a Declaratory Judgment declaring A3371 and Defendants
actions in applying A3371 unconstitutional under the United States Constitution, declaring:
i. Defendant violated Plaintiffs right to freedom of speech by prohibiting them
from seeking and receiving information concerning SOCE counseling;
ii. Defendant violated Plaintiffs right to the free exercise of religion by
prohibiting Plaintiffs from seeking or receiving information concerning SOCE
counseling in accordance with their sincerely held religious beliefs; and
iii. Defendant violated Plaintiffs Jack and Jane Does fundamental parental rights
to direct the upbringing and education of their children.
D. That this Court adjudge, decree, and declare the rights and other legal relations
with the subject matter here in controversy so that such declaration shall have the force and
effect of final judgment;
E. That this Court award Plaintiffs nominal damages for the past violations of their
constitutional rights;
F. That this Court retain jurisdiction of this matter for the purpose of enforcing this
Courts order;
G. That this Court award Plaintiffs the reasonable costs and expenses of this action,
including attorneys fees, in accordance with 42 U.S.C. 1988.
H. That this Court grant such other and further relief as it deems equitable and just
under the circumstances.

Respectfully submitted,

/s/ Demetrios Stratis
Demetrios Stratis
New Jersey Bar No. !""#$%$$%
Mathew D. Staver*
Stephen M. Crampton*
Daniel J. Schmid*
Liberty Counsel
Attorneys for Plaintiffs
P.O. Box 11108
Lynchburg, VA 24502
Tel. 434-592-7000
Fax: 434-592-7700
court@LC.org

* Application to appear Pro Hac Vice pending

(Sponsorship Updated As Of: 6/7/2013)
ASSEMBLY, No. 3371

STATE OF NEW JERSEY
215th LEGISLATURE

INTRODUCED OCTOBER 15, 2012

Sponsored by:
Assemblyman TIMOTHY J. EUSTACE
District 38 (Bergen and Passaic)
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington)
Assemblywoman HOLLY SCHEPISI
District 39 (Bergen and Passaic)
Assemblyman REED GUSCIORA
District 15 (Hunterdon and Mercer)
Assemblyman JOHN J. BURZICHELLI
District 3 (Cumberland, Gloucester and Salem)

Co-Sponsored by:
Assemblywomen Vainieri Huttle, Lampitt, Tucker, Assemblyman
Wisniewski, Assemblywomen Caride, Mosquera and Jasey

SYNOPSIS
Protects minors by prohibiting attempts to change sexual orientation.

CURRENT VERSION OF TEXT
As introduced.

Case 3:13-cv-06629-FLW-LHG Document 1-1 Filed 11/01/13 Page 1 of 6 PageID: 29
A3371 EUSTACE, CONAWAY
2

AN ACT concerning the protection of minors from attempts to 1
change sexual orientation and supplementing Title 45 of the 2
Revised Statutes. 3
4
BE IT ENACTED by the Senate and General Assembly of the State 5
of New Jersey: 6
7
1. The Legislature finds and declares that: 8
a. Being lesbian, gay, or bisexual is not a disease, disorder, 9
illness, deficiency, or shortcoming. The major professional 10
associations of mental health practitioners and researchers in the 11
United States have recognized this fact for nearly 40 years; 12
b. The American Psychological Association convened a Task 13
Force on Appropriate Therapeutic Responses to Sexual Orientation. 14
The task force conducted a systematic review of peer-reviewed 15
journal literature on sexual orientation change efforts, and issued a 16
report in 2009. The task force concluded that sexual orientation 17
change efforts can pose critical health risks to lesbian, gay, and 18
bisexual people, including confusion, depression, guilt, 19
helplessness, hopelessness, shame, social withdrawal, suicidality, 20
substance abuse, stress, disappointment, self-blame, decreased self- 21
esteem and authenticity to others, increased self-hatred, hostility 22
and blame toward parents, feelings of anger and betrayal, loss of 23
friends and potential romantic partners, problems in sexual and 24
emotional intimacy, sexual dysfunction, high-risk sexual behaviors, 25
a feeling of being dehumanized and untrue to self, a loss of faith, 26
and a sense of having wasted time and resources; 27
c. The American Psychological Association issued a resolution 28
on Appropriate Affirmative Responses to Sexual Orientation 29
Distress and Change Efforts in 2009, which states: [T]he 30
[American Psychological Association] advises parents, guardians, 31
young people, and their families to avoid sexual orientation change 32
efforts that portray homosexuality as a mental illness or 33
developmental disorder and to seek psychotherapy, social support, 34
and educational services that provide accurate information on 35
sexual orientation and sexuality, increase family and school 36
support, and reduce rejection of sexual minority youth; 37
d. (1) The American Psychiatric Association published a 38
position statement in March of 2000 in which it stated: 39
Psychotherapeutic modalities to convert or repair homosexuality 40
are based on developmental theories whose scientific validity is 41
questionable. Furthermore, anecdotal reports of cures are 42
counterbalanced by anecdotal claims of psychological harm. In the 43
last four decades, reparative therapists have not produced any 44
rigorous scientific research to substantiate their claims of cure. 45
Until there is such research available, [the American Psychiatric 46
Association] recommends that ethical practitioners refrain from 47
attempts to change individuals sexual orientation, keeping in mind 48
the medical dictum to first, do no harm; 49
3

(2) The potential risks of reparative therapy are great, including 1
depression, anxiety and self-destructive behavior, since therapist 2
alignment with societal prejudices against homosexuality may 3
reinforce self-hatred already experienced by the patient. Many 4
patients who have undergone reparative therapy relate that they 5
were inaccurately told that homosexuals are lonely, unhappy 6
individuals who never achieve acceptance or satisfaction. The 7
possibility that the person might achieve happiness and satisfying 8
interpersonal relationships as a gay man or lesbian is not presented, 9
nor are alternative approaches to dealing with the effects of societal 10
stigmatization discussed; and 11
(3) Therefore, the American Psychiatric Association opposes 12
any psychiatric treatment such as reparative or conversion therapy 13
which is based upon the assumption that homosexuality per se is a 14
mental disorder or based upon the a priori assumption that a patient 15
should change his or her sexual homosexual orientation; 16
e. The American School Counselor Associations position 17
statement on professional school counselors and lesbian, gay, 18
bisexual, transgender, and questioning (LGBTQ) youth states: It is 19
not the role of the professional school counselor to attempt to 20
change a students sexual orientation/gender identity but instead to 21
provide support to LGBTQ students to promote student 22
achievement and personal well-being. Recognizing that sexual 23
orientation is not an illness and does not require treatment, 24
professional school counselors may provide individual student 25
planning or responsive services to LGBTQ students to promote self- 26
acceptance, deal with social acceptance, understand issues related to 27
coming out, including issues that families may face when a student 28
goes through this process and identify appropriate community 29
resources; 30
f. The American Academy of Pediatrics in 1993 published an 31
article in its journal, Pediatrics, stating: Therapy directed at 32
specifically changing sexual orientation is contraindicated, since it 33
can provoke guilt and anxiety while having little or no potential for 34
achieving changes in orientation; 35
g. The American Medical Association Council on Scientific 36
Affairs prepared a report in 1994 in which it stated: Aversion 37
therapy (a behavioral or medical intervention which pairs unwanted 38
behavior, in this case, homosexual behavior, with unpleasant 39
sensations or aversive consequences) is no longer recommended for 40
gay men and lesbians. Through psychotherapy, gay men and 41
lesbians can become comfortable with their sexual orientation and 42
understand the societal response to it; 43
h. The National Association of Social Workers prepared a 1997 44
policy statement in which it stated: Social stigmatization of 45
lesbian, gay, and bisexual people is widespread and is a primary 46
motivating factor in leading some people to seek sexual orientation 47
changes. Sexual orientation conversion therapies assume that 48
homosexual orientation is both pathological and freely chosen. No 49
4

data demonstrates that reparative or conversion therapies are 1
effective, and, in fact, they may be harmful; 2
i. The American Counseling Association Governing Council 3
issued a position statement in April of 1999, and in it the council 4
states: We oppose the promotion of reparative therapy as a 5
cure for individuals who are homosexual; 6
j. (1) The American Psychoanalytic Association issued a 7
position statement in June 2012 on attempts to change sexual 8
orientation, gender, identity, or gender expression, and in it the 9
association states: As with any societal prejudice, bias against 10
individuals based on actual or perceived sexual orientation, gender 11
identity or gender expression negatively affects mental health, 12
contributing to an enduring sense of stigma and pervasive self- 13
criticism through the internalization of such prejudice; and 14
(2) Psychoanalytic technique does not encompass purposeful 15
attempts to convert, repair, change or shift an individuals sexual 16
orientation, gender identity or gender expression. Such directed 17
efforts are against fundamental principles of psychoanalytic 18
treatment and often result in substantial psychological pain by 19
reinforcing damaging internalized attitudes; 20
k. The American Academy of Child and Adolescent Psychiatry 21
in 2012 published an article in its journal, Journal of the American 22
Academy of Child and Adolescent Psychiatry, stating: Clinicians 23
should be aware that there is no evidence that sexual orientation can 24
be altered through therapy, and that attempts to do so may be 25
harmful. There is no empirical evidence adult homosexuality can 26
be prevented if gender nonconforming children are influenced to be 27
more gender conforming. Indeed, there is no medically valid basis 28
for attempting to prevent homosexuality, which is not an illness. 29
On the contrary, such efforts may encourage family rejection and 30
undermine self-esteem, connectedness and caring, important 31
protective factors against suicidal ideation and attempts. Given that 32
there is no evidence that efforts to alter sexual orientation are 33
effective, beneficial or necessary, and the possibility that they carry 34
the risk of significant harm, such interventions are contraindicated; 35
l. The Pan American Health Organization, a regional office of 36
the World Health Organization, issued a statement in May of 2012 37
and in it the organization states: These supposed conversion 38
therapies constitute a violation of the ethical principles of health 39
care and violate human rights that are protected by international and 40
regional agreements. The organization also noted that reparative 41
therapies lack medical justification and represent a serious threat 42
to the health and well-being of affected people; 43
m. Minors who experience family rejection based on their 44
sexual orientation face especially serious health risks. In one study, 45
lesbian, gay, and bisexual young adults who reported higher levels 46
of family rejection during adolescence were 8.4 times more likely to 47
report having attempted suicide, 5.9 times more likely to report high 48
levels of depression, 3.4 times more likely to use illegal drugs, and 49
5

3.4 times more likely to report having engaged in unprotected 1
sexual intercourse compared with peers from families that reported 2
no or low levels of family rejection. This is documented by Caitlin 3
Ryan et al. in their article entitled Family Rejection as a Predictor 4
of Negative Health Outcomes in White and Latino Lesbian, Gay, 5
and Bisexual Young Adults (2009) 123 Pediatrics 346; and 6
n. New Jersey has a compelling interest in protecting the 7
physical and psychological well-being of minors, including lesbian, 8
gay, bisexual, and transgender youth, and in protecting its minors 9
against exposure to serious harms caused by sexual orientation 10
change efforts. 11
12
2. a. A person who is licensed to provide professional 13
counseling under Title 45 of the Revised Statutes, including, but not 14
limited to, a psychiatrist, licensed practicing psychologist, certified 15
social worker, licensed clinical social worker, licensed social 16
worker, licensed marriage and family therapist, certified 17
psychoanalyst, or a person who performs counseling as part of the 18
person's professional training for any of these professions, shall not 19
engage in sexual orientation change efforts with a person under 18 20
years of age. 21
b. As used in this section, "sexual orientation change efforts" 22
means the practice of seeking to change a person's sexual 23
orientation, including, but not limited to, efforts to change 24
behaviors, gender identity, or gender expressions, or to reduce or 25
eliminate sexual or romantic attractions or feelings toward a person 26
of the same gender; except that sexual orientation change efforts 27
shall not include counseling for a person seeking to transition from 28
one gender to another, or counseling that: 29
(1) provides acceptance, support, and understanding of a person 30
or facilitates a person's coping, social support, and identity 31
exploration and development, including sexual orientation-neutral 32
interventions to prevent or address unlawful conduct or unsafe 33
sexual practices; and 34
(2) does not seek to change sexual orientation. 35
36
3. This act shall take effect immediately. 37
38
39
STATEMENT 40
41
This bill prohibits counseling to change the sexual orientation of 42
a minor. 43
Under the provisions of the bill, a person who is licensed to 44
provide professional counseling, including, but not limited to, a 45
psychiatrist, licensed practicing psychologist, certified social 46
worker, licensed clinical social worker, licensed social worker, 47
licensed marriage and family therapist, certified psychoanalyst, or a 48
person who performs counseling as part of the person's professional 49
6

training, is prohibited from engaging in sexual orientation change 1
efforts with a person under 18 years of age. 2
The bill defines "sexual orientation change efforts" as the 3
practice of seeking to change a person's sexual orientation, 4
including, but not limited to, efforts to change behaviors or gender 5
expressions, or to reduce or eliminate sexual or romantic attractions 6
or feelings toward a person of the same gender. The term, however, 7
does not include counseling for a person seeking to transition from 8
one gender to another, or counseling that: provides acceptance, 9
support, and understanding of a person or facilitates a person's 10
coping, social support, identity exploration and development, 11
including sexual orientation-neutral interventions to prevent or 12
address unlawful conduct or unsafe sexual practices; and does not 13
seek to change sexual orientation. 14
Appropriate Therapeutic Responses
to Sexual Orientation
Report of the American Psychological Association Task Force on
Task Force Members
Judith M. Glassgold, PsyD, Chair
Lee Beckstead, PhD
Jack Drescher, MD
Beverly Greene, PhD
Robin Lin Miller, PhD
Roger L. Worthington, PhD
Clinton W. Anderson, PhD, Staff Liaison
Available online at www.apa.org/pi/lgbc/publications/
Printed copies available from:
!osbInn, Cny, IIsoxunI, nnd Trnnsgondor Concorns Ofhco
Public Interest Directorate
American Psychological Association
750 First Street, NE
Washington, DC 20002-4242
202-336-6041
lgbc@apa.org
Suggested bibliographic reference:
APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Report of the Task Force on Appropriate
Therapeutic Responses to Sexual Orientation. Washington, DC: American Psychological Association.
Copyright 2009 by the American Psychological Association. This material may be reproduced in whole or in part without fees or
permission provided that acknowledgment is given to the American Psychological Association. This material may not be reprinted,
translated, or distributed electronically without prior permission in writing from the publisher. For permission, contact APA, Rights and
Permissions, 750 First Street, NE, Washington, DC 20002-4242.
APA reports synthesize current psychological knowledge in a given area and may offer recommendations for future action. They do not
constitute APA policy or commit APA to the activities described therein. This particular report originated with the APA Task Force on
Appropriate Therapeutic Responses to Sexual Orientation.
August 2009
Printed in the USA
iii
CONTENTS
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Laying the Foundation of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Psychology, Religion, and Homosexuality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2. A Brief History of Sexual Orientation Change Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Homosexuality and Psychoanalysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Sexual Orientation Change Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
/''dt.vo /,,dco '.o/ 'd dd 'odc dd o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Decline of SOCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
od .otdt. d_o -''t 'v.dod t 'o._. 'd.v.dd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
. A S,sead|c |ev|ew o| |esedc' o 'e |||cdc, o| SOC| . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
vov.o. ' to /todt.c 'ov.o. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Methodological Problems in the Research Literature on SOCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
4. A S,sead|c |ev|ew o| |esedc' o 'e |||cdc, o| SOC|. Occoaes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
'o,t ' 'oo't . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Reports of Harm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
iv 'o,t ' to /o.cd '/c_.cd /c.dt. d 'co /,,,.dto od,ot.c 'o,o t od .otdt.
5. Research on Adults Who Undergo Sexual Orientation Change Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
\/ 'd.v.dd Undergo SOCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
'o,tod ',dct ' - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
'od.._ 'o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Summary and Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
. !'e Aqqoq|de Aqq||cd|o o| A||ad|ve !'edqec|c |eve|os |o Adc|s w'o See\ SOC| . . . . . . . . . . . 54
/ 'do. ' to /,,,.dto /,,.cdt. ' /''dt.vo od,ot.c 'tovot. . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
7. Ethical Concerns and Decision Making in Psychotherapy With Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
'do ' c.ot.'c dd ''o.d 'd_ot dd ,otoco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
'oo't dd d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
't.co dd 'o,oct ' '._t dd '._.t/ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
8. Issues for Children, Adolescents, and Their Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
d 'co d_o dd 't c.d tot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
'.todto 'ov.o. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
/,,,.dto /,,.cdt. ' /''dt.vo 'tovot. \.t .do dd /docot . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
9. Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
d/ ' to /todt.c 'ov.o. ' to '.todto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Recommendations and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Aqqed| A. |eso|c|o o Aqqoq|de A||ad|ve |esqoses
to Sexual Orientation Distress and Change Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Aqqed| b. Scd|es |ev|ewed | 'e |eqo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
v Abstract
T
he American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation
conducted a systematic review of the peer-reviewed journal literature on sexual orientation change efforts
(SOCE) and concluded that 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
fo chnngo fhoIr soxunI orIonfnfIon. Thus, fho nrorInfo nIIcnfIon of nfhrmnfIvo fhornoufIc InforvonfIons for
those who seek SOCE involves therapist acceptance, support, and understanding of clients and the facilitation of
cIIonfs` ncfIvo coIng, socInI suorf, nnd IdonfIfy oxIornfIon nnd dovoIomonf, wIfhouf ImosIng n socIhc soxunI
orientation identity outcome.
ABSTRACT
1 -oct.vo d/
'
n February 2007, the American Psychological
Association (APA) established the Task Force on
Appropriate Therapeutic Responses to Sexual
Orientation with a charge that included three major
tasks:
Review and update the Resolution on Appropriate 1.
Therapeutic Responses to Sexual Orientation (APA,
1998).
Generate a report that includes discussion of 2.
the following:
Tho nrorInfo nIIcnfIon of nfhrmnfIvo -
therapeutic interventions for children and
adolescents who present a desire to change either
their sexual orientation or their behavioral
expression of their sexual orientation, or both, or
whose guardian expresses a desire for the minor
to change.
therapeutic interventions for adults who present a
desire to change their sexual orientation or their
behavioral expression of their sexual orientation,
or both.
The presence of adolescent inpatient facilities -
that offer coercive treatment designed to change
sexual orientation or the behavioral expression of
sexual orientation.
Education, training, and research issues as they -
pertain to such therapeutic interventions.
Recommendations regarding treatment protocols -
that promote stereotyped gender-normative
behavior to mitigate behaviors that are perceived
to be indicators that a child will develop a
homosexual orientation in adolescence and
adulthood.
Inform APAs response to groups that promote 3.
treatments to change sexual orientation or its
behavioral expression and support public policy that
furfhors nfhrmnfIvo fhornoufIc InforvonfIons.
As nrf of fho fuIhIImonf of Ifs chnrgo, fho fnsk
force undertook an extensive review of the recent
literature on psychotherapy and the psychology of
sexual orientation. There is a growing body of evidence
concluding that sexual stigma, manifested as prejudice
and discrimination directed at non-heterosexual sexual
orientations and identities, is a major source of stress
for sexual minorities. This stress, known as minority
stress, is a factor in mental health disparities found in
some sexual minorities. The minority stress model also
provides a framework for considering psychotherapy
with sexual minorities, including understanding
stress, distress, coping, resilience, and recovery. For
Insfnnco, fho nfhrmnfIvo nronch fo sychofhorny
grow ouf of nn nwnronoss fhnf soxunI mInorIfIos bonohf
EXECUTIVE SUMMARY
Note. We use the term sexual minority (cf. Blumenfeld, 1992; McCarn
& Fassinger, 1996; Ullerstam, 1966) to designate the entire group of
IndIvIdunIs who oxorIonco sIgnIhcnnf orofIc nnd romnnfIc nffrncfIons
to adult members of their own sex, including those who experience
attractions to members of both their own and the other sex. This term
is used because we recognize that not all sexual minority individuals
adopt a lesbian, gay, or bisexual identity.
2 'o,t ' to /o.cd '/c_.cd /c.dt. d 'co /,,,.dto od,ot.c 'o,o t od .otdt.
when the sexual stigma they experience is addressed
in psychotherapy with interventions that reduce and
counter internalized stigma and increase active coping.
The task force, in recognition of human diversity,
concofunIIzod nfhrmnfIvo InforvonfIons wIfhIn
the domain of cultural competence, consistent with
general multicultural approaches that acknowledge
the importance of age, gender, gender identity, race,
ethnicity, culture, national origin, religion, sexual
orientation, disability, language, and socioeconomic
status. We see this multiculturally competent and
nfhrmnfIvo nronch ns groundod In nn nccofnnco of
fho foIIowIng scIonfIhc fncfs:
Same-sex sexual attractions, behavior, and :
orientations per se are normal and positive variants
of human sexualityin other words, they do not
indicate either mental or developmental disorders.
Homosexuality and bisexuality are stigmatized, :
and this stigma can have a variety of negative
consequences (e.g., minority stress) throughout
the life span.
Same-sex sexual attractions and behavior occur :
in the context of a variety of sexual orientations
and sexual orientation identities, and for some,
sexual orientation identity (i.e., individual or group
momborshI nnd nfhIInfIon, soIf-InboIIng) Is uId or
hns nn IndohnIfo oufcomo.
Gay men, lesbians, and bisexual individuals form :
stable, committed relationships and families that are
equivalent to heterosexual relationships and families
in essential respects.
Some individuals choose to live their lives in :
accordance with personal or religious values
(e.g., telic congruence).
Summary of the Systematic
Review of the Literature
|||coc, oo o|e,
In order to ascertain whether there was a research
basis for revising the 1997 Resolution and providing
moro socIhc rocommondnfIons fo IIconsod monfnI
health practitioners, the public, and policymakers, the
task force performed a systematic review of the peer-
reviewed literature to answer three questions:
Are sexual orientation change efforts (SOCE) effective :
at changing sexual orientation?
Are SOCE harmful? :
Aro fhoro nny nddIfIonnI bonohfs fhnf cnn bo :
reasonably attributed to SOCE?
The review covered the peer-reviewed journal articles
in English from 1960 to 2007 and included 83 studies.
Most studies in this area were conducted before 1978,
and only a few studies have been conducted in the last
10 years. We found serious methodological problems
in this area of research, such that only a few studies
met the minimal standards for evaluating whether
psychological treatments, such as efforts to change
sexual orientation, are effective. Few studiesall
conducted in the period from 1969 to 1978could be
considered true experiments or quasi-experiments that
would isolate and control the factors that might effect
change (Birk, Huddleston, Miller, & Cohler, 1971; S.
James, 1978; McConaghy, 1969, 1976; McConaghy,
Proctor, & Barr, 1972; Tanner, 1974, 1975). Only one
of these studies (i.e., Tanner, 1974) actually compared
people who received a treatment with people who did
not and could therefore rule out the possibility that
other things, such as being motivated to change, were
the true cause of any change the researchers observed
in the study participants.
None of the recent research (19992007) meets
methodological standards that permit conclusions
rognrdIng ofhcncy or snfofy. Tho fow hIgh-qunIIfy
studies of SOCE conducted recently are qualitative (e.g.,
Beckstead & Morrow, 2004; Ponticelli, 1999; Wolkomir,
2001) and aid in an understanding of the population
that undergoes sexual orientation change but do not
rovIdo fho kInd of InformnfIon noodod for dohnIfIvo
nnswors fo quosfIons of snfofy nnd ofhcncy. CIvon fho
limited amount of methodologically sound research,
claims that recent SOCE is effective are not supported.
We concluded that the early high-quality evidence
is the best basis for predicting what would be the
outcome of valid interventions. These studies show that
enduring change to an individuals sexual orientation
is uncommon. The participants in this body of research
continued to experience same-sex attractions following
SOCI nnd dId nof roorf sIgnIhcnnf chnngo fo ofhor-
sex attractions that could be empirically validated,
though some showed lessened physiological arousal to
all sexual stimuli. Compelling evidence of decreased
same-sex sexual behavior and of engagement in sexual
behavior with the other sex was rare. Few studies
3 -oct.vo d/
provided strong evidence that any changes produced in
laboratory conditions translated to daily life. Thus, the
rosuIfs of scIonfIhcnIIy vnIId rosonrch IndIcnfo fhnf If Is
unlikely that individuals will be able to reduce same-
sex attractions or increase other-sex sexual attractions
through SOCE.
We found that there was some evidence to indicate
that individuals experienced harm from SOCE. Early
studies documented iatrogenic effects of aversive
forms of SOCE. These negative side effects included
loss of sexual feeling, depression, suicidality, and
anxiety. High drop rates characterized early aversive
treatment studies and may be an indicator that
research participants experienced these treatments
as harmful. Recent research reports on religious and
nonaversive efforts indicate that there are individuals
who perceive they have been harmed. Across studies,
If Is uncIonr whnf socIhc IndIvIdunI chnrncforIsfIcs
and diagnostic criteria would prospectively distinguish
those individuals who will later perceive that they been
harmed by SOCE.
|oo.o| \o ee |
oo e |oeece
Although the recent SOCE research cannot provide
concIusIons rognrdIng ofhcncy or snfofy, If doos
provide some information on those individuals who
nrfIcInfo In chnngo offorfs. SOCI rosonrch IdonfIhod
n ouInfIon of IndIvIdunIs who oxorIoncod conIcfs
and distress related to same-sex attractions. The
vast majority of people who participated in the early
studies were adult White males, and many of these
individuals were court-mandated to receive treatment.
In the research conducted over the last 10 years, the
population was mostly well-educated individuals,
predominantly men, who consider religion to be an
extremely important part of their lives and participate
in traditional or conservative faiths (e.g., The Church
of Jesus Christ of Latter-Day Saints, evangelical
Christianity, and Orthodox Judaism). These recent
studies included a small number of participants who
IdonfIhod ns mombors of ofhnIc mInorIfy grous, nnd n
few studies included women.
Most of the individuals studied had tried a variety of
methods to change their sexual orientation, including
psychotherapy, support groups, and religious efforts.
Many of the individuals studied were recruited from
groups endorsing SOCE. The relation between the
characteristics of the individuals in samples used in
these studies and the entire population of people who
seek SOCE is unknown because the studies have relied
entirely on convenience samples.
Former participants in SOCE reported diverse
evaluations of their experiences: Some individuals
orcoIvod fhnf fhoy hnd bonohfod from SOCI,
while others perceived that they had been harmed.
Individuals who failed to change sexual orientation,
while believing they should have changed with such
offorfs, doscrIbod fhoIr oxorIoncos ns n sIgnIhcnnf
cause of emotional and spiritual distress and negative
self-image. Other individuals reported that SOCE was
helpfulfor example, it helped them live in a manner
consistent with their faith. Some individuals described
hndIng n sonso of communIfy fhrough roIIgIous SOCI
and valued having others with whom they could
identify. These effects are similar to those provided by
mutual support groups for a range of problems, and the
osIfIvo bonohfs roorfod by nrfIcInnfs In SOCI, such
as reduction of isolation, alterations in how problems
are viewed, and stress reduction, are consistent with
fho hndIngs of fho gonornI mufunI suorf grou
literature. The research literature indicates that
fho bonohfs of SOCI mufunI suorf grous nro nof
unIquo nnd cnn bo rovIdod wIfhIn nn nfhrmnfIvo
and multiculturally competent framework, which can
mitigate the harmful aspects of SOCE by addressing
sexual stigma while understanding the importance of
religion and social needs.
Recent studies of SOCE participants do not
adequately distinguish between sexual orientation and
sexual orientation identity. We concluded
that the failure to distinguish these aspects of
human sexuality has led SOCE research to obscure
what actually can or cannot change in human sexuality.
The available evidence, from both early and recent
studies, suggests that although sexual orientation
Is unIIkoIy fo chnngo, somo IndIvIdunIs modIhod
their sexual orientation identity (i.e., individual or
grou momborshI nnd nfhIInfIon, soIf-InboIIng) nnd
other aspects of sexuality (i.e., values and behavior).
They did so in a variety of ways and with varied and
unpredictable outcomes, some of which were temporary.
For instance, in some research, individuals, through
participating in SOCE, became skilled in ignoring or
tolerating their same-sex attractions. Some individuals
report that they went on to lead outwardly heterosexual
lives, developing a sexual relationship with an other-
sex partner, and adopting a heterosexual identity.
These results were less common for those with no prior
heterosexual experience.
|eo.e o |oe
oo /oo|ece
As nrf of fho fuIhIImonf of our chnngo, wo rovIowod
the limited research on child and adolescent issues and
drew the following conclusions. There is no research
demonstrating that providing SOCE to children or
adolescents has an impact on adult sexual orientation.
The few studies of children with gender identity
disorder found no evidence that psychotherapy provided
to those children had an impact on adult sexual
orientation. There is currently no evidence that teaching
or reinforcing stereotyped gender-normative behavior
in childhood or adolescence can alter sexual orientation.
We have concerns that such interventions may increase
self-stigma and minority stress and ultimately increase
the distress of children and adolescents.
We were asked to report on adolescent inpatient
facilities that offer coercive treatment designed to
change sexual orientation or the behavioral expression
of sexual orientation. The limited published literature
on these programs suggests that many do not present
nccurnfo scIonfIhc InformnfIon rognrdIng snmo-
sex sexual orientations to youths and families, are
excessively fear-based, and have the potential to
increase sexual stigma. These efforts pose challenges
to best clinical practices and professional ethics, as
they potentially violate current practice guidelines
by not providing treatment in the least-restrictive
setting possible, by not protecting client autonomy, and
by IgnorIng curronf scIonfIhc InformnfIon on soxunI
orientation.
Recommendations
and Future Directions
|occe
The task force was asked to report on the appropriate
nIIcnfIon of nfhrmnfIvo fhornoufIc InforvonfIons
for adults who present a desire to change their sexual
orientation or their behavioral expression of their sexual
orientation, or both. The clinical literature indicated
fhnf nduIfs orcoIvo n bonohf whon fhoy nro rovIdod
with client-centered, multicultural, evidence-based
approaches that provide (a) acceptance and support, (b)
assessment, (c) active coping, (d) social support, and (e)
identity exploration and development. Acceptance and
support include unconditional acceptance and support
for the various aspects of the client; respect for the
clients values, beliefs, and needs; and a reduction in
internalized sexual stigma. Active coping includes both
cognitive and emotional strategies to manage stigma
nnd conIcfs, IncIudIng fho dovoIomonf of nIfornnfIvo
cognitive frames to resolve cognitive dissonance and
the facilitation of affective expression and resolution of
losses. Identity exploration and development include
offering permission and opportunity to explore a wide
rnngo of ofIons nnd roducIng fho conIcfs cnusod
by dIchofomous or conIcfIng concofIons of soIf nnd
identity without prioritizing a particular outcome.
This framework is consistent with multicultural and
evidence-based practices in psychotherapy (EBPP) and
Is buIIf on fhroo koy hndIngs:
Our systematic review of the early research found :
that enduring change to an individuals sexual
orientation was unlikely.
Our review of the scholarly literature on individuals :
distressed by their sexual orientation indicated that
cIIonfs orcoIvod n bonohf whon offorod InforvonfIons
that emphasize acceptance, support, and recognition
of important values and concerns.
Studies indicate that experiences of felt stigma :
such as self-stigma, shame, isolation and rejection
from relationships and valued communities, lack of
emotional support and accurate information, and
conIcfs bofwoon muIfIIo IdonfIfIos nnd bofwoon
values and attractionsplayed a role in creating
distress in individuals. Many religious individuals
desired to live their lives in a manner consistent
with their values (telic congruence); however, telic
congruence based on stigma and shame is unlikely to
result in psychological well-being.
In terms of formulating the goals of treatment, we
propose that, on the basis of research on sexual
orientation and sexual orientation identity, what
appears to shift and evolve in some individuals lives is
sexual orientation identity, not sexual orientation. Given
fhnf fhoro Is dIvorsIfy In how IndIvIdunIs dohno nnd
oxross fhoIr soxunI orIonfnfIon IdonfIfy, nn nfhrmnfIvo
approach is supportive of clients identity development
without an a priori treatment goal concerning how
clients identify or live out their sexual orientation or
spiritual beliefs. This type of therapy can provide a
safe space where the different aspects of the evolving
self can be acknowledged, explored, and respected and
potentially rewoven into a more coherent sense of self
that feels authentic to the client, and it can be helpful to
5 -oct.vo d/
those who accept, reject, or are ambivalent about their
same-sex attractions. The treatment does not differ,
although the outcome of the clients pathway to a sexual
orientation identity does. Other potential targets of
treatment are emotional adjustment, including shame
and self-stigma, and personal beliefs, values, and norms.
We were asked to report on the appropriate
for children and adolescents who present a desire to
change either their sexual orientation or the behavioral
whose parent or guardian expresses a desire for the
minor to change. The framework proposed for adults
(i.e., acceptance and support, assessment, active
coping, social support, and identity exploration and
development) is also relevantwith unique relevant
featuresto children and adolescents. For instance,
the clinical literature stresses interventions that accept
and support the development of healthy self-esteem,
facilitate the achievement of appropriate developmental
milestonesincluding the development of a positive
identityand reduce internalized sexual stigma.
Research indicates that family interventions that
reduce rejection and increase acceptance of their child
and adolescent are
helpful. Licensed
mental health
providers (LMHP) can
provide to parents
who are concerned
or distressed by
their childs sexual
orientation accurate
information about
sexual orientation and
sexual orientation
identity and can
offer anticipatory guidance and psychotherapy that
support family reconciliation (e.g., communication,
understanding, and empathy) and maintenance of the
childs total health and well-being.
Additionally, the research and clinical literature
indicates that increasing social support for sexual
minority children and youth by intervening in schools
and communities to increase their acceptance and safety
is important. Services for children and youth should
support and respect age-appropriate issues of self-
determination; services should be provided in the least
restrictive setting that is clinically possible and should
maximize self-determination. At a minimum, the assent
of the youth should be obtained and, whenever possible,
a developmentally appropriate informed consent to
treatment.
Some religious individuals with same-sex attractions
oxorIonco sychoIogIcnI dIsfross nnd conIcf duo fo fho
perceived irreconcilability of their sexual orientation
and religious beliefs. The clinical and research
literature encourages the provision of acceptance,
support, and recognition of the importance of faith
to individuals and communities while recognizing
the science of sexual orientation. This includes an
understanding of the clients faith and the psychology
of religion, especially issues such as religious coping,
motivation, and identity. Clients exploration of
possible life paths can address the reality of their
sexual orientation and the possibilities for a religiously
and spiritually meaningful and rewarding life. Such
psychotherapy can enhance clients search for meaning,
sIgnIhcnnco, nnd n roInfIonshI wIfh fho sncrod In
their lives; increase positive religious coping; foster an
understanding of religious motivations; help integrate
religious and sexual orientation identities; and reframe
sexual orientation identities to reduce self-stigma.
Licensed mental health providers strive to provide
interventions that are consistent with current ethical
standards. The APA Ethical Principles of Psychologists
and Code of Conduct (APA, 2002b) and relevant APA
guidelines and resolutions (e.g., APA, 2000, 2002c, 2004,
2005a, 2007b) are resources for psychologists, especially
IfhIcnI IrIncIIos I (Ionohf nnd Hnrm), (JusfIco),
and E (Respect for Peoples Rights and Dignity,
including self-determination). For instance, LMHP
roduco ofonfInI hnrm nnd Incronso ofonfInI bonohfs
by bnsIng fhoIr scIonfIhc nnd rofossIonnI judgmonfs
nnd ncfIons on fho mosf curronf nnd vnIId scIonfIhc
evidence, such as the evidence provided in this report
(soo AIA, 2002b, Sfnndnrd 2.04, Insos for ScIonfIhc
and Professional Judgment). LMHP enhance principles
of social justice when they strive to understand the
effects of sexual stigma, prejudice, and discrimination
on the lives of individuals, families, and communities.
Further, LMHP aspire to respect diversity in all aspects
of their work, including age, gender, gender identity,
race, ethnicity, culture, national origin, religion, sexual
orientation, disability, and socioeconomic status.
Self-determination is the process by which a person
controls or determines the course of her or his own life
(according to the Oxford American Dictionary). LMHP
maximize self-determination by (a) providing effective
psychotherapy that explores the clients assumptions
and goals, without preconditions on the outcome; (b)
providing resources to manage and reduce distress;
|\| co oooe o
ooe wo oe coceeo
o oeeo o, e c|o
e.o| oeoo occ.oe
|omoo ooo. e.o|
oeoo oo e.o|
oeoo oe, oo co
o||e ocooo, .ooce
oo o,coeoo, o
.ooo |om|, ecoc|oo
and (c) permitting the client to decide the ultimate
goal of how to self-identify and live out her or his
sexual orientation. Although some accounts suggest
that providing SOCE increases self-determination, we
were not persuaded by this argument, as it encourages
LMHP to provide treatment that has not provided
ovIdonco of ofhcncy, hns fho ofonfInI fo bo hnrmfuI, nnd
delegates important professional decisions that should
bo bnsod on qunIIhod oxorfIso nnd frnInIngsuch
as diagnosis and type of therapy. Rather, therapy
that increases the clients ability to cope, understand,
acknowledge, and integrate sexual orientation concerns
into a self-chosen life is the measured approach.
|o.coo oo o
The task force was asked to provide recommendations
on education and training for licensed mental health
practitioners working with this population. We
recommend that mental health professionals working
with individuals who are considering SOCE learn about
evidence-based and multicultural interventions and
obtain additional knowledge, awareness, and skills in
the following areas:
Sexuality, sexual orientation, and sexual identity :
development.
Various perspectives on religion and spirituality, :
including models of faith development, religious
coping, and the positive psychology of religion/
Identity development, including integration of :
multiple identities and the resolution of identity
conIcfs.
The intersections of age, gender, gender identity, :
race, ethnicity, culture, national origin, religion,
sexual orientation, disability, language, and
socioeconomic status.
Sexual stigma and minority stress. :
We also recommend that APA (a) take steps to
encourage community colleges, undergraduate
programs, graduate school training programs,
internship sites, and postdoctoral programs in
psychology to include this report and other relevant
material on lesbian, gay, bisexual, and transgender
(LGBT) issues in their curriculum; (b) maintain
the currently high standards for APA approval of
continuing professional education providers and
programs; (c) offer symposia and continuing professional
education workshops at APAs annual convention that
focus on treatment of individuals distressed by their
same-sex attractions, especially those who struggle to
integrate religious and spiritual beliefs with sexual
orientation identities; and (d) disseminate this report
widely, including publishing a version of this report in
an appropriate journal or other publication.
The information available to the public about
SOCE is highly variable and can be confusing and
misleading. Sexual minorities, individuals aware of
same-sex attractions, families, parents, caregivers,
policymakers, the public, and religious leaders can
bonohf from nccurnfo scIonfIhc InformnfIon nbouf
sexual orientation and about appropriate interventions
for individuals distressed by their same-sex attractions.
We recommend that APA take the lead in creating
informational materials for sexual minority individuals,
families, parents, and other stakeholders, including
religious organizations, on appropriate multiculturally
competent and client-centered interventions for those
distressed by their sexual orientation and who may seek
SOCE and that APA collaborate with other relevant
organizations, especially religious organizations, to
disseminate this information.
|eeoc
The task force was asked to provide recommendations
for future research. We recommend that researchers
and practitioners investigate multiculturally competent
nnd nfhrmnfIvo ovIdonco-bnsod fronfmonfs for soxunI
minorities. In addition, we recommend that researchers
and practitioners provide such treatments to those who
are distressed by their sexual orientation but not aim
to alter sexual orientation. For such individuals, the
focus would be on frameworks that include acceptance
and support, assessment, active coping, social support,
and identity exploration, development, and integration
without prioritizing one outcome over another.
The research on SOCE has not adequately assessed
ofhcncy nnd snfofy. Any fufuro rosonrch shouId conform
fo bosf-rncfIco sfnndnrds for fho dosIgn of ofhcncy
research. Research on SOCE would (a) use methods
that are prospective and longitudinal; (b) employ
sampling methods that allow proper generalization; (c)
use appropriate, objective, and high-quality measures
of sexual orientation and sexual orientation identity; (d)
address preexisting and co-occurring conditions, mental
health problems, other interventions, and life histories
to test competing explanations for any changes; and (e)
include measures capable of assessing harm.
7 -oct.vo d/
|o|c,
The task force was asked to inform (a) the associations
response to groups that promote treatments to change
sexual orientation or its behavioral expression and
(b) ubIIc oIIcy fhnf furfhors nfhrmnfIvo fhornoufIc
interventions. We encourage APA to continue its
advocacy for LGBT individuals and families and
to oppose stigma, prejudice, discrimination, and
violence directed at sexual minorities. We recommend
that APA take a leadership role in opposing the
dIsforfIon nnd soIocfIvo uso of scIonfIhc dnfn nbouf
homosexuality by individuals and organizations and
In suorfIng fho dIssomInnfIon of nccurnfo scIonfIhc
and professional information about sexual orientation
in order to counteract bias. We encourage APA to
engage in collaborative activities with religious
communities in pursuit of shared prosocial goals
when such collaboration can be done in a mutually
respectful manner that is consistent with psychologists
rofossIonnI nnd scIonfIhc roIos.
Finally, the task force recommends that the 1997
APA Resolution on Appropriate Responses to Sexual
Orientation be retained. This resolution focuses on
ethical issues for practitioners and still serves this
purpose. However, on the basis of (a) our systematic
rovIow of ofhcncy nnd snfofy Issuos, (b) fho rosonco
of SOCE directed at children and adolescents, (c) the
importance of religion for those who currently seek
SOCE, and (d) the ideological and political disputes that
affect this area, we recommend that APA adopt a new
rosoIufIon, fho !osoIufIon on ArorInfo AfhrmnfIvo
Responses to Sexual Orientation Distress and Change
Efforts, to address these issues (see Appendix A).
'
n February 2007, the American Psychological
Association (APA) established the Task Force on
Appropriate Therapeutic Responses to Sexual
Orientation with the following charge:
Review and update the Resolution on Appropriate 1.
Therapeutic Responses to Sexual Orientation (APA,
1998);
Generate a report that includes discussion of the 2.
following:
whose guardian expresses a desire for the minor to
change.
therapeutic interventions for adults who present
a desire to change their sexual orientation or their
or both.
The presence of adolescent inpatient facilities -
sexual orientation.
adulthood.
Nominations of task force members were solicited
through an open process that was widely publicized
through professional publications, electronic media,
nnd orgnnIznfIons. Tho qunIIhcnfIons soughf woro (n)
advanced knowledge of current theory and research
on the development of sexual orientation; (b) advanced
knowledge of current theory and research on therapies
that aim to change sexual orientation; and (c) extensive
oxorfIso In nfhrmnfIvo monfnI honIfh fronfmonf for
one or more of the following populations: children
and adolescents who present with distress regarding
their sexual orientation, religious individuals in
distress regarding their sexual orientation, and adults
who present with desires to their change sexual
orientation or have undergone therapy to do so. An
additional position was added for an expert in research
design and methodology. Nominations were open to
sychoIogIsfs, qunIIhod counsoIors, sychInfrIsfs, or
social workers, including members and nonmembers
of APA. Nominations of ethnic minority psychologists,
bisexual psychologists, psychologists with disabilities,
transgender psychologists, and other psychologists
PREFACE
9 Preface
who are members of underrepresented groups were
welcomed. In April 2007, then-APA President Sharon
Stephens Brehm, PhD, appointed the following people
to serve on the task force: Judith M. Glassgold, PsyD
(chair); Lee Beckstead, PhD; Jack Drescher, MD;
Beverly Greene, PhD; Robin Lin Miller, PhD; and Roger
L. Worthington, PhD.
The task force met face-to-face twice in 2007 and
supplemented these meetings with consultation and
collaboration via teleconference and the Internet.
InIfInIIy, wo rovIowod our chnrgo nnd dohnod nocossnry
bodIos of scIonfIhc nnd rofossIonnI IIfornfuro fo rovIow
to meet that charge. In light of our charge to review the
1997 resolution, we concluded that the most important
fnsk wns fo rovIow fho oxIsfIng scIonfIhc IIfornfuro on
treatment outcomes of sexual orientation change efforts.
We also concluded that a review of research before
1997 as well as since 1997 was necessary to provide
n comIofo nnd fhorough ovnIunfIon of fho scIonfIhc
literature. Thus, we conducted a review of the available
omIrIcnI rosonrch on fronfmonf ofhcncy nnd rosuIfs
published in English from 1960 on and also used
common databases such as PsycINFO and Medline,
as well as other databases such as ATLA Religion
Database, LexisNexis, Social Work Abstracts, and
Sociological Abstracts, to review evidence regarding
hnrm nnd bonohf from soxunI orIonfnfIon chnngo
efforts (SOCE). The literature review for other areas
of the report was also drawn from these databases
and included lay sources such as GoogleScholar and
material found through Internet searches. Due to our
charge, we limited our review to sexual orientation and
dId nof nddross gondor IdonfIfy, bocnuso fho hnnI roorf
of another APA task force, the Task Force on Gender
Identity and Gender Variance, was forthcoming (see
APA, 2009).
The task force received comments from the public,
professionals, and other organizations and read all
comments received. We also welcomed submission of
material from the interested public, mental health
professionals, organizations, and scholarly communities.
All nominated individuals who were not selected for the
task force were invited to submit suggestions for articles
and other material for the task force to review. We
reviewed all material received. Finally, APA staff met
with interested parties to understand their concerns.
The writing of the report was completed in 2008, with
editing and revisions occurring in 2009. After a draft
report was generated in 2008, the task force asked for
professional review by noted scholars in the area who
were also APA members. Additionally, APA boards and
committees were asked to select reviewers to provide
feedback to the task force. After these reviews were
received, the report was revised in line with these
comments. In 2009, a second draft was sent to a second
group of reviewers, including those who had previously
rovIowod fho roorf, schoInrs In fho hoId (IncIudIng
some who were not members of APA), representatives
of APA boards and committees, and APA staff. The
task force consulted with Nathalie Gilfoyle, JD, of the
AIA Ofhco of ConornI CounsoI, ns woII ns wIfh Sfohon
Iohnko, Ih, J, of fho AIA IfhIcs Ofhco. Ofhor sfnff
members of APA were consulted as needed.
We would like to thank the following two individuals
who were invaluable to the accomplishment of our
charge: Clinton W. Anderson, PhD, and Charlene
DeLong, who supported the task force. Dr. Andersons
knowIodgo of fho hoId of !CIT sychoIogy ns woII ns hIs
sage counsel, organizational experience, and editorial
advice and skills were indispensable. Ms. DeLong was
fundamental in providing technological support and
aid in coordinating the activities of the task force. Mary
Campbell also provided editorial advice on the report,
and Stephanie Liotta provided assistance in preparing
fho hnnI mnnuscrIf.
We would also like to acknowledge 2007 APA
President Sharon Stephens Brehm, PhD, who was
supportive of our goals and provided invaluable
orsocfIvo nf our hrsf moofIng, nnd fo fhnnk AInn
E. Kazdin, PhD, past president, James H. Bray, PhD,
president, and Carol D. Goodheart, EdD, president-
elect, for their support. Douglas C. Haldeman, PhD,
served as the Board of Directors liaison to the task
force in 20072008 and provided counsel and expertise.
Melba J.T. Vasquez, PhD, Michael Wertheimer, PhD,
and Armand R. Cerbone, PhD, members of the APA
Board of Directors, also reviewed this report and
provided feedback.
We would very much like to thank Gwendolyn
Puryear Keita, PhD, the executive director of the APA
Public Interest Directorate, for her advice, support,
and expertise. In addition, we acknowledge Rhea
Farberman, executive director, and Kim Mills, associate
executive director, of the APA Public and Member
CommunIcnfIons ofhco, for fhoIr oxorfIso nnd suorf.
Stephen H. Behnke, PhD, director of the APA Ethics
Ofhco, nnd nfhnIIo CIIfoyIo, AIA Ofhco of fho ConornI
Counsel, provided invaluable feedback on the report.
We acknowledge the following individuals, who
sorvod ns schoInrIy rovIowors of fho hrsf nnd socond
drafts of the report; their feedback on the content was
invaluable (in alphabetical order): Eleonora Bartoli,
PhD; Rosie Phillips Bingham, PhD; Elizabeth D.
Cardoso, PhD; Isiaah Crawford, PhD; June W. J. Ching,
PhD; David Michael Corey, PhD; Anthony DAugelli,
PhD; Sari H. Dworkin, PhD; Randall D. Ehrbar, PsyD;
Angela Rose Gillem, PhD; Terry Sai-Wah Gock, PhD;
Marvin R. Goldfried, PhD; John C. Gonsiorek, PhD;
Perry N. Halkitis, PhD; Kristin A. Hancock, PhD;
J. Judd Harbin, PhD; William L. Hathaway, PhD;
Gregory M. Herek, PhD; W. Brad Johnson, PhD; Jon
S. Lasser, PhD; Alicia A. Lucksted, PhD; Connie R.
Matthews, PhD; Kathleen M. Ritter, PhD; Darryl S.
Salvador, PsyD; Jane M. Simoni, PhD; Lori C. Thomas,
JD, PhD; Warren Throckmorton, PhD; Bianca D. M.
Wilson, PhD; Mark A. Yarhouse, PsyD; and Hirokazu
Yoshikawa, PhD.
11 'tdct.
'
n fho mId-l9?0s, on fho bnsIs of omorgIng scIonfIhc
evidence and encouraged by the social movement
for ending sexual orientation discrimination, the
American Psychological Association (APA) and other
rofossIonnI orgnnIznfIons nfhrmod fhnf homosoxunIIfy
per se is not a mental disorder and rejected the
stigma of mental illness that the medical and mental
health professions had previously placed on sexual
minorities.
1
This action, along with the earlier action
of the American Psychiatric Association that removed
homosexuality from the Diagnostic and Statistical
Manual of Mental Disorders (DSM; American
Psychiatric Association, 1973), helped counter the social
stigma that the mental illness concept had helped to
create and maintain. Through the 1970s and 1980s,
APA and its peer organizations not only adopted a range
of position statements supporting nondiscrimination
on the basis of sexual orientation (APA, 1975, 2005a;
American Psychiatric Association, 1973; American
Psychoanalytic Association, 1991, 1992; National
Association of Social Workers [NASW], 2003) but also
acted on the basis of those positions to advocate for legal
and policy changes (APA, 2003, 2005a, 2008b; NASW,
2003). On fho bnsIs of growIng scIonfIhc ovIdonco
(Gonsiorek, 1991), licensed mental health providers
1
We use the term sexual minority (cf. Blumenfeld, 1992; McCarn &
Fassinger, 1996; Ullerstam, 1966) to designate only those individuals
who oxorIonco sIgnIhcnnf orofIc nnd romnnfIc nffrncfIons fo nduIf
members of their own sex, including those who experience attractions
to members of both their own and the other sex. This term is used
because we recognize that not all sexual minority individuals adopt a
lesbian, gay, or bisexual identity.
(LMHP)
2
of all professions increasingly took the
perspective throughout this period that homosexuality
per se is a normal variant
3
of human sexuality and that
lesbian, gay, and bisexual (LGB) people deserve to be
nfhrmod nnd suorfod In fhoIr soxunI orIonfnfIon,
4

relationships, and social opportunities. This approach
to psychotherapy is generally termed of[rno/ite,
go, of[rno/ite, or lesbian, gay, and bisexual (LGB)
of[rno/ite.
Consequently, the published literature on
psychotherapeutic efforts to change sexual orientation
that had been relatively common during the 1950s
and 1960s began to decline, and approaches to
sychofhorny fhnf woro nof !CI nfhrmnfIvo cnmo
under increased scrutiny (cf. Mitchell, 1978; Wilson
& Davison, 1974). The mainstream organizations for
psychoanalysis and behavior therapythe two types
of therapeutic orientation most associated with the
published literature on sexual orientation change
therapiespublicly rejected these practices (American
Psychoanalytic Association, 1991, 1992; Davison, 1976,
1978; Davison & Wilson, 1973; Martin, 2003).
2
We use the term licensed mental health providers (LMHP) to refer
to professional providers of mental health services with a variety
of educational credentials and training backgrounds, because state
licensure is the basic credential for independent practice.
3
We use the adjective normal to denote both the absence of a mental
disorder and the presence of a positive and healthy outcome of human
development.
4
Wo dohno soxunI orIonfnfIon ns nn IndIvIdunI`s nfforns of orofIc,
sexual, romantic, and affectional arousal and desire for other persons
based on those persons gender and sex characteristics (see pp. 2932
for a more detailed discussion).
1. INTRODUCTION
In the early 1990s, some APA members began to
express concerns about the resurgence of individuals
and organizations that actively promoted the idea of
homosexuality as a developmental defect or a spiritual
and moral failing and that advocated psychotherapy
and religious ministry to alter homosexual feelings
and behaviors, because these practices seemed to
be an attempt to repathologize sexual minorities
(Drescher & Zucker, 2006; Haldeman, 1994; S. L.
Morrow & Beckstead, 2004). Many of the individuals
and organizations appeared to be embedded within
conservative political and religious movements
that supported the stigmatization of homosexuality
(Drescher, 2003; Drescher & Zucker, 2006; Southern
Poverty Law Center, 2005).
The concerns led to APAs adoption in 1997 of the
Resolution on Appropriate Therapeutic Responses to
Sexual Orientation (APA, 1998). In the resolution,
AIA ronfhrmod fho concIusIon shnrod by nII
mainstream health and mental health professions that
homosexuality is not a mental disorder and rejected any
form of discrimination based on sexual orientation. In
addition, APA highlighted the ethical issues that are
raised for psychologists when clients present with a
request to change their sexual orientationissues such
as bias, deception, competence, and informed consent
(APA, 1997; Schneider, Brown, & Glassgold, 2002). APA
ronfhrmod In fhIs rosoIufIon Ifs oosIfIon fo orfrnynIs
of lesbian, gay, and bisexual youths and adults as
monfnIIy III duo fo fhoIr soxunI orIonfnfIon nnd dohnod
nrorInfo InforvonfIons ns fhoso fhnf counforncf bIns
that is based in ignorance or unfounded beliefs about
sexual orientation (APA, 1998, p. 934).
In the years since APAs adoption of the 1997
resolution, there have been several developments
that have led some APA members to believe that the
resolution needed to be reevaluated. First, several
professional mental health and medical associations
adopted resolutions that opposed sexual orientation
change efforts
5
(SOCE) on the basis that such efforts
were ineffective and potentially harmful (e.g., American
Counseling Association, 1998; American Psychiatric
Association, 2000; American Psychoanalytic Association,
2000; NASW, 1997). In most cases, these statements
5
In this report, we use the term sexual orientation change efforts
(SOCE) to describe methods that aim to change a same-sex sexual
orientation (e.g., behavioral techniques, psychoanalytic techniques,
medical approaches, religious and spiritual approaches) to
heterosexual, regardless of whether mental health professionals or lay
individuals (including religious professionals, religious leaders, social
groups, and other lay networks, such as self-help groups) are involved.
were substantially different from APAs position, which
dId nof nddross quosfIons of ofhcncy or snfofy of SOCI.
Second, several highly publicized research reports
on samples of individuals who had attempted sexual
orientation change (e.g., Nicolosi, Byrd, & Potts,
2000; Shidlo & Schroeder, 2002; Spitzer, 2003) and
other empirical and theoretical advances in the
understanding of sexual orientation were published
(e.g., Blanchard, 2008; Chivers, Seto, & Blanchard,
2007; Cochran & Mays, 2006; Diamond, 2008; Diaz,
Ayala, & Bein, 2004; DiPlacido, 1998; Harper,
Jernewall, & Zea, 2004; Herek, 2009; Herek & Garnets,
2007; Mays & Cochran, 2001; Meyer, 2003; Mustanski,
Chivers, & Bailey, 2002; Mustanski, Rahman & Wilson,
2005; Savic & Lindstrom 2008; Szymanski, Kashubeck-
West, & Meyer, 2008).
Third, advocates who promote SOCE as well as those
who oppose SOCE have asked that APA take action on
the issue. On the one hand, professional organizations
and advocacy groups that believe that sexual
orientation change is unlikely, that homosexuality is
a normal variant of human sexuality, and that efforts
to change sexual orientation are potentially harmful
6

wanted APA to take a clearer stand and to clarify
fho conIcfIng modIn roorfs nbouf fho IIkoIIhood of
sexual orientation change (Drescher, 2003; Stlstrm
& Nissinen, 2003). On the other hand, the proponents
of SOCE that consist of organizations that adopt a
disorder model of homosexuality and/or advocate a
religious view of homosexuality as sinful or immoral
wanted APA to clearly declare that consumers have
the right to choose SOCE (Nicolosi, 2003; Nicolosi &
Nicolosi, 2002; Rosik, 2001).
For these reasons, in 2007, APA established the Task
Force on Appropriate Therapeutic Responses to Sexual
Orientation, with the following charge:
Revise and update the Resolution on Appropriate 1.
Therapeutic Responses to Sexual Orientation
(APA, 1998);
Generate a report that includes discussion of the 2.
following:
6
Two advocacy organizations (Truth Wins Out and Lambda Legal) are
encouraging those who feel they were harmed by SOCE to seek legal
action against their providers.
13 'tdct.
whose guardian expresses a desire for the minor
to change.
therapeutic interventions for adults who present a
desire to change their sexual orientation or their
or both.
The presence of adolescent inpatient facilities that -
offer coercive treatment designed to change sexual
orientation or the behavioral expression of sexual
orientation.
adulthood.
The task force addressed its charge by completing a
review and analysis of the broad psychological literature
In fho hoId. Affor rovIowIng fho oxIsfIng l99? rosoIufIon
in light of this literature review, we concluded that
a new resolution was necessary. The basis for this
conclusion, including a review and analysis of the
extant research, is presented in the body of this report,
and a new resolution for APA adoption is presented in
Appendix A.
The report starts with a brief review of the task
force charge and the psychological issues that form
the foundation of the report. The second chapter is a
brief history of the evolution of psychotherapy, from
treatments based on the idea that homosexuality is a
dIsordor fo fhoso fhnf focus on nfhrmnfIvo nronchos
to sexual orientation diversity. Chapters 3 and 4 are
a review of the peer-reviewed research on SOCE.
Chapter 3 provides a methodological evaluation of this
research, and Chapter 4 reports on the outcomes of this
research. Chapter 5 reviews a broader base of literature
regarding the experience of individuals who seek SOCE
in order to elucidate the nature of clients distress and
IdonfIfy conIcfs. Chnfor 6 fhon oxnmInos nfhrmnfIvo
approaches for psychotherapy practice with adults and
rosonfs n socIhc frnmowork for InforvonfIons. Chnfor
7 returns to the 1997 APA resolution and its focus on
ethics to provide an updated discussion of the ethical
issues surrounding SOCE. Chapter 8 considers the
more limited body of research on SOCE and reports of
nfhrmnfIvo sychofhorny wIfh chIIdron, ndoIosconfs,
and their families. Chapter 9 summarizes the report
and presents recommendations for research, practice,
education, and policy. The policy resolution that the task
force recommends for APAs adoption is Appendix A.
Laying the Foundation
of the Report
Joeoo /||moe
eooe.c |eeo
The task force was asked to report on appropriate
nIIcnfIon of nfhrmnfIvo sychofhornoufIc
interventions for those who seek to change their
soxunI orIonfnfIon. As somo dobnfos In fho hoId
frame SOCE and conservative religious values as
comofIng vIowoInfs fo nfhrmnfIvo nronchos (cf.
Throckmorton, 1998; Yarhouse, 1998a) and imply that
fhoro Is nn nIfornnfIvo noufrnI sfnnco, wo consIdorod
it necessary to explain the term of[rno/ite /leropeu/ic
interventions, its history, its relationship to our
charge and current psychotherapy literature, and our
nIIcnfIon nnd dohnIfIon of fho form. Tho concof of
gny-nfhrmnfIvo fhornoufIc InforvonfIons omorgod
in the early literature on the psychological concerns
of sexual minorities (Paul, Weinrich, Gonsiorek, &
Hotvedt, 1982; Malyon, 1982), and its meaning has
evolved over the last 25 years to include more diversity
and complexity (Bieschke, Perez, & DeBord, 2007;
Herek & Garnets, 2007; Perez, DeBord, & Bieschke,
2000; Ritter & Terndrup, 2002).
Tho nfhrmnfIvo nronch grow ouf of n orcofIon
fhnf soxunI mInorIfIos bonohf whon fho soxunI sfIgmn
7

they experience is addressed in psychotherapy with
interventions that address the impacts of stigma (APA,
2000; Brown, 2006; Browning, Reynolds, & Dworkin,
1991; Davison, 1978; Malyon, 1982; Ritter & Terndrup,
2002; Shannon & Woods, 1991; Sophie, 1987). For
example, Garnets, Hancock, Cochran, Goodchilds,
and Peplau (1991) proposed that LHMP use an
understanding of societal prejudice and discrimination
to guide treatment for sexual minority clients and
help these clients overcome negative attitudes about
themselves.
7
Soo . l5 for fho dohnIfIon of soxunI sfIgmn.
Tho mosf roconf IIfornfuro In fho hoId (o.g., AIA,
2000, 2002c, 2004, 2005b, 2007b; Bartoli & Gillem,
2008; Brown, 2006; Herek & Garnets, 2007) places
nfhrmnfIvo fhornoufIc InforvonfIons wIfhIn fho Inrgor
domain of cultural competence, consistent with general
multicultural approaches. Multicultural approaches
recognize that individuals, families, and communities
exist in social, political, historical, and economic
contexts (cf. APA, 2002b) and that human diversity is
multifaceted and includes age, gender, gender identity,
status. Understanding and incorporating these aspects
of diversity are important to any intervention (APA,
2000, 2002c, 2004, 2005b, 2007b).
The task force takes the perspective that a multi-
cuIfurnIIy comofonf nnd nfhrmnfIvo nronch wIfh
soxunI mInorIfIos Is bnsod on fho scIonfIhc knowIodgo
in key areas: (a) homosexuality and bisexuality are
stigmatized, and this stigma can have a variety
of negative consequences throughout the life span
(DAugelli & Patterson, 1995, 2001); (b) same-sex
sexual attractions, behavior, and orientations per se are
normal and positive variants of human sexuality and
are not indicators of either mental or developmental
disorders (American Psychiatric Association, 1973;
APA, 2000; Gonsiorek, 1991); (c) same-sex sexual
attractions and behavior can occur in the context of a
variety of sexual orientation identities (Klein, Sepekoff,
& Wolf, 1985; McConaghy, 1999; Diamond, 2006,
2008); and (d) lesbians, gay men, and bisexual people
can live satisfying lives and form stable, committed
relationships and families that are equivalent to
heterosexuals relationships and families in essential
respects (APA, 2005c; Kurdek, 2001, 2003, 2004; Peplau
& Fingerhut, 2007).
AIfhough nfhrmnfIvo nronchos hnvo hIsforIcnIIy
been conceptualized around helping sexual minorities
accept and adopt a gay or lesbian identity (e.g.,
Browning et al., 1991; Shannon & Woods, 1991), the
recent research on
sexual orientation
identity diversity
illustrates that
sexual behavior,
sexual attraction,
and sexual
orientation identity
are labeled and expressed in many different ways, some
of whIch nro uId (o.g., Inmond, 2006, 2008; IIrosfoIn,
2007; Fox, 2004; Patterson, 2008; Savin-Williams, 2005;
!. !. WorfhIngfon & !oynoIds, 2009). Wo dohno nn
nfhrmnfIvo nronch ns suorfIvo of cIIonfs` IdonfIfy
development without a priori treatment goals for how
clients identify or express their sexual orientations.
Thus, n muIfIcuIfurnIIy comofonf nfhrmnfIvo nronch
aspires to understand the diverse personal and cultural
Inuoncos on cIIonfs nnd onnbIos cIIonfs fo doformIno
(a) the ultimate goals for their identity process; (b) the
behavioral expression of their sexual orientation; (c)
their public and private social roles; (d) their gender
roles, identities, and expression;
8
(e) the sex
9
and gender
of their partner; and (f) the forms of their relationships.
-v''-`-'/-' ''/'- /`' -'''''/''
''''-' '-/'-`
Inforosf In fho ofhcncy,
10
effectiveness, and empirical
basis of psychotherapeutic interventions has grown in
the last decade. Levant and Hasan (2009) distinguished
between two types of treatments: empirically supported
treatments (EST) and evidence-based approaches
to psychotherapy (EBPP). EST are interventions for
IndIvIdunIs wIfh socIhc dIsordors fhnf hnvo boon
demonstrated as effective through rigorously controlled
frInIs (!ovnnf & Hnsnn, 2009). IIII Is, ns dohnod by
APAs Policy Statement on Evidence-Based Practice
in Psychology
11
(2005n), fho InfogrnfIon of fho bosf
available research with clinical expertise in the context
of patient characteristics, culture, and preferences
(p. 1; see also, Sackett, Rosenberg, Gray, Haynes, &
Richardson, 1996).
Wo woro nof nbIo fo IdonfIfy nfhrmnfIvo IST for
this population (cf. Martell, Safran, & Prince, 2004).
The lack of EST is a common dilemma when working
with diverse populations for whom EST have not been
developed or when minority populations have not been
8
Gender refers to the cultural roles, behaviors, activities, and
psychological attributes that a particular society considers appropriate
for men and women. Gender identity is a persons own psychological
sonso of IdonfIhcnfIon ns mnIo or fomnIo, nnofhor gondor, or
identifying with no gender. Gender expression is the activities and
behaviors that purposely or inadvertently communicate our gender
identity to others, such as clothing, hairstyles, mannerisms, way of
speaking, and social roles.
9
Wo dohno sex as biological maleness and femaleness in contrast to
gondor, dohnod nbovo.
10
1f[coc, is the measurable effect of an intervention, and effectiveness
aims to determine whether interventions have measurable effects
in real-world settings across populations (Nathan, Stuart, & Dolan,
2000).
11
Discussion of the overall implications for practice can be found in
Goodheart, Kazdin, and Sternberg (2006) and the Report of the 2005
Presidential Task Force on Evidence-Based Practice (APA, 2005b).
\e oe|e o o||moe
oooooc o .oooe o|
c|e oe, oee|oome
wo. o oo eome
oo| |o ow c|e oe|, o
eoe e e.o| oeoo
15 'tdct.
included in trials (Brown, 2006; Martell et al., 2004; Sue
& Zane, 2006; Whaley & Davis, 2007). Thus, we provide
nn nfhrmnfIvo modoI In Chnfor 6 fhnf Is consIsfonf
wIfh AIA`s dohnIfIon of IIII In fhnf If nIIos fho
most current and best evidence available to guide
decisions about the care of this population (APA, 2005a;
Sackett et al., 1996). We considered the APA EBPP
rosoIufIon ns ufIIIzIng n oxIbIo concof of ovIdonco,
because it incorporates research based on well-designed
studies with client values and clinical expertise. Given
that the distress surrounding sexual orientation is not
included in psychotherapy research (because it is not a
cIonrIy dohnod syndromo) nnd mosf fronfmonf sfudIos
In sychoIogy nro for socIhc monfnI honIfh dIsordors,
not for problems of adjustment or identity relevant to
soxunI orIonfnfIon concorns, wo snw fhIs oxIbIIIfy ns
nocossnry (Irown, 2006). Howovor, IST for socIhc
dIsordors cnn bo Incorornfod Info fhIs nfhrmnfIvo
approach (cf. Martell et al., 2004). We acknowledge that
fho modoI rosonfod In fhIs roorf wouId bonohf from
rigorous evaluation.
AfhrmnfIvo nronchos, ns undorsfood by fhIs fnsk
forco, nro ovIdonco-bnsod In fhroo sIgnIhcnnf wnys:
They are based on the evidence that homosexuality :
is not a mental illness or disorder, which has
n sIgnIhcnnf omIrIcnI foundnfIon (AIA, 2000;
Gonsiorek, 1991).
They are based on studies of the role of stigma :
in creating distress and health disparities in
sexual minorities (Cochran & Mays, 2006; Mays &
Cochran, 2001; Meyer, 1995, 2003; Pachankis, 2007;
Pachankis & Goldfried, 2004; Pachankis, Goldfried, &
Ramrattan, 2008; Safren & Heimberg, 1999).
They are based on the literature that has shown :
the importance of the therapeutic alliance and
relationship on outcomes in therapy and that these
outcomes are linked to empathy, positive regard,
honesty, and other factors encompassed in the
nfhrmnfIvo orsocfIvo on fhornoufIc InforvonfIons
(Ackerman & Hilsenroth, 2003; Brown, 2006; Farber
& Lane, 2002; Horvath & Bedi, 2002; Norcross, 2002;
Norcross & Hill, 2004).
Tho nfhrmnfIvo nronch wns fho subjocf of n roconf
literature review that found that clients describe the
snfofy, nfhrmnfIon, omnfhy, nnd nonjudgmonfnI
nccofnnco Inhoronf In fho nfhrmnfIvo nronch ns
helpful in their therapeutic process (M. King, Semlyen,
Killaspy, Nazareth, & Osborn, 2007; see also, M. A.
Jones & Gabriel, 1999). King et al. concluded that a
knowledge base about sexual minorities lives and social
context is important for effective practice.

e.o| mo
To understand the mental health concerns of
sexual minorities, one must understand the social
psychological concept of stigma (Herek & Garnets,
200?). Coffmnn (l963) dohnod sfIgmn ns nn undosIrnbIo
difference that discredits the individual. Link and
Phelan (2001) characterized stigma as occurring
when (a) individual differences are labeled; (b) these
differences are linked to undesirable traits or negative
stereotypes; (c) labeled individuals are placed in distinct
categories that separate them from the mainstream;
and (d) labeled persons experience discrimination and
loss of status that lead to unequal access to social,
economic, and political power. This inequality is a
consequence of stigma and discrimination rather than
of the differences themselves (Herek, 2009). Stigma is
a fact of the interpersonal, cultural, legal, political, and
social climate in which sexual minorities live.
Tho sfIgmn fhnf dohnos soxunI mInorIfIos hns boon
termed sexual stigma:
12
fho sfIgmn nffnchod fo nny
non-heterosexual behavior, identity, relationship or
community (Herek, 2009, p. 3). This stigma operates
both at the societal level and at the individual level. The
impact of this stigma as a stressor may be the unique
factor that characterizes sexual minorities as a group
(Herek, 2009; Herek & Garnets, 2007; Katz, 1995).
Further, stigma has shaped the attitudes of mental
health professions and related institutions toward
this population
(Drescher, 1998a;
Haldeman, 1994;
LeVay, 1996; Murphy,
1997; Silverstein,
1991). Moral and
religious values in
North America and
Europe provided the
initial rationale for
criminalization, discrimination, and prejudice against
same-sex behaviors (Katz, 1995). In the late modern
period, the medical and mental health professions
added a new type of stigmatization and discrimination
12
Herek (2009) coined this term, and we use it because of the
comprehensive analysis in which it is embedded. There are other
terms for the same construct, such as Balsam and Mohrs (2007)
sexual orientation stigma.
| e |oe mooe oeoo
e meoco| oo meo|
eo| oo|eo oooeo o
ew ,oe o| mozoo
oo ocmoo o,
coceo.o|z oo eo
omoe.o|, o o meo|
||e o oooe
by conceptualizing and treating homosexuality as a
mental illness or disorder (Brown, 1996; Katz, 1995).
Sexual minorities may face additional stigmas,
as well, such as those related to age, gender, gender
identity, race, ethnicity, culture, national origin,
religion, sexual orientation, disability, language, and
socioeconomic status. At the societal level, sexual
stigma is embedded in social structures through civil
and criminal law, social policy, psychology, psychiatry,
medicine, religion, and other social institutions.
SoxunI sfIgmn Is roocfod In dIsnrnfo IognI nnd
social treatment by institutions and is apparent in,
for example, (a) the long history of criminalization
of same-sex sexual behaviors; (b) the lack of legal
protection for LGB individuals from discrimination
in employment, health care, and housing; and (c) the
Inck of bonohfs for !CI roInfIonshIs nnd fnmIIIos fhnf
would support their family formation, in contrast to the
oxfonsIvo bonohfs fhnf nccruo fo hoforosoxunI mnrrIod
couples and even sometimes to unmarried heterosexual
couples.
13
The structural sexual stigma, called
heterosexism in the scholarly literature, legitimizes
and perpetuates stigma against sexual minorities and
perpetuates the power differential between sexual
minorities and others (Herek, 2007; see also Szymanski
et al., 2008).
Expressions of stigma, such as violence, discrimin-
ation, rejection, and other negative interpersonal
interactions, are enacted stigma (Herek, 2009).
Individuals expectations about the probability that
stigma will be enacted in various situations is felt
stigma. Individuals efforts to avoid enacted and felt
stigma may include withdrawing from self (e.g., self-
denial or compartmentalization) and withdrawing from
others (e.g., self-concealment or avoidance) (e.g., see
Beckstead & Morrow, 2004; Drescher, 1998a; Malyon,
1982; Pachankis, 2007; Pachankis, Goldfried, &
Ramrattan, 2008; Troiden, 1993).
In Hereks (2009) model, internalized stigma
14
is
the adoption of the social stigma applied to sexual
13
Same-sex sexual behaviors were only recent universally
decriminalized in the United States by Supreme Court action
in Lawrence v. Texas (2003). There is no federal protection from
employment and housing discrimination for LGB individuals, and
only 20 states offer this protection. Only 4 states permit same-sex
couples to marry, 7 permit civil unions or domestic partnerships,
and 5 have some limited form of recognition. For more examples, see
National Gay and Lesbian Task Force, n.d.).
14
Horok (2009) dohnod InfornnIIznfIon ns fho rocoss whoroby
individuals adopt a social value, belief, regulation, or prescription for
conduct as their own and experience it as part of themselves (p. 7).
The internalization of negative attitudes and assumptions concerning
homosexuality has often been termed internalized homophobia
minorities. Members of the stigmatized groups as well
as nonmembers of the group can internalize these
values. Self-stigma is internalized stigma in those
individuals who experience same-sex sexual attractions
and whose self-concept matches the stigmatizing
interpretations of society. Examples of this self-stigma
are (a) accepting societys negative evaluation and (b)
harboring negative attitudes toward oneself and ones
own same-sex sexual attractions. Sexual prejudice
is the internalized sexual stigma held by the non-
stigmatized majority.
e |mooc o| mo o \emoe
o| mozeo o.o
One of the assumptions of the stigma model is that
socInI sfIgmn Inuoncos fho IndIvIdunI fhrough
its impact on the different settings, contexts, and
relationships that each human being is a part of
(DAugelli, 1994). This hypothesis appears to be
conhrmod by n body of IIfornfuro comnrIng soxunI
minority populations to the general population that
has found health disparities between the two (Cochran
& Mays, 2006; Mays & Cochran, 2001). The concept of
minority stress (e.g., DiPlacido, 1998; Hatzenbuehler,
Nolen-Hoeksema, & Erickson, 2008; Meyer, 1995,
2003) has been increasingly used to explain these
health disparities in much the same way that concepts
of racism-derived stress and minority stress have
been used to explain health disparities and mental
health concerns in ethnic minority groups (Carter,
2007; Harrell, 2000; Mays, Cochran, & Barnes, 2007;
Saldaina, 1994; Wei, Ku, Russell, Mallinckrodt, &
Liao, 2008). Theoretically any minority group facing
social stigma and prejudice, including stigma due to
age, gender, gender identity, race, ethnicity, culture,
national origin, religion, sexual orientation, disability,
language, and socioeconomic status, could develop
minority stress.
In theory, minority stresschronic stress experienced
by members of minority groupscauses distress in
certain sexual minority individuals (DiPlacido, 1998;
Meyer, 1995, 2003). Meyer (2003) described these stress
processes as due to (a) external objective events and
conditions, such as discrimination and violence;
(b) expectations of such events, and the vigilance that
(Malyon, 1982; Sophie, 1987; Weinberg, 1972). However, this term has
been criticized because holding negative attitudes does not necessarily
InvoIvo n hobIn; In ofhor words, nn oxnggornfod usunIIy InoxIIcnbIo
and illogical fear of a particular object, class of objects, situation
(Merriam-Websters Online Dictionary, n.d.).
17 'tdct.
such expectations bring; and (c) internalization of
negative social and cultural attitudes. For instance,
mental health outcomes among gay men have been
found fo bo Inuoncod by nognfIvo nrnIsnIs of sfIgmn-
related stressors (Meyer, 1995).
The task force sees stigma and minority stress as
playing a manifest role in the lives of individuals
who seek to change their sexual orientation (Davison,
1978, 1982, 1991; Herek, Cogan, Gillis, & Glunt, 1998;
Green, 2003; Silverstein, 1991; Tozer & Hayes, 2004).
Davison, in particular, has argued that individuals who
seek psychotherapy to change their sexual orientation
do so because of the distress arising from the impact
of stigma and discrimination. A survey of a small
sample of former SOCE clients in Britain supports
this hypothesis, as many of the former participants
reported that hostile social and family attitudes and the
criminalization of homosexual conduct were the reasons
they sought treatment (Smith, Bartlett, & King, 2004).
One of the advantages of the minority stress model
is that it provides a framework for considering the
social context of stress, distress, coping, resilience
(Allen, 2001; David & Knight, 2008; Herek, Gillis, &
Cogan, 2009; Selvidge, Matthews, & Bridges, 2008;
Levitt et al., 2009; Pachankis, 2007), and the goals of
nfhrmnfIvo sychofhorny (Iocksfond & IsrnoI, 200?;
Bieschke, 2008; Frost & Meyer, 2009; Glassgold, 2007;
Rostosky, Riggle, Horne, & Miller, 2009; Martell et al.,
2004; Russell & Bohan, 2007). Some authors propose
that lesbians, gay men, and bisexual men and women
improve their mental health and functioning through
a process of positive coping, termed stigma competence
(David & Knight, 2008). In this model, it is proposed
that through actions such as personal acceptance of
ones LGB identity and reduction of internalized stigma,
an individual develops a greater ability to cope with
stigma (cf. Crawford, Allison, Zamboni, & Soto, 2002;
DAugelli, 1994). For instance, Herek and Garnets
(2007) proposed that collective identity (often termed
social identity)
15
mitigates the impact of minority stress
above and beyond the effects of individual factors such
as coping skills, optimism, and resiliency. Individuals
with a strong sense of positive collective identity
Infogrnfo fhoIr grou nfhIInfIon Info fhoIr coro soIf-
concept and have community resources for responding
to stigma (Balsam & Mohr, 2007; Crawford et al.,
2002; Levitt et al., 2009). In support of this hypothesis,
Balsam and Mohr (2007) found that collective identity,
15
A collective or social identity refers to an individuals sense of
belonging to a group (the collective), and the collective or social
identity forms a part of his or her personal identity.
community participation, and identity confusion
predicted coping with sexual stigma.
Psychology, Religion,
and Homosexuality
Most of the recent studies on SOCE focus on
populations with strong religious beliefs (e.g., Beckstead
& Morrow, 2004; Nicolosi et al., 2000; Schaeffer, Hyde,
Kroencke, McCormick, & Nottebaum, 2000; Ponticelli,
1999; Spitzer, 2003; Tozer & Hayes, 2004; Wolkomir,
2001). Beliefs about sexual behavior and sexual
orientation rooted in interpretations of traditional
religious doctrine also guide some efforts to change
others sexual orientation as well as political opposition
to the expansion of civil rights for LGB individuals
and their relationships (Burack & Josephson, 2005; S.
L. Morrow & Beckstead, 2004; Southern Poverty Law
Center, 2005; Pew Forum on Religion and Public Life,
2003; Olyam & Nussbaum, 1998). One of the issues
in SOCE is the expansion of religiously based SOCE.
Religious beliefs, motivations, and struggles play a role
in the motivations of individuals who currently engage
in SOCE (Beckstead & Morrow, 2004; Ponticelli, 1999;
Shidlo & Schroeder, 2002; Wolkomir, 2001; Yarhouse,
Tan, & Pawlowski, 2005). Thus, we considered an
examination of issues in the psychology of religion to be
nn Imorfnnf nrf In fuIhIIIng our chnrgo.

|eeco o| |,co|o, |e|o
oo e.o| eoo
World religions regard homosexuality from a spectrum
of viewpoints. It is important to note that some
religious denominations beliefs and practices have
chnngod ovor fImo, roocfIng ovoIvIng scIonfIhc nnd
civil rights perspectives on homosexuality and sexual
orientation (see, e.g., Dorff, Nevins, & Reisner, 2006;
Hebrew Union College, n.d.; Olyam & Nussbaum,
1998; Ontario Consultants on Religious Tolerance,
n.d). A number of religious denominations in the
United States welcome LGB laity, and a smaller
number ordain LGB clergy (e.g., Reconstructionist
Judaism, Reform Judaism, Conservative Judaism,
Buddhist Peace Fellowship, Buddhist Churches
of America, Episcopal Church of America, Friends
General Conference, Unitarian Society, United Church
of Christ Congregational) (Greenberg, 2004; Hebrew
Union College, n.d.; Olyam & Nussbaum, 1998; Ontario
Consultants on Religious Tolerance, n.d.). However,
others view homosexuality as immoral and sinful (e.g.,
Christian Reformed Church of North America, Church
of Jesus Christ of Latter-Day Saints, Eastern Orthodox
Christianity, Orthodox Judaism, Presbyterian Church
in American, Roman Catholicism, Southern Baptist
Convention, United Methodist Church) (Ontario
Consultants on Religious Tolerance, n.d.). These issues
are being discussed within numerous denominations
(e.g., Van Voorst, 2005), and some views are in
ux (o.g., fho IrosbyforInn Church (!SA) (OnfnrIo
Consultants on Religious Tolerance, n.d).
Several professional publications (e.g., Journal of Gay
and Lesbian Psychotherapy, 2001, 5[3/4]; Professional
Psychology, 2002, 33[3]; Archives of Sexual Behavior,
2003, 32[5]; The
Counseling Psychologist,
2004, 32[5]; Journal
of Psychology and
Christianity, 2005,
24|4]) hnvo socIhcnIIy
considered the
interactions among
scIonfIhc vIows of soxunI
orientation, religious
beliefs, psychotherapy,
and professional ethics.
Somo dIfhcuIfIos nrIso
because the professional
psychological community considers same-sex sexual
attractions and behaviors to be a positive variant of
human sexuality, while some traditional faiths continue
to consider it a sin, moral failing, or disorder that needs
to be changed.
Tho conIcf bofwoon sychoIogy nnd frndIfIonnI fnIfhs
may have its roots in different philosophical viewpoints.
Some religions give priority to telic congruence (i.e.,
living consistently within ones valuative goals
16
) (W.
Hathaway, personal communication, June 30, 2008; cf.
Richards & Bergin, 2005). Some authors propose that
for adherents of these religions, religious perspectives
and values should be integrated into the goals of
psychotherapy (Richards & Bergin, 2005; Throckmorton
& Ynrhouso, 2006). AfhrmnfIvo nnd muIfIcuIfurnI
models of LGB psychology give priority to organismic
congruence (i.e., living with a sense of wholeness in
ones experiential self
17
) (W. Hathaway, personal
16
Thoso conIcfs nro nof unIquo fo roIIgIous IndIvIdunIs buf nro
applicable to individuals making commitments and decisions about
how fo IIvo nccordIng fo socIhc ofhIcs nnd IdonIs (cf. InumoIsfor &
Exline, 2000; Diener, 2000; Richards & Bergin, 2005; Schwartz, 2000).
17
Such naturalistic and empirically based models stress the
communication, June 30, 2008; cf. Gonsiorek, 2004;
Malyon, 1982). This perspective gives priority to the
unfolding of developmental processes, including self-
awareness and personal identity.
This difference in worldviews can impact
psychotherapy. For instance, individuals who have
strong religious beliefs can experience tensions and
conIcfs bofwoon fhoIr IdonI soIf nnd boIIofs nnd fhoIr
sexual and affectional needs and desires (Beckstead
& Morrow, 2004; D. F. Morrow, 2003). The different
worldviews would approach psychotherapy for these
individuals from dissimilar perspectives: The telic
strategy would prioritize values (Rosik, 2003; Yarhouse
& Burkett, 2002), whereas the organismic approach
would give priority to the development of self-awareness
and identity (Beckstead & Israel, 2007; Gonsiorek,
2004; Haldeman, 2004). It is important to note that
the organismic worldview can be congruent with
and respectful of religion (Beckstead & Israel, 2007;
Glassgold, 2008; Gonsiorek, 2004; Haldeman, 2004;
Mark, 2008), and the telic worldview can be aware
of sexual stigma and respectful of sexual orientation
(Throckmorton & Yarhouse, 2006; Tan, 2008; Yarhouse,
2008). Understanding this philosophical difference may
improve the dialogue between these two perspectives
represented in the literature, as it refocuses the debate
not on one groups perceived rejection of homosexuals
or the other groups perceived minimization of religious
viewpoints but on philosophical differences that extend
beyond this particular subject matter. However, some of
the differences between these philosophical assumptions
mny bo dIfhcuIf fo brIdgo.
Contrasting views exist within psychology regarding
religious views about homosexuality. One way in which
psychology has traditionally examined the intersections
between religion and homosexuality is by studying the
impact of religious beliefs and motivations on attitudes
and framing the discussion in terms of tolerance and
prejudice (Fulton, Gorsuch, & Maynard, 1999; Herek,
1987; Hunsberger & Jackson, 2005; Plugge-Foust
& Strickland, 2000; Schwartz & Lindley, 2005). For
Insfnnco, ono hndIng Is fhnf roIIgIous fundnmonfnIIsm
is correlated with negative views of homosexuality,
whereas a quest orientation is associated with decreased
discriminatory or prejudicial attitudes (Batson, Flink,
Schoenrade, Fultz, & Pych, 1986; Batson, Naifeh,
& Pate, 1978; Fulton et al., 1999; Plugge-Foust &
Strickland, 2000). However, some authors have argued,
organization, unity, and integration of human beings expressed
through each individuals inherent growth or developmental tendency
(see, e.g., Rogers, 1961; Ryan, 1995).
ome o||c.|e oe
oeco.e e oo|eoo|
o,co|oco| comm.,
cooe omee e.o|
ooco oo oeoo
o oe o ooe oo o|
.mo e.o|, w|e ome
oooo| |o co.e
o cooe o moo|
|o| o oooe o
eeo o oe coeo
19 'tdct.
in contrast to this approach, that conservative religious
moral beliefs and evaluations about same-sex sexual
behaviors and LGB individuals and relationships should
be treated as religious diversity rather than as sexual
prejudice (e.g., Rosik, 2007; Yarhouse & Burkett, 2002;
Yarhouse & Throckmorton, 2002).
/|/ |o|ce o e |eeco
o| |e|o oo |,co|o,
APA has addressed the interactions of religion and
psychology in two recent resolutions: the Resolution
!ojocfIng InfoIIIgonf osIgn ns ScIonfIhc nnd
!onfhrmIng Suorf for IvoIufIonnry Thoory (AIA,
2008b) and the Resolution on Religious, Religion-
Related, and/or Religion-Derived Prejudice (2008c). The
hrsf rosoIufIon nrfIcuInfos sychoIogy`s oIsfomoIogIcnI
commitment: Hypothesis testing through rigorous
scIonfIhc mofhods Is fho bosf monns fo gnIn now
knowledge and to evaluate current practices, and
psychologists base their theories on such research:
While we are respectful of religion and individuals
right to their own religious beliefs, we also
recognize that science and religion are separate and
distinct. For a theory to be taught as science it must
be testable, supported by empirical evidence and
subjocf fo dIsconhrmnfIon. (AIA, 200?n)
This is in contrast to viewpoints based on faith, as faith
doos nof nood conhrmnfIon fhrough scIonfIhc ovIdonco.
Further, science assumes some ideas can be rejected
when proven false; faith and religious beliefs cannot be
fnIsIhod In fho oyos of ndhoronfs.
The APA Council of Representatives also passed
a Resolution on Religious, Religion-Related, and/or
Religion-Derived Prejudice (2008b). This resolution
acknowledges the
existence of two forms
of prejudice related to
religion: one derived
from religious beliefs
and another directed
at religions and their
adherents. The APA
strongly condemns
both forms of prejudice.
Tho rosoIufIon nfhrms
APAs position that
prejudices directed at individuals because of their
roIIgIous boIIofs nnd rojudIcos dorIvod from or jusfIhod
by religion are harmful to individuals, society, and
international relations.
In nrons of conIcfs bofwoon sychoIogy nnd
religion, as the APA Resolution on Religious, Religion-
Related, and/or Religion-Derived Prejudice (2008b)
states, psychology has no legitimate function in
nrbIfrnfIng mnffors of fnIfh nnd fhooIogy (IIno 433)
or fo ndjudIcnfo roIIgIous or sIrIfunI fonofs, nnd
psychologists are urged to limit themselves to speak
fo sychoIogIcnI ImIIcnfIons of roIIgIous/sIrIfunI
boIIofs or rncfIcos whon roIovnnf sychoIogIcnI hndIngs
about those implications exist (line 433). Further,
fho rosoIufIon sfnfos fhnf fnIfh frndIfIons hnvo no
legitimate place arbitrating behavioral or other
scIoncos (IIno 432) or fo ndjudIcnfo omIrIcnI scIonfIhc
issues in psychology (line 432).
The APA (2002b, 2008c) recommends that
psychologists acknowledge the importance of religion
and spirituality as forms of meaning-making,
tradition, culture, identity, community, and diversity.
Psychologists do not discriminate against individuals
based on those factors. Further, when devising
interventions and conducting research, psychologists
consider the importance of religious beliefs and cultural
values and, where appropriate, consider religiously and
culturally sensitive techniques and approaches (APA,
2008c).
|,co|o, o| |e|o
Historically, some in psychology and psychiatry have
held negative views of religion (Wulff, 1997). Yet, with
the development of more sophisticated methodologies
nnd concofunIIznfIons, fho hoId of fho sychoIogy of
roIIgIon hns ourIshod In fho Insf 30 yonrs (Immons
& Paloutzian, 2003), culminating in new interest in a
dIvorso hoId (o.g., KoonIg & !nrson, 200l; InIoufzInn &
Park, 2005; Pargament, 2002; Pargament & Mahoney,
2005; Richards & Bergin, 2005; Sperry & Shafranske,
2004; Spilka, Hood, Hunsberger, & Gorsuch, 2003).
Many scholars have attempted to elucidate what is
sIgnIhcnnf nnd unIquo nbouf roIIgIous nnd sIrIfunI
faith, beliefs, and experiences (e.g., George, Larson,
Koenig, & McCullough, 2000; McClennon, 1994).
Pargament, Maygar-Russell, and Murray-Swank
(2005) summarized religions impact on peoples lives
as a unique form of motivation regarding how to
live ones life and how to respond to self, others, and
IIfo ovonfs; n sourco of sIgnIhcnnco rognrdIng whnf
aspects of life one imbues with meaning and power; a
contributor to mortality and health; a form of positive
e eo|.o o||m /|/
ooo o oe.oce
oeceo o oo.o|
oeco.e o| e e|o.
oe|e| oo oe.oce
oeeo |om o .|eo
o, e|o oe om|.| o
oo.o| oce, oo
eooo| e|oo
nnd nognfIvo coIng; nnd n sourco of fuIhIImonf nnd
distress. Others, such as Fowler (1981, 1991) and
colleagues (Oser, 1991; Streib, 2001, 2005) have posited
developmental models of religious identity that are
helpful in understanding personal faith.
Additionally, there is a growing literature on
integrating spirituality into psychotherapy practice
(Richards & Bergin, 2000, 2004, 2005; Shafranske,
2000; Sperry & Shafranske, 2004; E. L. Worthington,
Kurusu, McCullough, & Sandage, 1996). These
approaches include delineating how LMHP can work
effectively with individuals from diverse religious
traditions (Richards & Bergin, 2000, 2004; Sperry &
Shafranske, 2004). Many of these techniques can be
effective (McCullough, 1999) and improve outcomes
in clinical treatment with religious clients (Probst,
Ostrom, Watkins, Dean, & Mashburn, 1992; Richards,
Berrett, Hardman, & Eggett, 2006; E. L. Worthington
et al., 1996), even for clients in treatment with secular
LMHP (Mayers, Leavey, Vallianatou, & Barker, 2007).
These innovations point to ways that psychology can
explore and understand religious beliefs and faith in an
evidence-based and respectful manner.
There have been claims that some LMHP do not
address the issues of conservative religious individuals
who are distressed by their same-sex sexual attractions
(e.g., Yarhouse, 1998a; Throckmorton, 2002; Yarhouse
& Burkett, 2002; Yarhouse & Throckmorton, 2002).
Ono of fho robIoms In fho hoId hns boon nn oIfhor/or
perspective in which sexual orientation and religion
are seen as incompatible (Phillips, 2004). Certainly,
some individuals may perceive their religion and
their sexual orientation as incompatible, because in
some faiths homosexuality is perceived as sinful and
immoral. However, there is a growing body of evidence
illustrating that many individuals do integrate their
religious and sexual orientation identities (Coyle &
Rafalin, 2000; Kerr, 1997; Mahaffy, 1996; Rodriguez,
2006; Rodriguez & Ouellete, 2000; Thumma, 1991;
Yip, 2002, 2003, 2005). Thus, this dichotomy may be
onnbIIng n dIscourso fhnf doos nof fuIIy roocf fho
ovIdonco nnd mny bo hIndorIng rogross fo hnd n
variety of viable solutions for clients.
Recently, some authors have suggested alternative
frameworks, many of which are drawn from a variety of
models of psychotherapy, such as multicultural views of
psychology and the psychology of religion, that provide
frames for appropriate psychotherapeutic interventions
seeking to bridge this divide (Bartoli & Gillem, 2008;
Beckstead & Israel, 2007; Buchanon, Dzelme, Harris,
& Hecker, 2001; Glassgold, 2008; Gonsiorek; 2004;
Haldeman, 2004; Lasser & Gottlieb, 2004; S. L.
Morrow & Beckstead, 2004; Ritter & ONeill, 1989;
Tan, 2008; Throckmorton & Yarhouse, 2006; Yarhouse,
2008). For instance, a growing number of authors
address the religious
and spiritual needs
of LGBT individuals
from integrative and
nfhrmnfIvo orsocfIvos
that provide resources
for LMHP working
with this population
(Astramovich, 2003;
Beckstead & Israel,
2007; Beckstead
& Morrow, 2004;
Glassgold, 2008; Haldeman, 1996, 2004; Horne &
Noffsinger-Frazier, 2003; Mark, 2008; D. F. Morrow,
2003; ONeill & Ritter, 1992; Ritter & ONeill, 1989;
Throckmorton & Yarhouse, 2006; Yarhouse, 2008).
Based on of these scholarly contributions, we take the
perspective that religious faith and psychology do not
have to be seen as being opposed to each other. Further,
psychotherapy that respects faith can also explore the
psychological implications and impacts of such beliefs.
Wo suorf nfhrmnfIvo nnd muIfI-cuIfurnIIy
competent approaches that integrate concepts from the
psychology of religion and the modern psychology of
sexual orientation. These perspectives are elaborated
later in this report. In the next chapter we review the
history of SOCE in order to provide a perspective on the
foundation and evolution of these approaches.
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21 / '.o' .t/ ' od .otdt. d_o -''t
2. A BRIEF HISTORY OF SEXUAL
ORIENTATION CHANGE EFFORTS
S
exual orientation change efforts within mental
honIfh hoIds orIgInnIIy dovoIood from fho scIonco
of sexuality in the middle of the 19th century
(Katz, 1995). At that time, same-sex eroticism and
gender nonconforming behaviors came under increased
modIcnI nnd scIonfIhc scrufIny. ow forms, such ns
urnings, inversion, homosexual, and homosexuality,
emerged as scientists, social critics, and physicians
soughf fo mnko sonso of whnf wns rovIousIy dohnod
ns sIn or crImo (Knfz, l995). ThIs shIff fo n scIonfIhc
approach did not challenge the underlying social values,
howovor, nnd fhus confInuod fo roocf fho oxIsfIng
sexual stigma, discrimination, criminalization, and
hoforosoxIsm. Much of fho modIcnI nnd scIonfIhc work
at that time conceptualized homosexual attractions and
behaviors as abnormal or as an illness (Katz, 1995).
In that era, homosexuality was predominantly
viewed as either a criminal act or a medical problem,
or both (Krafft-Ebing, 1886/1965). Homosexuality was
seen as caused by psychological immaturity (i.e., as
a passing phase to be outgrown on the road to adult
heterosexuality) or pathology (e.g., genetic defects,
gender-based confusions, intrauterine hormonal
oxosuro, foo much nronfnI confroI, InsufhcIonf
parenting, hostile parenting, seduction, molestation, or
docndonf IIfosfyIos) (roschor, l998n, 2002). Tho hrsf
treatments attempted to correct or repair the damage
done by pathogenic factors or to facilitate maturity
(Drescher, 1998a, 2002; LeVay, 1996; Murphy, 1992,
1997). These perspectives on homosexuality lasted into
fho hrsf hnIf of fho 20fh confury, shnIng fho vIows of
psychoanalysis, the dominant psychiatric paradigm of
that time (Drescher, 1998a).
Homosexuality
and Psychoanalysis
Initial psychotherapeutic approaches to homosexuality
of fho hrsf hnIf of fho 20fh confury roocfod
psychoanalytic theory. Freuds own views on sexual
orientation and homosexuality were complex. Freud
viewed homosexuality as a developmental arrest and
heterosexuality as the adult norm, although bisexuality
was normative (Freud, 1905/1960). However, in a now-
famous letter, Freud (1935/1960) reassured a mother
writing to him about her son that homosexuality was
nofhIng fo bo nshnmod of, no vIco, no dogrndnfIon, If
cnnnof bo cInssIhod ns nn IIInoss, buf n vnrInfIon of
sexual function (p. 423). He further went on to say
fhnf sychonnnIysfs couId nof romIso fo nboIIsh
homosexuality and make normal heterosexuality take
its place (p. 423), as the results of treatment could
not be determined. Freuds only report (1920/1960)
about his deliberate attempt to change someones
sexual orientation described his unsuccessful efforts
at changing the sexual orientation of a young woman
brought for involuntary treatment by her parents. At
the end of this case, Freud concluded that attempts to
change homosexual sexual orientation were likely to be
unsuccessful.
18

18
Analyses of this case have focused on Freuds intense negative
reactions to this young woman and his attempts to enforce social
In the psychoanalysis that dominated the mental
honIfh hoIds nffor Iroud, osocInIIy In fho !nIfod Sfnfos,
homosexuality was viewed negatively, considered to be
abnormal, and believed to be caused by family dynamics
(Bieber et al., 1962; Rado, 1940; Socarides, 1968).
Other approaches based loosely on psychoanalytic ideas
advocated altering gender-role behaviors to increase
conformity with traditional gender roles (Moberly, 1983;
IcoIosI, l99l). SIgnIhcnnfIy ImncfIng sychInfrIc
thought in the mid-20th century, these theories were
part of the rationale for including homosexuality as a
monfnI IIInoss In bofh fho hrsf (l952) nnd socond (l968)
editions of the American Psychiatric Associations
Diagnostic and Statistical Manual of Mental Disorders
(DSM), thus reinforcing and exacerbating sexual stigma
and sexual prejudice. It was during this period that
fho hrsf nffomfs fo sfudy fho ofhcncy of SOCI woro
conducted (e.g., Bieber et al., 1962).
Sexual Orientation
Change Efforts
The pathologizing psychiatric and psychological
conception of homosexuality and concomitant efforts
to alter sexual orientation through psychoanalytic
and behavior therapy were prevalent through the
1960s and into the early 1970s. Although behavior
therapy emerged in the 1960s, adding a different
set of techniques to psychotherapy, the goals of
SOCE did not change. For example, Ovesey (1969)
based his behavioral interventions on the belief that
homosexuality developed from a phobia of taking on
the normal qualities of ones gender and that sexual
intercourse with the other
19
sex would cure the so-
called phobia.
Behavior therapists tried a variety of aversion
treatments, such as inducing nausea, vomiting, or
paralysis; providing electric shocks; or having the
individual snap an elastic band around the wrist
when the individual became aroused to same-sex
erotic images or thoughts. Other examples of aversive
behavioral treatments included covert sensitization,
shame aversion, systematic desensitization, orgasmic
conformityespecially with regard to traditional female gender
roles and sexuality (e.g., Lesser & Schoenberg, 1999; OConnor &
Ryan, 1993).
19
We use other sex instead of opposite sex, as the latter term makes
assumptions regarding the binary nature of male and female that
are unsupported. We acknowledge that this term also has limitations,
ns fhoro nro uId nnd dIvorso rorosonfnfIons of sox nnd gondor In
many cultures.
reconditioning, and satiation therapy (Beckstead
& Morrow, 2004; S. James, 1978; Langevin, 1983;
LeVay, 1996; Katz, 1995; Murphy, 1992, 1997). Some
nonaversive treatments used an educational process of
dating skills, assertiveness, and affection training with
physical and social reinforcement to increase other-sex
sexual behaviors (Binder, 1977; Greenspoon & Lamal,
1987; Stevenson & Wolpe, 1960). Cognitive therapists
attempted to change gay mens and lesbians thought
patterns by reframing desires, redirecting thoughts,
or using hypnosis, with the goal of changing sexual
arousal, behavior, and orientation (e.g., Ellis, 1956,
1959, 1965).
A||ad|ve Aqqodc'es. ||se,,
|od dd bedc', dd oo\e
At the same time that the pathologizing views of
homosexuality in American psychiatry and psychology
woro boIng codIhod, counforvnIIIng ovIdonco wns
accumulating that this stigmatizing view was ill
founded. The publication of Sexual Behavior in the
Human Male (Kinsey, Pomeroy, & Martin, 1948)
and Sexual Behavior in the Human Female (Kinsey,
Pomeroy, Martin, & Gebhard, 1953) demonstrated
that homosexuality was more common than previously
assumed, thus suggesting that such behaviors were part
of a continuum of sexual behaviors and orientations.
C. S. Ford and Beach (1951) revealed that same-sex
behaviors and homosexuality were present in a wide
range of animal species and human cultures. This
hndIng suggosfod fhnf fhoro wns nofhIng unnnfurnI
about same-sex behaviors or homosexual sexual
orientation.
Psychologist Evelyn Hookers (1957) research put
the idea of homosexuality as mental disorder to a
scIonfIhc fosf. Sho sfudIod n noncIInIcnI snmIo of
homosexual men and compared them with a matched
sample of heterosexual men. Hooker found, among
other things, that based on three projective measures
(the Thematic Apperception Test, the Make-a-Picture-
Story test, and the Rorschach), the homosexual men
were comparable to their matched heterosexual peers
on ratings of adjustment. Strikingly, the experts
who examined the Rorschach protocols could not
distinguish the protocols of the homosexual cohort from
the heterosexual cohort, a glaring inconsistency with
the then-dominant understanding of homosexuality
and projective assessment techniques. Armon (1960)
23 / '.o' .t/ ' od .otdt. d_o -''t
performed research on homosexual women and found
similar results.
In the years following Hookers (1957) and Armons
(1960) research, inquiry into sexuality and sexual
orientation proliferated. Two major developments
marked an important change in the study of
homosexuality. First, following Hookers lead, more
researchers conducted studies of nonclinical samples
of homosexual men and women. Prior studies
primarily included participants who were in distress or
incarcerated. Second, quantitative methods to assess
human personality (e.g., Eysenck Personality Inventory,
Cattells Sixteen Personality Factor Questionnaire
[16PF]) and mental disorders (Minnesota Multiphasic
Personality Inventory
[MMPI]) were
developed and were
a vast psychometric
improvement over
prior measures,
such as the
Rorschach, Thematic
Apperception Test,
and House-Tree-Person Test. Research conducted
with these newly developed measures indicated that
homosexual men and women were essentially similar
to heterosexual men and women in adaptation and
functioning (Siegelman, 1979; M. Wilson & Green, 1971;
see also review by Gonsiorek, 1991). Studies failed to
support theories that regarded family dynamics, gender
identity, or trauma as factors in the development
of sexual orientation (e.g., Bell, Weinberg, &
Hammersmith, 1981; Bene, 1965; Freund & Blanchard,
1983; Freund & Pinkava, 1961; Hooker, 1969; McCord,
McCord, & Thurber, 1962; D. K. Peters & Cantrell,
1991; Siegelman, 1974, 1981; Townes, Ferguson, &
CIIIom, l9?6). ThIs rosonrch wns n sIgnIhcnnf chnIIongo
to the model of homosexuality as psychopathology.
omoe.o|, |emoeo |om e
Diagnostic and Statistical Manual
In recognition of the legal nexus between psychiatric
diagnosis and civil rights discrimination, especially
for government employees, activists within the
homophile
20
rights movement, including Frank Kameny
and the Mattachine Society of Washington, DC,
launched a campaign in late 1962 and early 1963 to
20
Homophile is an early term for what would become the gay rights or
gay and lesbian rights movement.
remove homosexuality as a mental disorder from the
American Psychiatric Associations DSM (DEmilio,
1983; Kameny, 2009). This campaign grew stronger
in the aftermath of the Stonewall riots in 1969. Those
riots were a watershed, as the movement for gay and
lesbian civil rights was embraced openly by thousands
rather than limited to small activist groups (D Emilio,
1983; Katz, 1995). In the area of mental health, given
the results of research, activists within and outside of
the professions led a large and vocal advocacy effort
directed at mental health professional associations,
such as the American Psychiatric Association, the
American Psychological Association, and the American
Association for Behavior Therapy, and called for the
evaluation of prejudice and stigma within mental health
associations and practices (DEmilio, 1983; Kameny,
2009). At the same time, some LGB professionals and
fhoIr nIIIos oncourngod fho hoId of sychofhorny fo
assist sexual minority clients to accept their sexual
orientation (Silverstein, 2007).
As a result of the research and the advocacy outside
of and within the American Psychiatric Association,
that association embarked upon an internal process
of evaluating the literature to address the issue of
homosexuality as a psychiatric disorder (Bayer, 1981;
Drescher 2003; Drescher & Merlino, 2007; Sbordone,
2003; Silverstein, 2007). Upon the recommendation of
its committee evaluating the research, the American
Psychiatric Association Board of Trustees and general
membership voted to remove homosexuality per se
21

from the DSM in December 1973 (Bayer, 1981). The
American Psychiatric Association (1973) then issued
a position statement supporting civil rights protection
for gay people in employment, housing, public
accommodation, and licensing, and the repeal of all
sodomy laws.
In December 1974, the American Psychological
AssocInfIon (AIA) nssod n rosoIufIon nfhrmIng fho
resolution of the American Psychiatric Association.
APA concluded:
Homosexuality per se implies no impairment in
judgment, stability, reliability, or general social
and vocational capabilities. Further, the American
Psychological Association urges all mental health
professionals to take the lead in removing the
stigma of mental illness that has long been
21
The diagnoses of sexual orientation disturbance and ego-dystonic
homosexuality sequentially replaced homosexuality. These diagnoses,
however, were ultimately removed, due to conceptual problems and
psychiatrys evolving evidence-based approach for delineating a
mental disorder (Drescher, Stein, & Byne, 2005).
|eeoc coo.ceo w
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meo.e ocoeo o
omoe.o| me oo wome
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eeoe.o| me oo wome
oooooo oo |.co
associated with homosexual orientations. (APA,
1975, p. 633)
Since that time, the APA has passed numerous
resolutions supporting LGB civil rights and
psychological well-being (see APA, 2005a).
Other mental health associations, including the
NASW and the American Counseling Association,
and medical associations, including the American
Medical Association and the American Academy of
Pediatrics, have passed similar resolutions. Gradual
shifts began to take place in the international mental
health community as well. In 1992, the World Health
Organization removed homosexuality per se from the
1n/erno/ionol Cloeei[co/ion of Dieeoeee (Nakajima,
2003).
Decline of SOCE
Following the removal of homosexuality from the
DSM, the publication of studies of SOCE decreased
drnmnfIcnIIy, nnd nonnfhrmIng nronchos fo
psychotherapy came under increased scrutiny. Behavior
therapists became increasingly concerned that aversive
therapies designed as SOCE for homosexuality were
inappropriate, unethical, and inhumane (Davison,
1976, 1978; Davison & Wilson, 1973; M. King, Smith, &
Bartlett, 2004; Martin, 2003; Silverstein, 1991, 2007).
The Association for Behavioral and Cognitive Therapies
(formerly the Association for Advancement of Behavior
Thorny) ns woII ns ofhor nssocInfIons nfhIInfod wIfh
cognitive and behavior therapies currently reject the
use of SOCE (Martin, 2003). Behavior therapy for
LGB individuals now focuses on issues of increasing
adjustment, as well as on addressing a variety of their
mental health concerns (Campos & Goldfried, 2001;
Hart & Heimberg, 2001; Martell et al., 2004; Pachankis
& Goldfried, 2004; Safren & Rogers, 2001).
Prominent psychoanalytic practitioners (see, e.g.,
Mitchell, 1978, 1981) began questioning SOCE within
their own profession and challenged therapies that
started with assumptions of pathology. However, such
a movement did not take hold until the late 1980s
and early 1990s (Drescher, 1998a, 1998b; Glassgold &
Iasenza, 1995). In 1991, the American Psychoanalytic
Association (ApsaA) effectively ended stigmatization of
homosexuality by mainstream psychoanalysis when it
adopted a sexual orientation nondiscrimination policy
regarding the selection of candidates for psychoanalytic
training. This policy was revised in 1992 to include
selection of faculty and training analysts as well
(ApsaA, 1991, 1992). In 2000, ApsaA adopted a policy
against SOCE, attempting to end that practice within
fho hoId:
As in all psychoanalytic treatments, the
goal of analysis with homosexual patients is
understanding. Psychoanalytic technique does
nof oncomnss urosofuI offorfs fo convorf or
ronIr nn IndIvIdunI`s soxunI orIonfnfIon. Such
directed efforts are against fundamental principles
of psychoanalytic treatment and often result in
substantial psychological pain by reinforcing
damaging internalized homophobic attitudes. ( 1)
Numerous publications document the theoretical
limitations and problems with SOCE within
psychoanalysis (Drescher, 1998a, 1998b; OConnor &
Ryan, 1993). In the last decade, many psychoanalytic
ubIIcnfIons hnvo doscrIbod nn nfhrmnfIvo nronch fo
sexual orientation variation and diversity.
22

Currently, mainstream mental health professional
nssocInfIons suorf nfhrmnfIvo nronchos fhnf focus
on helping sexual minorities cope with the impact
of minority stress and stigma (American Counseling
Association Governing Council, 1998; American
Psychiatric Association, 2000; APA, 1997, 2000; NASW,
l99?). Tho IIfornfuro on nfhrmnfIvo sychofhorny hns
grown enormously during this time (e.g., Bieschke et
al., 2007; Eubanks-Carter, Burckell, & Goldfried, 2005;
Ritter & Terndrup, 2002). Included in this literature are
publications that aim to support individuals with strong
religious beliefs and same-sex sexual orientation in
exploring ways to integrate the two (e.g., Astramovich,
2003; Beckstead & Israel, 2007; Glassgold, 2008;
Haldeman, 1996, 2004; Horne & Noffsinger-Frazier,
2003; Mark, 2008; D. F. Morrow, 2003; ONeill & Ritter,
1992; Ritter & ONeill, 1989, 1995; Ritter & Terndrup,
2002; Tan, 2008; Throckmorton & Yarhouse, 2006;
Yarhouse, 2008). These changes within the mental
honIfh hoIds nro roocfod In fho Inrgor socIofy, whoro
there have been increasing shifts in acceptance of LGB
individuals (National Gay and Lesbian Task Force,
n.d.). For instance, in 2003, the U.S. Supreme Court
made a landmark ruling in Lawrence v. Texas that
declared as unconstitutional the sodomy laws of the 13
states that still criminalized homosexuality. However,
22
ApsaA and Divisions 39 (Psychoanalysis) and 44 (Society
for the Psychological Study of Lesbian, Gay, & Bisexual
Concorns) hnvo coIInbornfod on n bIbIIogrnhy of nfhrmnfIvo
resources in psychoanalysis, and the American Psychoanalytic
Association maintains its own bibliography: http://www.apsa.
org/APSAAMEMBERSSECTION/COMMITTEEWORKROOMS/
GAYANDLESBIANISSUES/tabid/381/Default.aspx.
25 / '.o' .t/ ' od .otdt. d_o -''t
issues such as same-sex marriage are still controversial
(Phy-Olsen, 2006).
However, SOCE is still provided by LMHP. Some
LMHP (Nicolosi, 2003, Nicolosi & Nicolosi, 2002;
Rosik, 2001) advocate for SOCE to be provided to
distressed individuals, and an organization was
founded to advocate for these types of treatments
(National Association for Research and Treatment of
Homosexuality). Additionally, a survey of randomly
selected British LMHP (psychologists, counselors, and
psychiatrists) completed in 2003 found that 17% of the
total sample of 1,328 had provided SOCE in the past
and that 4% would consider providing such therapy
upon client request in the future. Among those who
provided such services, the number of clients provided
SOCE had remained constant over time (cf. M. King et
al., 2004).
Sexual Orientation Change Efforts
Provided to Religious Individuals
The visibility of SOCE has increased in the last decade
(Drescher, 2003; Drescher & Zucker, 2006; Herek,
2003). From our survey of recent publications and
research, most SOCE currently seem directed to those
holding conservative religious and political beliefs, and
recent research on SOCE includes almost exclusively
individuals who have strong religious beliefs (e.g.,
Beckstead & Morrow, 2004; S. L. Jones & Yarhouse,
2007; Nicolosi et al., 2000; Ponticelli, 1999; Shidlo &
Schroeder, 2002; Spitzer, 2003). In an evolution for
some religious communities, sexual minorities are
not automatically expelled or shunned (Drescher &
Zucker, 2006; Sanchez, 2007; SPLC, n.d.). Instead,
individuals with a same-sex sexual orientation are
embraced for renouncing their homosexuality and
sookIng honIIng or chnngo (Iurnck & Josohson,
2005; Erzen, 2006; Ponticelli, 1999). This development
has led to a movement of religiously based self-help
groups for distressed individuals who often refer to
themselves as ex-gay (Erzen, 2006; Ponticelli, 1999;
Wolkomir, 2001, 2006). Individuals and organizations
that promote religion-based efforts to change sexual
orientation often target messages to adults, adolescents,
and their families that include negative portrayals of
homosexuality, religious outreach efforts, and support
groups, as well as psychotherapy (Burack & Josephson,
2005; Cianciotto & Cahill, 2006; Wolkomir, 2006).
Debates between those who advocate SOCE and
those who oppose it have at times become polemical,
with charges that professional psychology has not
roocfod fho concorns of roIIgIous IndIvIdunIs,
23
and
both supporters and opponents of SOCE have presented
themselves as advocates for consumers (cf. Brooke,
2005). Despite the polarization, there have been recent
attempts to envision alternate frameworks to address
these issues (e.g., Bartoli & Gillem, 2008; Beckstead &
Israel, 2007; Benoit, 2005; Haldeman, 2004; McMinn,
2005; Phillips, 2004; Tan, 2008; Throckmorton &
Yarhouse, 2006).
We conclude that these debates can only be resolved
through an evidence-based appraisal of the potential
bonohfs nnd hnrm of SOCI. In fho noxf fwo chnfors,
we consider the research evidence on SOCE. In Chapter
3 we discuss methodological concerns; in Chapter 4, the
results that can be drawn from this literature.
23
APA has received correspondence from individuals and
organizations asserting this point.
A
lthough the charge given to the task force did not
explicitly call for a systematic review of research
on fho ofhcncy nnd snfofy of soxunI orIonfnfIon
change efforts (SOCE), we decided in our initial
deliberations that such a review was important to the
fuIhIImonf of our chnrgo. IIrsf, fho dobnfo ovor SOCI
hns conforod on fho Issuos of ofhcncy, bonohf, nnd hnrm.
Thus, we believe it was incumbent on us to address
those issues in our report. We attempt to answer the
following questions in this review:
Do SOCE alter sexual orientation? :
Are SOCE harmful? :
Do SOCE result in any outcomes other than changing :
sexual orientation?
Second, systematic literature reviews are frequently
used to answer questions about the effectiveness of
interventions in health care to provide the basis for
informed treatment decisions (D. J. Cook, Mulrow, &
Haynes, 1998; Petticrew, 2001). Current criteria for
offocfIvo fronfmonfs nnd InforvonfIons nro socIhc In
stating that to be considered effective, an intervention
has consistent positive effects without serious harmful
side effects (Beutler, 2000; Flay et al., 2005). Based on
Lilienfelds (2007) comprehensive review of the issue of
harm in psychotherapy, our systematic review examines
harm in the following ways:
Negative side effects of treatment (iatrogenic effects) :
Client reports of perceptions of harm from treatment :
High drop-out rates :
Indirect harm such as the costs (time, energy, money) :
of ineffective interventions
IInnIIy, wo woro chnrgod fo Inform AIA`s rosonso
to groups that promote treatments to change sexual
orientation or its behavioral expression and support
ubIIc oIIcy fhnf furfhors nfhrmnfIvo fhornoufIc
interventions. We decided that a systematic review
24

would likely be the only effective basis for APAs
response to advocacy groups for SOCE.
In our review, we considered only peer-reviewed
research, in keeping with current standards for
conducfIng scIonfIhc rovIows (soo Khnn, Kunz, KIoIjnon,
& Antes, 2003), which exclude the grey literature
25
and
lay material. In this chapter, we provide an overview of
the review and a detailed report on the methodological
concerns that affect the validity
26
of the research. In the
next chapter, we present our review of the outcomes of
the research.
24
A systematic review starts with a clear question to be answered,
strives to locate all relevant research, has clear inclusion and
exclusion criteria, and carefully assesses study quality and
synthesizes study results (Petticrew, 2001).
25
Grey literature refers to any publication in any format published
oufsIdo of oor-rovIowod scIonfIhc journnIs.
26
VnIIdIfy Is dohnod ns fho oxfonf fo whIch n sfudy or grou of
sfudIos roduco InformnfIon fhnf Is usofuI for n socIhc uroso. If
also includes an overall evaluation of the plausibility of the intended
interpretationsin this case, does SOCE produce a change in sexual
orientation (see American Educational Research Association, APA, &
National Council on Measurement in Education, 1999).
3. A SYSTEMATIC REVIEW OF RESEARCH
ON !| ||||CACY O| SOC|.
OVERVIEW AND METHODOLOGICAL LIMITATIONS
27 / /todt.c 'ov.o. ' 'oodc to -''cdc/ ' - vov.o. dd 'otd_.cd '..tdt.
Overview of the
Systematic Review
Our review included peer-reviewed empirical research
on treatment outcomes published from 1960 to the
rosonf. SfudIos woro IdonfIhod fhrough sysfomnfIc
searches of scholarly databases including PsycINFO
and Medline, using such search terms as reparative
therapy, sexual orientation, homosexuality, and ex-
gays cross-referenced with treatment and therapy.
!oforonco IIsfs from nII IdonfIhod nrfIcIos woro sonrchod
for additional nonindexed, peer-reviewed material.
We also obtained review articles and commentaries
and searched the reference lists from these articles
to identify refereed publications of original research
investigations on treatment of same-sex attraction
fhnf hnd nof boon IdonfIhod vIn fho nforomonfIonod
procedures. In all, we obtained and reviewed original
publications of 83 studies. The reviewed studies are
listed in Appendix B.
27
The vast majority of research on SOCE was conducted
prior to 1981. This early research predominantly
focused on evaluating behavioral interventions,
including those using aversive methods. Following the
docInssIhcnfIon of homosoxunIIfy ns n monfnI dIsordor
in 1973 (American Psychiatric Association, 1973)
and subsequent statements of other mental health
professional associations, including APA (Conger,
1975), research on SOCE declined dramatically. Indeed,
we found that the peer-reviewed empirical literature
after 1981 contains no rigorous intervention trials on
changing same-sex sexual attractions.
There is a small, more recent group of studies
conducted since 1999 that assess perceived effects of
SOCE among individuals who have participated in
psychotherapy as well as efforts based in religious
beliefs or practices, including support groups, faith
healing, and prayer. There are distinct types of research
within this recent literature. One type focused on
evaluating individuals positive accounts of sexual
orientation change (Nicolosi et al., 2000; Schaeffer
et al., 2000; Spitzer, 2003). Another type examined
27
A meta-analytic review of 14 research articles (Byrd & Nicolosi,
2002) is not discussed in this report. The review suffers from
sIgnIhcnnf mofhodoIogIcnI shorfcomIngs nnd dovInfIons from
recommended meta-analytic practice (see, e.g., Durlak, Meerson, &
Ewell-Foster, 2003; Lipsey & Wilson, 2001) that preclude reliable
conclusions to be drawn from it. However, studies that were included
in the meta-analysis and were published in refereed journals between
1960 and the present are included and described in the current review.
Additionally, a recent study (Byrd, Nicolosi, & Potts, 2008) is not
included, as it was published after the review period and appears to be
a reworking of an earlier study by Nicolosi, Byrd, and Potts (2000).
potential harm of SOCE and experiences of those who
seek sexual orientation (Schroeder & Shidlo, 2001;
Shidlo & Schroeder, 2002). A third type is high-quality
28

qualitative research investigations that provide insight
into peoples experiences of efforts aimed at altering
their same-sex sexual attractions (e.g., Beckstead &
Morrow, 2004; Ponticelli, 1999; Wolkimir, 2001).
29
In all areas of intervention evaluation, the quality
of the methods used in the research affects the validity
and credibility of any claims the researcher can make
about whether the intervention works, for whom it
works, and under what circumstances it works. Many
have described
methodological
concerns regarding
the research
literature on sexual
orientation change
efforts (e.g., Cramer,
Golom, LoPresto,
& Kirkley, 2008; Haldeman, 1994; S. L. Morrow &
Beckstead, 2004; Murphy, 1992; Sandfort, 2003).
Overall, we found that the low quality of the research on
SOCE is such that claims regarding its effectiveness and
widespread applicability must be viewed skeptically.
As shown in Appendix B, few studies on SOCE
produced over the past 50 years of research rise to
curronf scIonfIhc sfnndnrds for domonsfrnfIng fho
ofhcncy of sychoIogIcnI InforvonfIons (ChnmbIoss
& Hollon, 1998; Chambless & Ollendick, 2001;
Flay et al., 2005; Shadish, Cook, & Campbell, 2002;
Society for Prevention Research, 2005) or provide for
unambiguous causal evidence regarding intervention
outcomes. Indeed, only six studies, all conducted in the
early period of research, used rigorous experimental
30

procedures. Only one of these experiments (Tanner,
28
These studies meet the standards of research rigor that are used for
the qualitative research paradigms that informed each of the studies
(e.g., grounded theory, ethnomethodology, phenomenology).
29
These studies are discussed more thoroughly in later sections of
the report.
30
True experiments have more methodological rigor because study
participants are randomly assigned to treatment groups such
that individual differences are more equally distributed and are
not confounded with any change resulting from the treatment.
Experiments are also rigorous because they include a way for the
researcher to determine what would have happened in the absence
of any treatment (e.g., a counterfactual), usually through the use of a
no-treatment control group. Quasi-experimental designs do not have
random assignment but do incorporate a comparison of some kind.
Although they are less rigorous than experiments, quasi-experiments,
if appropriately designed and conducted, can still provide for
reasonable causal conclusions to be made.
eo|| we |o.o o e
|ow o.o|, o| e eeoc
o | .c o c|om
eoo e||ecee oo
woeoeoo ooo|coo|, m.
oe eweo eoco||,
1974) assessed treatment outcomes in comparison
to an untreated control group. Only three additional
studies used strong quasi-experimental procedures such
as a nonequivalent comparison group (see Appendix
B). All of these studies were also from the early
period. The rest of the studies that we reviewed are
nonexperimental (see Appendix B). We thus concluded
that there is little in the way of credible evidence that
could clarify whether SOCE does or does not work in
changing same-sex sexual attractions.
The studies in this area also include a highly
select group of people who are unique among those
who experience same-sex sexual attractions. Thus,
psychologists should be extremely cautious in
attributing success to SOCE and assuming that the
hndIngs of fho sfudIos of If cnn bo nIIod fo nII soxunI
minorities. An overview of the methodological problems
in determining the effects of SOCE and making
fronfmonf docIsIons bnsod on hndIngs from fhoso
studies follows.
Methodological Problems in the
Research Literature on SOCE
|oo|em \o o.o| |om
A principal goal of the available research on SOCE was
to demonstrate that SOCE consistently and reliably
produce changes in aspects of sexual orientation.
OvornII, duo fo wonknossos In fho scIonfIhc vnIIdIfy
of research on SOCE, the empirical research does not
provide a sound basis for making compelling causal
claims. A detailed analysis of these issues follows.
'`-'`/' v/'''' `-'`
Internally valid research convincingly demonstrates
that a cause (such as SOCE) is the only plausible
explanation for an observed outcome such as change
in same-sex sexual
attractions. Lack
of internal validity
limits certainty that
observed changes in
peoples attitudes,
beliefs, and behaviors
are a function of the
particular interventions to which they were exposed. A
major limitation to research on SOCE, both the early
and the recent research, stems from the use of weak
research designs that are prone to threats to internal
validity. Research on SOCE has rarely used designs
fhnf nIIow for conhdonf concIusIons rognrdIng cnuso-
and-effect relationships between exposure to SOCE
and outcomes.
As noted previously, true experiments and rigorous
quasi-experiments are rare in the SOCE research.
There are only a few studies in the early period that
are experiments or quasi-experiments, and no true
experiments or quasi-experiments exist within the
recent research. Thus, none of these recent studies meet
current best practice standards for experimental design
nnd cnnnof osfnbIIsh whofhor SOCI Is ofhcncIous.
In early studies, comparison and no-treatment
control groups were uncommon procedures, and early
studies rarely employed multiple baseline assessments,
randomization to condition, multiple long-term follow-
up assessments, or other procedures to aid in making
causal inferences. These procedures are widely accepted
as providing the most compelling basis for ruling out
the possibility that an alternative source is responsible
for causing an observed or reported treatment effect.
Common threats to internal validity in early
studies include history (i.e., other events occurring
over the same time period as the treatment that could
produce the results in the absence of the intervention),
regression (i.e., extreme scores are typically less
extreme on retest in the absence of intervention), and
fosfIng (I.o., fnkIng n fosf onco Inuoncos fufuro scoros
on the test in the absence of intervention). Within-
subject and patient case studies are the most common
designs in the early SOCE research (see Appendix
B). In these designs, an individuals scores or clinical
status prior to treatment is compared with his or her
scores or status following treatment. These designs
are particularly vulnerable to internal validity threats,
notably threats to internal validity due to sample
attrition and retrospective pretests.
omo|e oo
Early research is especially vulnerable to threats
to internal validity related to sample attrition. The
proportions of participants in these studies who dropped
out of the intervention and were lost to follow-up are
unacceptably high; drop-out rates go as high as 74%
of the initial study sample. Authors also reported high
rates of refusal to undergo treatment after participants
were initially enrolled in the studies. For instance,
6 men in Bancrofts (1969) study refused to undergo
treatment, leaving only 10 men in the study. Callahan
and Leitenberg (1973) reported that of 23 men enrolled,
|eeoc o | o
oe|, .eo oe o o||ow
|o co|oe coc|.o
eoo co.eooe||ec
e|ooo oewee eoo.e
o | oo o.come
7 refused and 2 dropped out of treatment; 8 also showed
inconsistent baseline responses in penile arousal to the
experimental stimuli so could not be included in the
analysis, leaving only 6 subjects on whom treatment
analyses could be performed. Of 37 studies reviewed by
H. E. Adams and Sturgis (1977), 31 studies lost from
36% to 58% of the sample. In many studies, therefore,
what appear to be intervention effects may actually
roocf sysfomnfIc chnngos In fho comosIfIon of fho
study sample; in the handful of available comparison
group studies, differences between the groups in the
studies in the rate of dropout and in the characteristics
of those who drop out may be the true cause of any
observed differences between the groups. Put simply,
dropout may undermine the comparability of groups in
ways that can bias study outcomes.
|eooece oee
With the exception of prospective ethnographic studies
(e.g., Ponticelli, 1999; Wolkomir, 2001), the recent
research relies exclusively on uncontrolled retrospective
pretest designs. In these studies, people who have been
exposed to SOCE are asked to recall and report on their
feelings, beliefs, and behaviors at an earlier age or time
and are then asked to report on these same issues at
present. Change is assessed by comparing contemporary
scores with scores provided for the earlier time period
based on retrospective recall. In a few studies, LMHP
who perform SOCE reported their view of how their
clients had changed. The design is problematic because
all of the pretest measures are not true pretests but
retrospective accounts of pretest status. Thus, the
recent research studies on SOCE have even weaker
designs than do nonexperimental studies from the early
period of research on SOCE. Again, none of these recent
sfudIos cnn osfnbIIsh whofhor SOCI Is ofhcncIous.
An extensive body of research demonstrates the
unreliability of retrospective pretests. For example,
retrospective pretests are extremely vulnerable to
response-shift biases resulting from recall distortion
and degradation (Schwarz & Clore, 1985; Schwartz
& !nkIn, 2004). IooIo hnd If dIfhcuIf fo rocnII
and report accurately on feelings, behaviors, and
occurrences from long ago and, with the passage of time,
will often distort the frequency, intensity, and salience
of things they are asked to recall.
Retrospective pretests are also vulnerable to biases
deriving from impression management (Fisher & Katz,
2000; Schwarz, Hippler, Deutsch, & Strack, 1985;
Wilson & Ross, 2001), change expectancy (Hill & Betz,
2005; Lam & Bengo, 2003; Norman, 2003; M. A. Ross,
l989; Srnngors, l989), nnd offorf jusfIhcnfIon (Aronson
& Mills, 1959; Beauvois & Joule, 1996; Festinger,
1957). Individuals tend to want to present themselves
in a favorable light. As a result, people have a natural
tendency to report on their current selves as improved
over their prior selves (impression management).
People will also report change under circumstances in
which they have been led to expect that change will
occur, even if no change actually does occur (change
expectancy) and will seek to justify the time and
effort that they have made in treatment to reduce any
dissonance they may feel at experiencing no or less
change than they had expected by overestimating the
offocfIvonoss of fho fronfmonf (offorf jusfIhcnfIon).
Ifforf jusfIhcnfIon hns boon domonsfrnfod fo bocomo
stronger as intervention experiences become more
unpleasant. In combination, these factors lead to
Innccurnfo soIf-roorfs nnd Innfod osfImnfos of
fronfmonf offocfs, dIsforfIons fhnf nro mngnIhod In fho
context of retrospective pretest designs.
`'' v/'''' `-'`
Consfrucf vnIIdIfy Is nIso n sIgnIhcnnf concorn In
research on SOCE. Construct validity refers to
the degree to which the abstract concepts that are
InvosfIgnfod In fho sfudy nro vnIIdIy dohnod, how
well these concepts are translated into the studys
treatments and measures, and, in light of these
dohnIfIonnI nnd oornfIonnI docIsIons, whofhor fho
sfudy hndIngs nro nrorInfoIy Inforrofod. Ior
Insfnnco, do fho rosonrchors ndoqunfoIy dohno nnd
measure sexual orientation? Are their interpretations
of the study results regarding change in sexual
orientation appropriate, given how the constructs were
dohnod nnd frnnsInfod Info monsuros On fho whoIo,
research on SOCE presents serious concerns regarding
construct validity.
|e|o o| e.o| oeoo
Sexual orientation is a complex human characteristic
involving attractions, behaviors, emotions, and identity.
Modern research of sexual orientation is usually seen
as beginning with the Kinsey studies (Kinsey et al.,
1948, 1953). Kinsey used a unidimensional, 7-category
taxonomic continuum, from 0 (exclusively heterosexual)
to 6 (exclusively homosexual), to classify his
participants. As the research has developed since the
Kinsey studies, the assessment of sexual orientation has
focused largely on measuring three variablesidentity,
behavior, and attraction. Many studies measure only
one or two, but very seldom all three, of these aspects.
A koy hndIng In fho Insf 2 docndos of rosonrch on
sexual orientation is that sexual behavior, sexual
attraction, and sexual orientation identity are labeled
and expressed in many different ways (Carrillo, 2002;
Diamond, 2003, 2006; Dunne, Bailey, Kirk, & Martin,
2000; Laumann, Gagnon, Michael, & Michals, 1994;
Savin-Williams, 2005). For instance, individuals
with sexual attractions may not act on them or may
undorsfnnd, dohno, nnd InboI fhoIr oxorIoncos
differently than those with similar desires because of
the unique cultural and historical constructs regarding
ethnicity, gender, and sexuality (Harper et al., 2004;
Mays & Cochran, 1998; Walters, Simoni, & Horwath,
2001; Weinrich & Williams, 1991).
Further, a subset of individuals who engage in
same-sex sexual behaviors or have same-sex sexual
attractions do not self-identify as LGB or may remain
unInboIod nnd somo soIf-IdonfIhod IosbInn nnd gny
individuals may engage in other-sex sexual behaviors
without self-identifying as bisexual or heterosexual
(Beckstead, 2003; Carrillo, 2002; Diamond, 2003, 2008;
Diamond & Savin-Williams, 2000; Dunne et al., 2000;
Fox, 2004; Gonsiorek, Sell, & Weinrich, 1995; Hoburg,
Konik, Williams, & Crawford, 2004; Kinsey et al., 1948,
1953; Klein et al., 1985; Masters & Johnson, 1979;
McConaghy, 1987; McConaghy, 1999; McConaghy,
Buhrich, & Silove, 1994; Storms, 1980; Thompson &
Morgan, 2008). Thus,
for some individuals,
personal and social
identities differ from
sexual attraction, and
sexual orientation
identities may vary
due to personal
concerns, culture,
contexts, ethnicity, nationality, and relationships.
As a result, a number of scholars have argued that
the construct of sexual orientation would be more easily
nnd roIInbIy nssossod nnd dohnod If If woro dIsonfnngIod
from sexual orientation identity (e.g., Chang &
Katayama, 1996; Drescher, 1998a, 1998b; Drescher,
Stein, & Byne, 2005; Rust, 2003; Stein, 1999; R. L.
Worthington, Savoy, Dillon, & Vernaglia, 2002). Recent
research has found that distinguishing the constructs of
sexual orientation and sexual orientation identity adds
clarity to an understanding of the variability inherent
in reports of these two variables (R. L. Worthington et
al., 2002; R. L. Worthington & Reynolds, 2009).
We adopted this current understanding of sexuality
to clarify issues in the research literature. For instance,
sexual orientation refers to an individuals patterns of
sexual, romantic, and affectional arousal and desire
for other persons based on those persons gender
and sex characteristics. Sexual orientation is tied to
physiological drives and biological systems that are
beyond conscious choice and involve profound emotional
fooIIngs, such ns fnIIIng In Iovo. Ofhor dImonsIons
commonly attributed to sexual orientation (e.g., sexual
bohnvIor wIfh mon nnd/or womon; socInI nfhIInfIons
with LGB or heterosexual individuals and communities,
emotional attachment preferences for men or women,
gender role and identity, lifestyle choices) are potential
correlates of sexual orientation rather than principal
dimensions of the construct.
Sexual orientation identity refers to acknowledgment
nnd InfornnIIznfIon of soxunI orIonfnfIon nnd roocfs
self-exploration, self-awareness, self-recognition,
grou momborshI nnd nfhIInfIon, cuIfuro, nnd soIf-
stigma. Sexual orientation identity involves private
and public ways of self-identifying and is a key
element in determining relational and interpersonal
decisions, as it creates a foundation for the formation of
community, social support, role models, friendship, and
partnering (APA, 2003; Jordan & Deluty, 1998; McCarn
& Fassinger, 1996; Morris, 1997; Ponticelli, 1999;
Wolkomir, 2001).
Given this new understanding of sexual orientation
and sexual orientation identity, a great deal of debate
surrounds the question of how best to assess sexual
orientation in research (Gonsiorek et al., 1995; Kinsey
et al., 1948, 1953; Masters & Johnson, 1979; Sell,
1997). For example, some authors have criticized the
Kinsey scale for dichotomizing sexual orientationwith
heterosexuality and homosexuality as opposites along
a single dimension and bisexuality in between
thus implying that in increasing desire for one sex
represents reduced desire for the other sex (Gonsiorek
et al., 1995; Sell, 1997; R. L. Worthington, 2003; R. L.
Worthington & Reynolds, 2009). An alternative that
has been proposed suggests that same-sex and other-
sex attractions and desires may coexist relatively
independently and may not be mutually exclusive
(Diamond, 2003, 2006; 2008; Fox, 2004; Klein et al.,
1985,
31
Sell, 1997; Shively & DeCecco, 1977; Storms,
31
Although Klein advanced the notion of sexual orientation as a
multidimensional variable, his Sexual Orientation Grid confounds
constructs of sexual orientation and sexual orientation identity, as it
IncIudos nffrncfIon; bohnvIor; IdonfIhcnfIon; nnd omofIonnI, oIIfIcnI,
and social preferences.
/ .moe o| co|o oe
o.eo o e co.c
o| e.o| oeoo wo.|o
oe moe eo|, oo e|oo|,
oeeo oo oe|eo |
wee oeo|eo |om e.o|
oeoo oe,
1980; R. L. Worthington, 2003; R. L. Worthington &
Reynolds, 2009). Models with multiple dimensions that
permit the rating of the intensity of an individuals
sexual desire or arousal for other-sex individuals
separately from the intensity of that individuals
sexual desire or arousal for same-sex individuals allow
individuals to have simultaneous levels of attractions.
Some commentators believe such models allow for
greater understanding of sexual diversity and its
interactions with other aspects of identity and culture
(Mays & Cochran, 1998; R. L. Worthington et al. 2002).
Considered in the context of the conceptual
complexities of and debates over the assessment of
sexual orientation, much
of the SOCE research
does not adequately
dohno fho consfrucf
of sexual orientation,
does not differentiate it
from sexual orientation
identity, or has
mIsIondIng dohnIfIons
that do not accurately
assess or acknowledge
bisexual individuals.
Early research that
focuses on sexual arousal may be more precise than that
which relies on self-report of behavior. Overall, recent
research may actually measure sexual orientation
identity (i.e., beliefs about sexual orientation, self-report
of IdonfIfy or grou nfhIInfIon, soIf-roorf of bohnvIor,
and self-labeling) rather than sexual orientation.
.o, eome
In general, what constitutes SOCE in empirical
research is quite varied. As we show in Appendix B,
early studies tested a variety of interventions that
include aversive conditioning techniques (e.g., electric
shock, deprivation of food and liquids, smelling salts,
chemically induced nausea), biofeedback, hypnosis,
masturbation reconditioning, psychotherapy, systematic
desensitization, and combinations of these approaches. A
small number of early studies compare approaches alone
or in combination. The more recent research includes
an even wider variety of interventions (e.g., gender role
reconditioning, support groups, prayer, psychotherapy)
and providers (e.g., licensed and unlicensed LMHP in
varied disciplines, pastoral counselors, laypersons).
The recent studies were conducted in such a way that
it is not possible to attribute results to any particular
intervention component, approach, or provider.
For instance, these interventions were provided
sImuIfnnoousIy or soquonfInIIy, wIfhouf socIhc sonrnfo
evaluations of each intervention. The recent research
and much of the early research cannot provide clarity
rognrdIng whIch socIhc offorfs nro nssocInfod wIfh
whIch socIhc oufcomos.
.come meo.e
Regarding assessment mode, outcomes in early studies
were assessed by one or more of the following: gauging
an individuals physiological responses when presented
with sexual stimuli, obtaining the persons self-report
of recent sexual behavior and attractions, and using
clinical opinion regarding improvement. In men
especially, physiological measures are considered more
dependable for detecting sexual arousal in men and
women than self-report of sexual arousal or attraction
(McConaghy, 1999). However, these measures have
important limitations when studying sexual orientation.
Many men are incapable of sexual arousal to any
stimuli in the laboratory and must be excluded from
research investigations in which the measure is the sole
outcome measure. More recent research indicates that
some penile circumference gauges are less consistent
than penile volume gauges (Kuban, Barbaree, &
Blanchard, 1999; McConaghy, 1999; Quinsey &
Lalumiere, 2001; Seto, 2004) and that some men can
intentionally produce false readings on the penile
circumference gauges by suppressing their standard
sexual arousal responses (Castonguay, Proulx, Aubut,
McKibben, & Campbell, 1993; Lalumiere & Harris,
1998) or consciously making themselves aroused when
presented with female erotic stimuli (Freund, 1971,
1976; Freund, Watson, & Rienzo, 1988; Lalumiere &
Earls, 1992; McConaghy, 1999, 2003). The physiological
measure used in all the SOCE experiements was the
penile circumference gauge. McConaghy (1999) has
questioned the validity of the results of SOCE research
using this gauge and believes that data illustrating
a reduction in same-sex sexual attraction should be
viewed skeptically.
In recent research on SOCE, overreliance on self-
report measures and/or on measures of unknown
validity and reliability is common. Reliance on self-
reports is especially vulnerable to a variety of
reactivity biases such that shifts in an individuals
scoro wIII roocf fncfors ofhor fhnn fruo chnngo. Somo
of these biases are related to individual motivations,
which have already been discussed, and others are
\.c o| e | eeoc
ooe o ooeo.oe|,
oe|e e co.c o|
e.o| oeoo ooe
o o||eeoe |om
e.o| oeoo oe,
o o m|eoo oe|o
o oo o occ.oe|,
oe o ocow|eoe
oe.o| oo.o|
due to features of the experimental situation. Knowing
that one is being studied and what the experimenter
hoos fo hnd cnn hoIghfon ooIo`s fondoncy fo soIf-
report in socially desirable ways and in ways that
please the experimenter.
Measures used in early studies vary tremendously
in their psychometric acceptability, particularly for
attitudinal and mental health measures, with a limited
number of studies using well-validated measures.
!oconf rosonrch hns nof ndvnncod sIgnIhcnnfIy In usIng
psychometrically sound measures of important study
variables such as depression, despite the widespread
use of measures that permit accurate assessment of
these variables in other studies. Measures in these
studies are also sources of bias due to problems such
as item wording and response anchors from which
participants may have inferred that other-sex attraction
is a normative standard, as well as from the exclusion
of items related to healthy homosexual functioning
to parallel items that ask for reports on healthy
heterosexual functioning.
.o, ooeoo
Regarding the adequacy of study operations, few of
the early studies attempted to overcome the demand
characteristics associated with the interventionists,
obtaining measures of change themselves. In other
words, few studies sought to minimize the possibility
that people receiving treatment would be motivated
to please their treatment providers by providing
them with reports that were consistent with what the
providers were perceived to desire and expect. Issues in
recruitment of participants may also contribute to this
effect; subjects were aware of the goals of the study,
were recruited by individuals with that knowledge,
or were participating in treatment to avoid legal and/
or religious sanction. Novelty effects associated with
exposure to an experimental laboratory situation
mny nIso hnvo Inuoncod sfudy rosuIfs. IooIo mny
become excited and energized by participating in a
research investigation, and these reactions to being in
the research environment may contribute to change in
scores. Recent research is also vulnerable to demand
characteristics as a function of how individuals are
recruited into samples, which is discussed in more
detail in the section on sampling concerns.
`'''` v/'''' `-'`
Conclusion validity concerns the validity of the
inferences about the presence or absence of a
relationship among variables that are drawn
from statistical tests. Small sample sizes, sample
heterogeneity, weak measures, and violations to the
assumptions of statistical tests (e.g., non-normally
distributed data) are central threats to drawing valid
conclusions. In this body of research, conclusion validity
is often severely compromised. Many of the studies from
the early period are characterized by samples that are
very small, containing on the average about 9 subjects
(see Appendix B; see also H. E. Adams & Sturgis,
1977). Coupled with high rates of attrition, skewed
distributions, unreliable measures, and infrequent
use of statistical tests designed for small and skewed
snmIos, conhdonco In fho sfnfIsfIcnI rosuIfs of mnny
of these studies may be misplaced. The recent research
involved unreliable measures and inappropriate
selection and performance of statistical tests, which are
threats to their statistical conclusion validity,
32
even
though these studies involved larger samples than the
early research.
|oo|em eeo|z |o
A sIgnIhcnnf chnIIongo fo InforrofIng fho rosonrch on
SOCE is establishing external validitythat is, judging
to whom and to what circumstances the results of any
particular study might reasonably be generalized.
32
For instance, to assess whether sexual orientation had changed,
Nicolosi et al. (2000) performed a chi-square test of association on
individuals prior and current self-rated sexual orientation. Several
fonfuros of fho nnnIysIs nro robIomnfIc. SocIhcnIIy, fho nnfuro of
the data and research question are inappropriate to a chi-square test
of association, and it does not appear that the tests were properly
performed. Chi-square tests of association assume that data are
independent, yet these data are not independent because the row
and column scores represent an individuals rating of his or her past
and present self. Chi-square tests ought not to be performed if a cell
In fho confIngoncy fnbIo IncIudos fowor fhnn hvo cnsos. Ofhor fosfs,
such as the nonparametric McNemars test for dichotomous variables
(McNemar, 1969) or the sign (Conover, 1980) or Wilcoxon signed-rank
tests (Wilcoxon, 1945) for nominal and ordinal data, respectively, are
usod fo nssoss whofhor fhoro nro sIgnIhcnnf dIfforoncos bofwoon nn
individuals before and after score and are appropriate when data
fail to meet the assumptions of independence and normality, as these
data do and would have been more appropriate choices. Paired t-tests
for mean differences could also have been performed on these data.
There are procedural problems in performing the chi-square test such
as missing data, and the analyses are conducted without adjustment
for chance, with different numbers of subjects responding to each
item, and without corrections to the gain scores to address regression
artifacts. Taken together, however, the problems associated with
running so many tests without adjusting for chance associations or
correcting for regression artifacts and having different respondents
In nonrIy ovory fosf mnko If dIfhcuIf fo nssoss whnf chnngos In scoros
ncross fhoso Ifoms ncfunIIy roocf.
/'''- ''''`
Concerns regarding the sample composition in these
studies are common in critiques (e.g., Cramer et
al., 2008). The studies from the early period are
characterized by samples that are narrow in their
demographic characteristics, composed almost
exclusively of Caucasian males over the age of 18.
No investigations are of children and adolescents
exclusively, although adolescents are included in a
very few study samples. Few SOCE studies in the early
period include women. Although more recent research
includes women
and respondents of
diverse ethnic and
racial backgrounds
(e.g., Moran, 2007;
Nicolosi et al., 2000;
Ponticelli, 1999; Schaeffer et al., 2000; Spitzer, 2003;
Wolkomir, 2001), White men continue to dominate
roconf sfudy snmIos. Thus, fho rosonrch hndIngs
from early and recent studies may have limited
applicability to non-Whites, youth, or women. The
samples in the recent research have been narrowly
dohnod In ofhor rosocfs, focusIng on woII-oducnfod,
middle-class individuals to whom religion is extremely
important (e.g., Beckstead & Morrow, 2004; Nicolosi
et al, 2000; Pattison & Pattison, 1980; Schaeffer et
al., 2000; Spitzer, 2003; Wolkomir, 2001). Same-sex
sexual attraction and treatments are confounded with
these particular demographic characteristics across
fho roconf IIfornfuro. Thoso rosonrch hndIngs mny bo
most applicable to educated White men who consider
themselves highly religious.
The early research sometimes included men who
were receiving intervention involuntarily (e.g., Barlow,
Agras, Abel, Blanchard, & Young, 1975; Callahan
& Leitenberg, 1973; S. James, 1978; MacCulloch &
Feldman, 1967; MacCulloch et al., 1965; McConaghy,
1969, 1976; McConaghy, Proctor, & Barr, 1972),
usually men who were court referred as a result of
convictions on charges related to criminalized acts of
homosexual sex.
33
The samples also include men who
were not receiving intervention because of same-sex
sexual attractions; rather, some of the men receiving
intervention are described as pedophiles, exhibitionists,
transvestites, and fetishists (Callahan & Leitenberg,
1973; Conrad & Wincze, 1976; Fookes, 1960; Hallam
& Rachman, 1972; Marquis, 1970; Thorpe, Schmidt,
33
Shidlo and Schroeder (2002) found that roughly 24% of their
respondents perceived that SOCE was imposed on them rather than
pursued voluntarily.
Brown, & Castell, 1964; Thorpe, Schmidt, & Castell,
1963). Thus, the early samples are notable for including
men who may not be same-sex attracted at all or who
may not be distressed by their attractions but who had
to undergo intervention by court order or out of fear of
being caught by law enforcement in the future.
Moreover, in the early researchto the extent that it
was assessedthe samples contained individuals who
varied widely along the spectrum of same-sex sexual
orientation prior to intervention, so that the studies
included men who were other-sex sexually attracted to
varying degrees alongside men who were primarily or
exclusively same-sex sexually attracted (Bancroft, 1969;
Barlow et al., 1975; Birk, 1974; Conrad & Wincze, 1976;
Fookes, 1960; Hallman & Rachman, 1972; Kendrick &
MacCulloch, 1972; LoPiccolo, Stewart, & Watkins, 1972;
Marquis, 1970; McCrady, 1973). Additionally, study
samples included men with and without histories of
current and prior sexual contact with men and women
(Bancroft, 1969; Colson, 1972; Curtis & Presly, 1972;
Fookes, 1960; Freeman & Meyer, 1975; Gray, 1970;
Hallman & Rachman, 1972; Herman, Barlow, & Agras,
1974; Larson, 1970; Levin, Hirsch, Shugar, & Kapche,
1968; LoPiccolo et al., 1972; MacCulloch & Feldman,
1967; McConaghy, 1969; McConaghy et al., 1972, 1981;
McConaghy & Barr, 1973; Segal & Sims, 1972; Thorpe
et al., 1964), so that
men who are or have
been sexually active
with women and men,
only women, only
men, or neither are
combined. Some recent
studies of SOCE
have similar problems (e.g., Spitzer, 2003). Including
participants with attractions, sexual arousal, and
behaviors to both sexes in the research on SOCE makes
ovnIunfIng chnngo moro dIfhcuIf (Inmond, 2003; !usf,
2003; Vasey & Rendell, 2003; R. L. Worthington, 2003).
Data analyses rarely adjust for preintervention
factors such as voluntary pursuit of intervention, initial
degree of other-sex attraction, or past and current
other-sex and same-sex behaviors; in very few studies
did investigators perform and report subgroup analyses
to clarify how subpopulations fared as a result of
intervention. The absence of these analyses obscure
results for men who are primarily same-sex attracted
and seeking intervention regarding these attractions
versus any other group of men in these studies, such
as men who could be characterized as bisexual in their
attractions and behaviors or those on whom treatment
e eeoc |o |om eo|,
oo ece .oe mo, oe
|meo ooo|coo|, o o
\e ,o. o wome
|c|.o oocoo w
ooco e.o| oo.o|
oo oeoo o oo ee
e eeoc o |
moe eo|.o coe
moe o||c.|
was imposed. For these reasons, the external validity
(generalizability) of the early studies is unclear, with
selection-treatment interactions of particular concern.
It is uncertain which effects observed in these studies
would hold for which groups of same-sex attracted
people.
/''''` /`' '-''''-` ''-'''-
Early and recent study samples are typically of
convenience, so it is unclear precisely what populations
these samples represent. Respondents in the recent
studies are typically recruited through ex-gay ministries
and advocates of SOCE rather than through population-
based probability sampling strategies designed to obtain
a representative sample of same-sex attracted people
or the subset of them who experience their attractions
as distressing and have sought and been exposed
to SOCE. Additionally, study respondents are often
invited to participate in these studies by LMHP who are
proponents of SOCE, introducing unknown selection
biases into the recruitment process (cf. Beckstead, 2003;
Shidlo & Schroeder, 2002).
Qualitative studies have been more successful in
nIyIng n vnrIofy of urosIvo sfrnfIhod snmIIng
strategies (e.g., Beckstead & Morrow, 2004; Ponticelli,
1999; Wolkomir, 2001) and developing appropriate
comparison samples. However, the qualitative studies
were not undertaken with the purpose of determining
if SOCE interventions are effective in changing sexual
orientation. These studies focused on understanding
aspects of the experience of participating in SOCE from
the perspective of same-sex attracted people in distress.
As noted previously, recent research has used designs
that are incapable of making attributions of intervention
effects. In many of the recent studies, the nature of
the procedures for recruiting samples is likely to have
accentuated response-shift biases rather than to have
minimized them, because study recruiters were open
proponents of the techniques under scrutiny; it cannot
be assumed that the recruiters sought to encourage the
participation of those individuals whose experiences
ran counter to their own view of the value of these
approaches. Proponents of these efforts may also have
limited access to the research for former clients who
were perceived to have failed the intervention or who
experienced it as harmful. Some of the recent research
to assess harm resulting from these interventions
(Schroeder & Shidlo, 2001; Shidlo & Schroeder, 2002)
suffers from sampling weaknesses and biases of a
similar nature.
eome |ome
Clinically trained professionals using reasonably
well-described change efforts generally conducted
early research in clinical laboratory settings. By
contrast, the recent research included a wide variety
of change efforts, providers, and settings in which these
efforts may take place. The recent research has not
been performed in a manner that permits examination
of the interactions among characteristics of change
efforts, providers, settings, and individuals seeking to
change, nor does the research associate these patterns
with outcomes.
Summary
Our analysis of the methodology of SOCE reveals
subsfnnfInI dohcIoncIos. Thoso dohcIoncIos IncIudo
limitations in making causal claims due to threats
to internal validity (such as sample attrition, use
of retrospective pretests, lack of construct validity
IncIudIng dohnIfIon nnd nssossmonf of soxunI
orientation, and variability of study treatments and
outcome measures). Additional limitations with
recent research
include problems with
conclusion validity
(the ability to make
inferences from the
data) due to small
or skewed samples,
unreliable measures, and inappropriate selection
and performance of statistical tests. Due to these
limitations, the recent empirical literature provides
little basis for concluding whether SOCE has any effect
on sexual orientation. Any reading of the literature on
SOCE outcomes must take into account the limited
generalizability of the study samples to the population
of people who experience same-sex sexual attraction and
are distressed by it. Taking into account the weaknesses
and limitations of the evidence base, we next
summarize the results from research in which same-sex
sexual attraction and behavior have been treated.
e ece emoco|
|eo.e oooe ||e oo
|o coc|.o wee
| o o, e||ec o
e.o| oeoo
35 / /todt.c 'ov.o. ' 'oodc to -''cdc/ ' - tco
'
n Chapter 3, we provided an overview of our
systematic review of research on sexual orientation
change efforts
34
(SOCE) and the results of the review
for methodological concerns. In this chapter, we describe
the evidence on outcomes associated with SOCE,
whofhor bonohcInI or hnrmfuI. o sfudIos roorfod
offocf sIzo osfImnfos or conhdonco InforvnIs, nnd mnny
studies did not report all of the information that
would be required to compute effect sizes. As a result,
sfnfIsfIcnI sIgnIhcnnco nnd mofhodoIogy nro consIdorod
In InforrofIng fho Imorfnnco of fho hndIngs. As fho
report will show, the peer-refereed empirical research
on the outcomes of efforts to alter sexual orientation
rovIdos IIffIo ovIdonco of ofhcncy nnd somo ovIdonco of
hnrm. Wo hrsf summnrIzo fho ovIdonco of ofhcncy nnd
then the evidence of unintended harmful effects.
|eqos o| bee|
Sexual orientation change efforts have aimed to address
distress in individuals with same-sex sexual attractions
by achieving a variety of different outcomes:
Decreased interest in, sexual attraction to, and sexual :
behavior with same-sex sexual partners
34
(SOCE) to describe a method that aims to change a same-sex
sexual orientation (e.g., behavioral techniques, psychoanalytic
techniques, medical approaches, religious and spiritual approaches) to
Increased interest in, sexual attraction to, and sexual :
behavior with other-sex sexual partners
Increased healthy relationships and marriages with :
other-sex partners
Improved quality of life and mental health :
Although not all of these aims are equally well
studied, these are the outcomes that have been studied
frequently enough to be reported in this systematic
review. One general point that we wish to emphasize
as we begin the discussion of the outcomes that have
been reported in this literature is that nonexperimental
sfudIos offon hnd osIfIvo offocfs fhnf do nof hoId u
under the rigor of experimentation. The literature on
SOCE is generally consistent with this point. In other
words, the least rigorous studies in this body of research
gonornIIy rovIdo n moro osIfIvo nssossmonf of ofhcncy
than do studies that meet even the most minimal
sfnndnrds of scIonfIhc rIgor.

|eceo omee e.o| /oco
-/'' '''-
A number of investigators have assessed aversion
therapy interventions to reduce physiological and
self-reported sexual arousal in response to same-sex
stimuli and self-reports of same-sex sexual attraction
(see Appendix B).
4. A SYSTEMATIC REVIEW OF RESEARCH
ON !| ||||CACY O| SOC|. Ou!CO'|S
|oemeo| .oe
Results from the experimental studies of aversive
techniques provide some evidence that these treatments
can reduce self-reported and physiological sexual
arousal for some men. The experimental studies that
we reviewed showed lower rates of change in sexual
arousal toward the same sex than did the quasi-
oxorImonfnI nnd nonoxorImonfnI sfudIos. ThIs hndIng
was consistent with H. E. Adams and Sturgiss (1977)
review of studies published through 1976.
In their review, H. E. Adams and Sturgis (1977)
found fhnf ncross fho sovon sfudIos fhnf fhoy cInssIhod
as controlled studies, 34% of the 179 subjects that were
retained in these studies decreased their same-sex
sexual arousal. McConaghy (1976) found that roughly
half of the men who received one of four treatment
regimens reported less intense sexual interest in men at
6 months. McConaghy, Proctor, and Barr (1972) found
reductions in penile response in the laboratory following
treatment. However, penile response to female nudes
also declined for those men who initially responded to
female stimuli. McConaghy (1969) similarly reported
a decline in sexual arousal to all stimuli as a result
of treatment for some men and that treatment also
increased same-sex sexual arousal for some men.
Overall, however, a majority of participants showed
decreases in same-sex sexual arousal immediately
following treatment. McConaghy and Barr (1973) found
that about half of men reported that their same-sex
sexual attractions were reduced. Tanner (1975) found
that aversive shock could lessen erectile response to
male stimuli.
An important caveat in considering the results of
these experiments is that none compared treatment
outcomes to an untreated control group. That is, these
studies compared treatments to one another. The fact
that four of these studies also involved men who were
being treated by court referral should also be considered
In InforrofIng fho hndIngs. Thoso oxorImonfs cnnnof
address whether men would have changed their sexual
arousal pattern in the absence of treatment. Only one of
fho oxorImonfs fhnf wo IdonfIhod comnrod fronfmonf
outcomes against the outcomes for an untreated control
group. Tanner (1974) examined change in sexual arousal
among 8 men receiving electric shock therapy. Tanner
found that physiological arousal to male stimuli in the
laboratory had declined at the 8-week follow-up, when
scores among the 8 men in the treatment were compared
with those of the 8 men in a control group. Changes
were not achieved for all of the men, and there were no
differences between the experimental and control groups
in the frequency of same-sex sexual behavior.
The results of the experimental studies suggest that
some men who participate in clinical treatment studies
may be conditioned to control their sexual arousal
response to sexual stimuli, although McConaghys
(cf. McConaghy, 1999) studies suggest that aversive
treatments may affect sexual arousal indiscriminately.
These studies found that not all men reduce their
sexual arousal to these treatments and that changes in
sexual arousal in the lab are not necessarily associated
with change in sexual behavior.
.oeoemeo| .oe
The three quasi-experiments listed in Appendix B all
compare treatment alternatives for nonequivalent
groups of men. Birk et al. (1971) found that 5 (62%)
of the 8 men in the aversive treatment condition
reported decreased sexual feelings following treatment;
one man out of the 8 (12%) demonstrated reduced
sexual arousal at long-term follow-up. In comparing
groups, the researchers found that reports of same-
sox cruIsIng, snmo-sox soxunI offIng, nnd orgnsm
docIInod sIgnIhcnnfIy for mon rocoIvIng shocks whon
compared with men receiving associative conditioning.
McConaghy and colleagues (1981) found that 50%
of respondents reported decreased sexual feelings at
1 year. S. James (1978) reported that anticipatory
avoidance learning was relatively ineffective when
compared with desensitization. In their review, H. E.
Adams and Sturgis (1977) found that 50% of the 124
participants in what they termed uncontrolled studies
reported reduced sexual arousal.
|oeoemeo| .oe
onoxorImonfnI sfudIos, whIch Inck sufhcIonf rIgor fo
nssoss ofhcncy buf whIch mny bo usofuI In IdonfIfyIng
potential treatment approaches, offer a similar view of
the impact of aversive treatment on reductions in sexual
arousal. For instance, Bancroft (1969), in a within-
subject study without a comparison group, delivered
electric shocks based on males penile volume response
to photographs of nude men as they were fantasizing
about homosexual sexual encounters. Research subjects
underwent a minimum of 30 treatment sessions.
Bancroft reported that of the men who were initially
sexually attracted to both sexes, 30% (n = 3) of these
men lessened their same-sex sexual interest over the
long-term. Among those with no initial other-sex sexual
attraction, no lasting changes were observed in sexual
arousal and attraction. Several other uncontrolled
studies found reductions in participants self-reported
sexual attraction and physiological response under
laboratory conditions (range = 7%100%; average
= 58%) (Callahan & Leitenberg, 1973; Feldman &
MacCulloch, 1965; Fookes, 1960; Hallan & Rachman,
1972; MacCulloch & Feldman, 1967; Sandford, Tustin,
& Priest, 1975).
As is typically found in intervention research, the
average proportion of men who are reported to change
in uncontrolled studies is roughly double the average
proportion of men who are reported to change in
controlled studies. For instance, as noted previously,
results from controlled studies show that far less
change can be produced in same-sex sexual arousal by
aversion techniques. H.E. Adams and Sturgis (1977)
reported that in the nonexperimental studies in their
review, 68% of 47 participants reduced their same-sex
sexual arousal, as compared with 34% of participants in
experimental studies.
The studies of nonaversive techniques as the
primary treatment, such as biofeedback and hypnosis,
were only assessed in the nonexperimental within-
subject and patient case studies. For example, Blitch
and Haynes (1972) treated a single female who was
heterosexually experienced and whom they described
as strongly committed to reducing her same-sex
sexual attractions. Using relaxation, rehearsal, and
masturbation reconditioning, she was reported to be
able to masturbate without female fantasies 2 months
after intervention. Curtis and Presly (1972) used covert
sensitization to treat a married man who experienced
guilt about his attraction to and extramarital
engagement with men. After intervention, he showed
reduced other-sex and same-sex sexual interest, as
measured by questionnaire items. Huff (1970) treated
a single male who was interested in becoming sexually
attracted to women. Following desensitization, his
journal entries showed that his same-sex sexual
fantasies continued, though the ratio of other-sex to
same-sex sexual fantasies changed by the 6-month
follow-up to favor other-sex sexual fantasies. His MMPI
scores showed improvement in his self-concept and
reductions in his distress.
By contrast, among the 4 men exposed to orgasmic
reconditioning by Conrad and Wincze (1976), all
reported decreased same-sex sexual attractions
immediately following intervention, but only one
demonstrated a short-term measurable alteration in
physiological responses to male stimuli. Indeed, one
subjects sexual arousal to same-sex sexual stimuli
increased rather than decreased, a result that was
obtained for some men in the experimental studies.
In a study by Barlow and colleagues (1975), among
3 men who were each exposed to unique biofeedback
treatment regimens, all maintained same-sex sexual
arousal patterns at follow-up, as measured by penile
circumference change in response to photos of male
stimuli.
Mintz (1966) found that 8 years after initiating group
and individual therapy, 5 of his 10 research participants
(50%) had dropped out of therapy. Mintz perceived
that among those who remained, 20% (n = 1) were
distressed, 40% (n = 2) accepted their same-sex sexual
attractions, and 40%
(n = 2) were free from
conIcf rognrdIng
same-sex sexual
attractions. Birk
(1974) assessed the
impact of behavioral
therapy on 66 men,
of whom 60% (n =
40) had dropped out
of intervention by 7
months. Among those
who remained in the study, a majority shifted toward
heterosexual scores on the Kinsey scale by 18 months.
OvornII, fho Iow dogroo of scIonfIhc rIgor In fhoso
sfudIos Is IIkoIy fo Iond fo ovorosfImnfos of fho bonohfs
of these treatments on reductions in same-sex sexual
arousal and attraction and may also explain the
contradictory results obtained in nonexperimental
studies.
'--` '''-
Recent studies have investigated whether people
who have participated in efforts to change their
sexual orientation report decreased same-sex sexual
attractions (Nicolosi et al., 2000; Schaeffer et al., 2000;
Spitzer, 2003) or how people evaluate their overall
experiences of SOCE (Beckstead & Morrow 2004;
Pattison & Pattison, 1980; Ponticelli, 1999; Schroeder
& Shidlo, 2001; Shidlo & Schroeder, 2002; Wolkomir,
2001). These studies all use designs that do not permit
cause-and-effect attributions to be made. We conclude
that although these studies may be useful in describing
people who pursue SOCE and their experiences of
SOCE, none of the recent studies can address the
ofhcncy of SOCI or Ifs romIso ns nn InforvonfIon.
These studies are therefore described elsewhere in the
eo|| e |ow oeee
o| ce|c o ee
.oe |e|, o |eoo
o oeemoe o| e
oee| o| ee eome
o eo.co omee
e.o| oo.o| oo ooco
oo mo, o|o eo|o e
coooco, e.| oooeo
oeoemeo| .oe
report in places where they contribute to understanding
respondents motivations for and experiences of SOCE.
'''/'
Overall, early studies suggest that modest short-term
effects on reducing same-sex sexual arousal in the
laboratory may be obtained for a minority of study
participants through some forms of SOCE, principally
interventions involving aversion procedures such
as electric shock. Short-term reductions in sexual
arousal to other-sex stimuli were also reported for
some treatments. When outcomes were described for
individual participants or subgroups of participants,
short-term reductions in same-sex sexual arousal
patterns were more commonly reported for people
described as having other-sex sexual attractions prior
to intervention and high levels of motivation to change.
Initial and sustained reductions in sexual arousal were
reported less commonly for people who were described
as having no other-sex sexual attraction prior to
intervention. The results from the uncontrolled studies
are more positive than those from the controlled studies,
as would be expected. Yet these studies also found that
reduction in sexual arousal may not occur for study
nrfIcInnfs. !oconf sfudIos rovIdo no sound scIonfIhc
basis for determining the impact of SOCE on decreasing
same-sex sexual attraction.
|eceo omee e.o| |eoo
-/'' '''-
Early studies show that SOCE have limited impact on
same-sex sexual behavior, even in cases when lab results
show some reduction in same-sex sexual arousal.
35

|oemeo| .oe
In their review, H. E. Adams and Sturgis (1977) found
that across the seven controlled studies published
between 1960 and 1976, 18% of 179 subjects in these
studies were reported to have decreased same-sex
sexual behavior; the percentage reporting reductions
in sexual arousal was nearly double that percentage,
at 34%. In our review, we found that the results of
the experimental studies that we reviewed provided a
35
In considering the results of early studies on this outcome, readers
are advised that data on this outcome are not always reported. In
some cases, not all research participants in these studies had engaged
in sexual activity with same-sex partners prior to treatment, though
they may have fantasized about doing so. In other studies, reducing
sexual arousal under lab conditions was examined and not behavior in
daily life.
picture of the effects of aversive forms of SOCE similar
to that painted by H. E. Adams & Sturgis.
For instance, in his study comparing aversion and
aversion relief therapies,
36
McConaghy (1969) reported
that about 20% of men had engaged in same-sex sexual
behavior within 2 weeks following treatment. No longer
term data are reported. McConaghy (1976) found that
50% of men had reduced the frequency of their same-sex
behavior, 25% had not changed their same-sex behavior,
and 25% reported no same-sex behavior at 1 year.
McConaghy and Barr (1973) reported that 25% of men
had reduced their same-sex sexual behavior at 1-year.
Tnnnor (l9?5) roorfod n sIgnIhcnnf docIIno In snmo-
sex behavior across treatments. In the only untreated
confroI grou sfudy fhnf wo IdonfIhod, Tnnnor (l9?4)
found that intervention had no effect on rates of same-
sex behavior, even though the intervention did reduce
changes in penile circumference in response to male
stimuli in the lab.
.oeoemeo| .oe
Birk and colleagues (1971) found that 2 of 18 men
(11%) had avoided same-sex behavior at 36 months.
McConaghy, Armstrong, and Blaszczynski (1981)
reported that among the 11 men who were sexually
active with same-sex partners, about 25% reduced their
same-sex behavior. S. James (1978) did not report on
behavior. In their review, H. E. Adams and Sturgis
(1977) found that 50% of the 124 participants in what
they called uncontrolled group studies reported reduced
sexual arousal, and 42% reported less frequent same-
sex sexual behavior. Among the quasi-experiments
that we reviewed, the reported reductions in sexual
behavior were lower (i.e., 11% and 25%) than what was
reported by Adams and Sturgis. These differences may
be due to our more rigorous criteria of what constitutes
a quasi-experiment than the criteria employed by
Adams and Sturgis.
|oeoemeo| .oe
Among the case and single-group within-subject studies,
the results are mixed. Some studies found that people
reported having abstained from same-sex behavior
in the months immediately following intervention or
having decreased its frequency. Bancroft (1969) found
that 4 of the 10 men in his study had reduced their
behavior at follow-up. Freeman and Meyer (1975) found
that 7 of the 9 men in their study were abstinent at 18
36
Aversive therapy is the application of a painful stimuli; aversion
relief therapy is the cessation of an aversive stimulus.
months. Other single-subject and case study subjects
reported declines in or no same-sex behavior (Gray,
1970; Huff, 1970; B. James, 1962, 1963; Kendrick &
McCullough, 1972; Larson, 1970; LoPiccolo, 1971; Segal
& Sims, 1972).
Not all individuals, however, successfully abstained
on every occasion of sexual opportunity (Colson, 1972;
Rehm & Rozensky, 1974), and some relapse occurred
within months following treatment (Bancroft, 1969;
Freeman & Meyer, 1975; Hallam & Rachman, 1972;
Levin et al., 1968; MacCulloch et al., 1965; Marquis,
1970). In other studies, the proportion reporting that
they changed their sexual behavior is a minority.
For instance, among Barlow et al.s (1975) research
participants, 2 of the 3 men demonstrated no change
in their same-sex behavior. In the case studies, clients
who were described as exclusively attracted to the same
sex prior to treatment were most commonly reported to
have failed to avoid same-sex sexual behavior following
treatment.
'--` '''-
As we have noted, recent studies provide no sound
basis for attributing individual reports of their current
behavior to SOCE. No results are reported for these
studies.
'''/'
In the early studies with the greatest rigor, it appears
that SOCE may have decreased short-term same-sex
sexual behavior for a minority of men. However, in the
only randomized control group trial, the intervention
had no effect on same-sex sexual behavior. Quasi-
experimental results found that a minority of men
reported reductions in same-sex sexual behavior
following SOCE. The nonexperimental studies found
that study participants often reported reduced behavior
but also found that reductions in same-sex sexual
behavior, when reported, were not always sustained.

|ceo ee e.o| /oco
Early studies provide limited evidence for reductions in
sexual arousal to same-sex stimuli and for reductions in
same-sex sexual behavior following aversive treatments.
The impact of the use of aversive treatments for
increasing other-sex sexual arousal is negligible.
-/'' '''-
|oemeo| .oe
In many of the early experiments on aversive
treatments, sexual arousal to female sexual stimuli
was a desired outcome. McConaghy (1969) found that
about 16% of 40 men increased their sexual arousal to
female stimuli immediately following treatment and
that 5% increased their sexual arousal to male stimuli.
It is unclear how the 50% of men in this study who
were aroused by females prior to the treatment were
distributed among the men who increased their sexual
arousal and among those who did not. In other words,
it is possible that most of the men who changed were
sexually aroused by women initially. In interviews
following treatment, McConaghy (1976) reported that
25% of 157 men indicated that they felt more sexual
arousal toward females than they did before treatment.
McConaghy, Proctor, and Barr (1972) found no change
in rates of sexual arousal to female stimuli. McConaghy
et al.s (1972) research participants showed no change
in penile volume in response to female stimuli after
intervention.
In a randomized control trial, Tanners (1974) 8
research participants reported increases in sexual
fantasizing about other-sex partners after aversive
conditioning. However, penile circumference data
showed no increased sexual arousal to female stimuli.
H. E. Adams and Sturgis (1977) found that 26% of 179
participants in the controlled studies that they reviewed
increased their sexual arousal toward the other-sex.
.oeoemeo| .oe
Birk and colleagues (1971) found no difference between
their treatment groups in reported sexual arousal to
women. Two men (11% of 18 participants) in the study
reported sustained sexual interest in women following
treatment. McConaghy and colleagues (1981) reported
no sIgnIhcnnf Imrovomonf In nffrncfIon fo fomnIos.
S. James (1978) reported little impact of treatment on
participants in anticipatory avoidance learning. He
noted a general improvement among 80% of the 40 men
undergoing desensitization to other-sex situations.
|oeoemeo| .oe
Among the nonexperimental studies, for men who were
described as having some degree of other-sex sexual
attraction and experience before the intervention,
the balance of studies showed an increase in other-
sex sexual attraction over time, although given the
nonexperimental nature of these studies, this change
cannot be validly attributed to SOCE. For men with
little or no preintervention other-sex sexual attraction,
the research provides little evidence of increased other-
sex sexual attraction.
As in some of the experimental studies, the results
reported in the nonexperiments were not always in
the desired direction. Studies occasionally showed
that reductions in sexual arousal and interest may
occur for same- and other-sex partners, suggesting the
possibility that treatments may lower sexual arousal
to sexual stimuli in general. For instance, Curtis and
Preslys (1972) married male subject reported slightly
lower rates of sexual arousal in response to women than
before intervention, in addition to reduced same-sex
sexual arousal.
Among early studies, many found little or no
increases in other-sex sexual attraction among
participants who showed limited or no other-sex
sexual attraction to begin with. For instance, 2 of
the 3 men in Barlow et al.s (1975) within-subject
biofeedback investigation reported little or no other-sex
sexual interest prior to intervention. As measured by
penile circumference, one of these men demonstrated
negligible increases in other-sex sexual attraction; one
other individual showed stable low other-sex sexual
attraction, which contradicted his self-report.
In contrast, a handful of the early single-patient
case studies found increases in other-sex attraction.
For instance, Hanson and Adessos (1972) research
participant, who was reported to be primarily same-sex
sexually attracted at the onset of intervention, increased
his sexual arousal to women and ultimately reported
that he enjoyed sex with women. Huffs (1970) male
research participant also reported increased other-sex
sexual attraction at 6 months following desensitization.
'--` '''-
As we have noted, recent studies provide no sound basis
for attributing individual reports of their current other-
sex sexual attraction to SOCE. No results are reported
for these studies.
'''/'
Taken together, the research provides little support
for the ability of interventions to develop other-sex
sexual attraction where it did not previously exist,
though it may be possible to accentuate other-sex sexual
attraction among those who already experience it.
|ceo ee e.o| |eoo
Studies on whether interventions can lead to other-sex
sexual activity show limited results. These studies
show more success for those who had an other-sex
sexual orientation (e.g., sexual arousal) and were
sexually experienced with members of the other sex
prior to intervention than for those who had no other-
sex sexual orientation and no history of other-sex sexual
behavior. The results for this outcome suggest that some
people can initiate other-sex sexual behavior whether or
not they have any observed other-sex sexual orientation.
As previously noted, in the early studies many people
were described as heterosexually experienced. From
the data provided by H.E. Adam and Sturgis in their
1977 review, 61%80% of male research participants
appeared to have histories of dating women, and
33%63% had sexual intercourse with women prior
to intervention. Additionally, some of the men were
married at the time of intervention. Because so many
of the research participants in these studies had other-
sex sexual attractions or intimate relationships at the
outset, it is unclear how to interpret changes in their
levels of other-sex sexual activity.
-/'' '''-
|oemeo| .oe
According to H. E. Adams and Sturgis (1977), only 8%
of participants in controlled studies are reported to have
engaged in other-sex sexual behavior following SOCE.
Among those studies we reviewed, only 2 participants
showod n sIgnIhcnnf Incronso In ofhor-sox soxunI
activity (McConaghy & Barr, 1973; Tanner, 1974). In
Tanners randomized controlled trial, men increased the
frequency of intercourse with females but maintained
the frequency of intercourse with males.
.oeoemeo| .oe
McConaghy et al. (1981) found no difference in the
frequency of other-sex sexual behavior following SOCE.
|oeoemeo| .oe
Among within-subject patient studies in which aversion
techniques were used, some studies reported that a
subset of 12%40% of people in the multiple-subject
studies and all people in single-patient studies engaged
in other-sex sexual behavior following intervention
(e.g., Bancroft, 1969; Fookes, 1960; Hallam & Rachman,
1972; Hanson & Adesso, 1972; Kendrick & McCullough,
1972; Larson, 1970). Regarding other techniques
studied in early intervention research, Barlow et
al. (1975) reported that 1 of 3 research participants
began to date women after biofeedback. Huffs (1970)
research participant also began to date women after
desensitization training. LoPiccolo (1971) used orgasmic
reconditioning to treat a malefemale couple. The male
could not achieve an erection with his female partner
and found sex with women dissatisfying. At 6 months,
he was able to develop and maintain an erection and
ejaculate intravaginally.
'--` '''-
As previously noted, recent studies provide no sound
basis for attributing individual reports of their current
sexual behavior to SOCE. No results are reported for
these studies.
'''/'
In general, the results from studies indicate that while
some people who undergo SOCE do engage in other-sex
sexual behavior afterward, the balance of the evidence
suggests that SOCE is unlikely to increase other-sex
sexual behavior. Findings show that the likelihood of
having sex with other-sex partners for those research
participants who possess no other-sex sexual orientation
prior to the intervention is low.

\ooe
One outcome that some proponents of efforts to change
sexual orientation are reported to value is entry into
heterosexual marriage. Few early studies reported on
whether people became heterosexually married after
intervention. In a quasi-experimental study, Birk et
al. (1971) found that 2 of 18 respondents (11%) were
married at 36 months. Two uncontrolled studies
(Birk, 1974; Larson, 1970) indicated that a minority of
research participants ultimately married, though it is
not clear what role, if any, intervention played in this
outcome. Recent research provides more information on
marriage, though research designs do not permit any
attribution of marital outcomes to SOCE.
|moo \eo| eo|
The relationship between mental health, psychological
well-being, sexual orientation, sexual orientation
identity, and sexual behavior is important. Few studies
report health and mental health outcomes, and those
that do report outcomes tend to use psychometrically
weak measures of these constructs and weak study
designs. Among the early studies that report on mental
health, three nonexperimental single-patient case
studies report that clients were more self-assured
(Blitch & Haynes, 1972) or less fearful and distressed
(Hanson & Adesso, 1972; Huff, 1970).
Overall, the lack of high-quality data on mental
health outcomes of efforts to change sexual orientation
provide no sound basis for claims that peoples mental
health and quality of life improve. Indeed, these studies
add little to understanding how SOCE affects peoples
long-term mental health.
Reports of Harm
oformInIng fho ofhcncy of nny InforvonfIon IncIudos
examination of its side effects and evidence of its harm
(Flay et al., 2005; Lilienfeld, 2007). A central issue
in the debates regarding efforts to change same-sex
sexual attractions concerns the risk of harm to people
that may result from attempts to change their sexual
orientation. Here we consider evidence of harm in early
and recent research.
-/'' '''-
Early research on efforts to change sexual orientation
focused heavily on interventions that include aversion
techniques. Many of these studies did not set out to
investigate harm. Nonetheless, these studies provide
some suggestion that harm can occur from aversive
efforts to change sexual orientation.
-/'-'''-`/' '''-
In McConaghy and Barrs (1973) experiment, 1
respondent of 46 subjects is reported to have lost all
sexual feeling and to have dropped out of the treatment
as a result. Two participants reported experiencing
severe depression, and 4 others experienced milder
depression during treatment. No other experimental
studies reported on iatrogenic effects.
'/'-/'-'''-`/' '''-
None reported on adverse events.
``-/'-'''-`/' '''-
A majority of the reports on iatrogenic effects are
provided in the nonexperimental studies. In the study
conducted by Bancroft (1969), the negative outcomes
reported include treatment-related anxiety (20% of 16
participants), suicidal ideation (10% of 16 participants),
depression (40% of 16 participants), impotence (10%
of 16 participants), and relationship dysfunction
(10% of 16 participants). Overall, Bancroft reported
the intervention had harmful effects on 50% of the
16 research subjects who were exposed to it. Quinn,
Harrison, and McAllister (1970) and Thorpe et al.
(1964) also reported cases of debilitating depression,
gastric distress, nightmares, and anxiety. Herman and
Prewett (1974) reported that following treatment, their
research participant began to engage in abusive use of
alcohol that required his rehospitalization. It is unclear
to what extent and how his treatment failure may have
contributed to his abusive drinking. B. James (1962)
reported symptoms of severe dehydration (acetonuria),
which forced treatment to be suspended. Overall,
although most early research provides little information
on how research participants fared over the longer term
and whether interventions were associated with long-
term negative effects, negative effects of treatment are
reported to have occurred for some people during and
immediately following treatment.
High dropout rates characterize early treatment
studies and may be an indicator that research
participants experience these treatments as harmful.
Lilienfelds (2007) review of harm in psychotherapy
IdonfIhos droouf ns nof onIy nn IndIcnfor of dIrocf
harm but also of treatment ineffectiveness.
'--` '''-
Although the recent studies do not provide valid causal
ovIdonco of fho ofhcncy of SOCI or of Ifs hnrm, somo
recent studies document that there are people who
perceive that they have been harmed through SOCE
(Beckstead & Morrow, 2004; Nicolosi et al., 2000;
Schaeffer et al., 2000; Schroeder & Shidlo, 2001; Shidlo
& Schroeder, 2002; Smith et al., 2004), just as other
recent studies document that there are people who
orcoIvo fhnf fhoy hnvo bonohfod from If (Iocksfond &
Morrow, 2004; Nicolosi et al., 2000; Pattison & Pattison,
1980; Schaeffer et al., 2000; Spitzer, 2003). Among
those studies reporting on the perceptions of harm, the
reported negative social and emotional consequences
include self-reports of anger, anxiety, confusion,
depression, grief, guilt, hopelessness, deteriorated
relationships with family, loss of social support, loss
of faith, poor self-image, social isolation, intimacy
dIfhcuIfIos, InfrusIvo Imngory, suIcIdnI IdonfIon,
self-hatred, and sexual dysfunction. These reports
of perceptions of harm are countered by accounts of
perceptions of relief, happiness, improved relationships
with God, and perceived improvement in mental
honIfh sfnfus, nmong ofhor roorfod bonohfs. Mnny
participants in studies by Beckstead and Morrow (2004)
and Shidlo and Schroeder (2002) described experiencing
hrsf fho osIfIvo offocfs nnd fhon oxorIoncIng or
acknowledging the negative effects later.
Overall, the recent studies do not give an indication of
the client characteristics that would lead to perceptions
of hnrm or bonohf. AIfhough fho nnfuro of fhoso sfudIos
rocIudos cnusnI nffrIbufIons for hnrm or bonohf fo
SOCE, these studies underscore the diversity of and
range in participants perceptions and evaluations of
their SOCE experiences.
.mmo,
Wo concIudo fhnf fhoro Is n donrfh of scIonfIhcnIIy
sound research on the safety of SOCE. Early and recent
research studies provide no clear indication of the
prevalence of harmful
outcomes among people
who have undergone
efforts to change their
sexual orientation
or the frequency of
occurrence of harm
because no study to date
of ndoqunfo scIonfIhc
rigor has been explicitly
designed to do so. Thus,
we cannot conclude how
likely it is that harm
will occur from SOCE.
However, studies from
both periods indicate
that attempts to change sexual orientation may cause
or exacerbate distress and poor mental health in some
individuals, including depression and suicidal thoughts.
The lack of rigorous research on the safety of SOCE
represents a serious concern, as do studies that report
perceptions of harm (cf. Lilienfeld, 2007).
Conclusion
The limited number of rigorous early studies and
complete lack of rigorous recent prospective research on
SOCI IImIfs cInIms for fho ofhcncy nnd snfofy of SOCI.
Within the early group of studies, there are a small
number of rigorous studies of SOCE, and those focus on
the use of aversive treatments. These studies show that
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coe e.o| oeoo
mo, co.e o eoceooe
oe oo ooo meo|
eo| ome oo.o|
c|.o oeoeo oo
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enduring change to an individuals sexual orientation is
uncommon and that a very small minority of people in
these studies showed any credible evidence of reduced
same-sex sexual attraction,
though some show lessened
physiological arousal
to all sexual stimuli.
Compelling evidence of
decreased same-sex sexual
behavior and increased
attraction to and engagement in sexual behavior with
the other sex was rare. Few studies provided strong
evidence that any changes produced in laboratory
conditions translated to daily life. We found that
nonaversive and recent approaches to SOCE have not
been rigorously evaluated. Given the limited amount
of methodologically sound research, we cannot draw a
conclusion regarding whether recent forms of SOCE are
or are not effective.
We found that there was some evidence to indicate
that individuals experienced harm from SOCE. Early
studies do document iatrogenic effects of aversive
forms of SOCE. High dropout rates characterize early
aversive treatment studies and may be an indicator
that research participants experience these treatments
as harmful. Recent research reports indicate that there
are individuals who perceive they have been harmed
nnd ofhors who orcoIvo fhoy hnvo bonohfod from
nonaversive SOCE. Across studies, it is unclear what
socIhc IndIvIdunI chnrncforIsfIcs nnd dIngnosfIc crIforIn
would prospectively distinguish those individuals
who will later perceive that they have succeeded and
bonohfod from nonnvorsIvo SOCI from fhoso who wIII
later perceive that they have failed or been harmed.
In the next chapter, we explore the literature on
individuals who seek to change their sexual orientation
to better understand their concerns.
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o, coe ooo.ceo
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o|oeo o oo|, ||e
'
n the three chapters preceding this one, we have
focused on sexual orientation change efforts
37
(SOCE),
because such interventions have been the primary
focus of attention and contention in recent decades. Now
we turn from the problem of sexual orientation change,
ns If hns boon dohnod by oxorf nnrrnfIvos of sIn,
crime, disorder, and dysfunction in previous chapters,
to the problem of sexual orientation distress, as it exists
in the lives of individuals who seek sexual orientation
change. We try to present what the research literature
revealsand clarify what it does notabout the natural
history of the phenomenon of people who present to
LMHP seeking SOCE.
Wo do fhIs for fwo mnjor ronsons. Tho hrsf Is fo
provide a scholarly basis for responding to the core task
forco chnrgo: fho nrorInfo nIIcnfIon of nfhrmnfIvo
therapeutic interventions for the population of those
individuals who seek sexual orientation change. The
second is our hope to step out of the polemic that has
dohnod nronchos fo soxunI orIonfnfIon dIsfross. As
discussed in the introduction, some professional articles
(e.g., Rosik, 2001, 2003; Yarhouse & Burkett, 2002),
organizations, and accounts of polemical debates (cf.
Drescher, 2003) have argued that APA and mainstream
psychology are ignoring the needs of those for whom
same-sex sexual attractions are unwanted, especially
37
(SOCE) to describe a method that aims to change a same-sex
sexual orientation (e.g., behavioral techniques, psychoanalytic
techniques, medical approaches, religious and spiritual approaches) to
for religious
populations. We hope
that an empathic
and comprehensive
review of the
scholarly literature
of the population
that seeks and
participates in
SOCE can facilitate
an increased
understanding of
fho noods of fhIs ouInfIon so fhnf nn nfhrmnfIvo
therapeutic approach may be developed.
We decided to expand our review beyond empirical
literature to have a fuller view of the population in
question. Because of the lack of empirical research in
this area, the conclusions must be viewed as tentative.
The studies that are included in this discussion are (a)
surveys and studies of individuals who participated
In SOCI nnd fhoIr orcofIons of chnngo, bonohf, nnd
harm (e.g., S. L. Jones & Yarhouse, 2007; Nicolosi et al.,
2000; Schaeffer et al., 2000; Schroeder & Shidlo, 2001;
Shidlo & Schroeder, 2002; Spitzer, 2003; Throckmorton
& Welton, 2005);
38
(b) high-quality qualitative studies
of the concerns of participants and the dynamics of
SOCE (e.g., Beckstead & Morrow, 2004; Erzen, 2006;
Ponticelli, 1999; Wolkomir, 2001, 2006); (c) case reports,
clinical articles, dissertations, and reviews where sexual
38
As rovIousIy nofod, fhoso sfudIos, duo fo fhoIr sIgnIhcnnf
methodological issues, cannot assess whether actual sexual
orientation change occurred.
5. RESEARCH ON ADULTS WHO UNDERGO
SEXUAL ORIENTATION CHANGE EFFORTS
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45 'oodc /dt \ '`'-' od .otdt. cd_o o''t
orientation or sexual orientation identity change were
considered or attempted (e.g., Borowich, 2008; Drescher,
1998a; Glassgold, 2008; Gonsiorek, 2004; Haldeman,
2004; Karten, 2006; Mark, 2008; Tan, 2008; Yarhouse et
al., 2005; Yarhouse, 2008); and (d) scholarly articles on
fho concorns of roIIgIous IndIvIdunIs who nro conIcfod
by their same-sex sexual attractions, many of whom
accept their same-sex sexual orientation (e.g., Coyle &
Rafalin, 2000; Horlacher, 2006; Kerr, 1997; Mahaffy,
1996; Moran, 2007; ONeill & Ritter, 1992; Ritter
& ONeill, 1989, 1995; Smith et al., 2004; Thumma,
1991; Yip, 2000, 2002, 2003, 2005). We also reviewed
a variety of additional scholarly articles on subtopics
such as individuals in other-sex marriages and general
literature on sexual orientation concerns.
Demographics
The majority of participants in research studies on
SOCE have been Caucasian men. Early studies included
some men who were court-referred (S. James, 1978;
McConaghy, 1969, 1976; McConaghy et al., 1972) and
whose participation was not voluntary, but more recent
research primarily includes men who indicated that
their religion is of central importance (Beckstead &
Morrow, 2004; S. L. Jones & Yarhouse, 2007; Wolkomir,
2001). Some studies included small numbers of women
(22%29%; Nicolosi et al., 2000; S. L. Jones & Yarhouse,
2007; Schaeffer et al., 2000; Schroeder & Shidlo, 2001;
Shidlo & Schroeder, 2002; Spitzer, 2003), and two
studies focused exclusively on women (Moran, 2007;
Ponticelli, 1999). However, these studies do not examine
if there are potential differences between the concerns
of men and women. Members of racial-ethnic groups are
not included in some samples (Beckstead & Morrow,
2004; Ponticelli, 1999; Wolkomir, 2001) and are a small
percentage (5%14%) of the sample in other studies (S.
L. Jones & Yarhouse,
2007; Nicolosi et al.,
2000; Schroeder &
Shidlo, 2001; Shidlo
& Schroeder, 2002;
Spitzer, 2003). In
the recent studies,
no comparisons were
reported between the
ethnic minorities in
the sample and others. Thus, there is no evidence that
can elucidate concerns of ethnic minority individuals
who have sought SOCE. To date, the research has
not fully addressed age, gender, gender identity, race,
ethnicity, culture, national origin, disability, language,
and socioeconomic status in the population of distressed
individuals who have sought SOCE.
Samples in recent SOCE studies have been composed
predominantly of individuals from conservative
Christian denominations (Beckstead & Morrow, 2004;
Erzen, 2006; Nicolosi et. al., 2000; Ponticelli, 1999;
Schroeder & Shidlo, 2001; Shidlo & Schroeder, 2002;
Spitzer, 2003; Wolkomir, 2001). These studies included
very few nonreligious individuals, and the concerns of
religious individuals of faiths other than Christian are
not described. The published literature focused on the
impact of religiously oriented self-help groups or was
performed by those who sought referrals from groups
that advocate SOCE. Thus, the existing literature
limits information to the concerns of a particular group
of religious individuals. Finally, most individuals in
studies of SOCE have tried multiple ways to change
their sexual orientation, ranging from individual
psychotherapy to religiously oriented groups, over long
periods of time and with varying degrees of satisfaction
and varying perceptions of success (Beckstead &
Morrow, 2004; Comstock, 1996; Horlacher, 2006; S. L.
Jones & Yarhouse, 2007; Mark, 2008; Nicolosi et al.,
2000; Shidlo & Schroeder, 2002).
Why Individuals
Undergo SOCE
Because no research provides prevalence estimates
of those participating in SOCE, we cannot determine
how prevalent the wish to change sexual orientation
is among the conservative Christian men who have
predominated in the recent research, or among any
other population. Clients motivations to seek out and
participate in SOCE seem to be complex and varied
and may include mental health and personality issues,
cultural concerns, religious faith, internalized stigma,
as well as sexual orientation concerns (Beckstead
& Morrow, 2004; Drescher, 1998a; Glassgold, 2008;
Gonsiorek, 2004; Haldeman, 2004; Lasser & Gottlieb,
2004; S. L. Jones & Yarhouse, 2007; Nicolosi et al.,
2000). Somo of fho fncfors InuoncIng n cIIonf`s roquosf
for SOCI fhnf hnvo boon IdonfIhod In fho IIfornfuro
include the following:
Confusion or questions about ones sexuality and :
sexual orientation (Beckstead & Morrow, 2004; Smith
et al., 2004)
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o. |
Religious beliefs that consider homosexuality sinful :
or unacceptable (Erzen, 2006; Haldeman, 2004;
S. L. Jones & Yarhouse, 2007; Mark, 2008; Ponticelli,
1999; Tan, 2008; Tozer & Hayes, 2004; Wolkomir,
2001, 2006; Yarhouse, 2008)
Fear, stress, and anxiety surrounding the :
implications of an LGB identity (especially the
illegitimacy of such an identity within the clients
religious faith or community) (Beckstead & Morrow,
2004; Glassgold, 2008; Haldeman, 2004; Mark, 2008;
Shidlo & Schroeder, 2002)
Family pressure to be heterosexual and community :
rejection of those who are LGB (Haldeman, 2004;
Glassgold, 2008; Mark, 2008; Shidlo & Schroeder,
2002; Smith et al., 2004)
Some individuals who have pursued SOCE report
hnvIng hnd onIy unsuccossfuI or unfuIhIIIng snmo-sox
sexual experiences in venues such as bars or sexual
cruIsIng nrons (Iocksfond & Morrow, 2004; ShIdIo
& Schroodor, 2002). Thoso oxorIoncos roocfod nnd
ro-cronfod rosfrIcfod vIows fhnf fho gny IIfosfyIo
is nonspiritual, sexually desperate, or addicted,
depressive, diseased, and lonely (Drescher, 1998a;
Green, 2003; Rosik, 2003; Scasta, 1998). Many sexual
minority individuals who do not seek SOCE are also
nffocfod by fhoso fncfors. Thus, fhoso hndIngs do nof
explain why some people seek SOCE and others do not.
Thoro nro somo InIfInI hndIngs fhnf suggosf
differences between those who seek SOCE and those
who resolve their sexual minority stress through
other means. For example, Ponticelli (1999) and S.
L. Jones and Yarhouse (2007) reported higher levels
of self-reported family violence and sexual abuse in
their samples than were reported by Laumann et al.
(1994) in a population-based sample. Beckstead and
Morrow (2004) and S. L. Jones and Yarhouse reported
high levels of parental rejection or authoritarianism
among their religious samples (see also Smith et al.,
2004). Wolkomir (2001) found that distress surrounding
nonconformity to traditional gender roles distinguished
the men in her sample who did not accept their sexual
orientation from those who did. Similarly, Beckstead
and Morrow found that distress and questions about
masculinity were an important appeal of SOCE; some
men who sought SOCE described feeling distress about
not acting more traditionally masculine. In reviewing
the SOCE literature, Miville and Ferguson (2004)
proposed that White, conservatively religious men
might not feel adept at managing a minority status and
thus seek out SOCE as a resolution.
Licensed mental health providers views about SOCE
nnd homosoxunIIfy nonr fo Inuonco cIIonfs` docIsIon
making in choosing SOCE; some clients reported being
urged by their provider to participate in SOCE (M.
King et al. 2004; Schroeder & Shidlo, 2001; Smith et al.,
2004). For example, Smith et al. (2004) found that some
who had received SOCE had not requested it. These
individuals stated they had presented with confusion
and distress about their orientation due to cultural
nnd roInfIonnI conIcfs nnd woro offorod SOCI ns
the solution.
oec|c oce
o| |e|o. |oo.o|
In general, the participants in research on SOCE have
come from faiths that believe heterosexuality and
other-sex relationships are part of the natural order
and are morally superior to homosexuality (Beckstead
& Morrow, 2004; Ponticelli, 1999; Shidlo & Schroeder,
2002; Wolkomir, 2001, 2006). The literature on SOCE
suggests that individuals reject or fear their same-sex
sexual attractions because of the internalization of the
values and attitudes of their religion that characterize
homosexuality negatively and as something to avoid
(Beckstead & Morrow, 2004; Erzen, 2006; Glassgold,
2008; Mark, 2008; Nicolosi et al., 2000; Ponticelli, 1999;
Wolkomir, 2001, 2006).
The experiences of some conservative religious
individuals with same-sex sexual attractions who
undorgo SOCI nonr fo InvoIvo sIgnIhcnnf sfross
due to the struggle to live life congruently with their
religious beliefs (S. L. Jones & Yarhouse, 2007;
Yarhouse et al., 2005; Yarhouse & Tan, 2004). These
individuals perceive homosexuality to be irreconcilable
with their faith and do not wish to surrender or change
their faith (Wolkomir, 2006). Some report fearing
considerable shifts or losses in their core identity, role,
purpose, and sense of order if they were to pursue an
outward LGB identity (Beckstead & Morrow, 2004;
Glassgold, 2008; Haldeman, 2004; Mark, 2008; ONeill
& Ritter, 1992; Ritter & ONeill, 1989, 1995; Wolkomir,
2006). Somo roorf dIfhcuIfy coIng wIfh Infonso guIIf
over the failure to live a virtuous life and inability to
sfo commIffIng unforgIvnbIo sIns, ns dohnod by fhoIr
religion (Beckstead & Morrow, 2004; Glassgold, 2008;
Mark, 2008). Some struggled with the belief in their
Higher Power, with the perception that this Power was
punishing or abandoning themor would if they acted
on their attractions; some expressed feelings of anger
at the situation in which their Power had placed them
(Beckstead & Morrow, 2004; Glassgold, 2008; cf. Exline,
2002; Pargament, Smith, Koenig, & Perez, 1998, 2005).
Some individuals distress took the form of a crisis
of faith in which their religious beliefs that a same-
sex sexual orientation and religious goodness are
diametrically opposed led them to question their faith
and themselves (Glassgold, 2008; Moran, 2007; Tozer
& Hayes, 2004). Spiritual struggles also occurred for
religious sexual
minorities due to
struggling with
conservatively
religious family,
friends, and
communities who
thought differently
than they did.
The distress
experienced by
religious individuals appeared intense, for not only did
they face sexual stigma from society at large but also
mossngos from fhoIr fnIfh fhnf fhoy woro dohcIonf,
sinful, deviant, and possibly unworthy of salvation
unless they changed sexual orientation (Beckstead &
Morrow, 2004).
These spiritual struggles had mental health
consequences. Clinical publications and studies of
religious clients (both male and female) (Beckstead &
Morrow, 2004; Glassgold, 2008; Haldeman, 2004; Mark,
2008) have described individuals who felt culpable,
unacceptable, unforgiven, disillusioned, and distressed
duo fo fho conIcf bofwoon fhoIr snmo-sox soxunI
attractions and religion. The inability to integrate
religion and sexual orientation into a religiously
sanctioned life (i.e., one that provides an option
for positive self-esteem and religiously sanctioned
sexuality and family life) has been described as
causing great emotional distress (Beckstead & Morrow,
2004; Glassgold, 2008; Mark, 2008; D. F. Morrow,
2003). These spiritual struggles were sometimes
associated with anxiety, panic disorders, depression,
and suicidality, regardless of the level of religiosity or
the perception of religion as a source of comfort and
coping (Beckstead & Morrow, 2004; Glassgold, 2008;
Haldeman, 2004). The emotional reactions reported in
the literature on SOCE among religious individuals
are consistent with the literature in the psychology of
religion that describes both the impact of an inability
to live up to religious motivations and the effects of
religion and positive and negative religious coping
(Ano & Vasconcelles, 2005; Exline, 2002; Pargament
& Mahoney, 2002; Pargament et al., 2005; Trenholm,
Trent, & Compton, 1998).
Some individuals coped by trying to compartmen-
talize their sexual orientation and religious identities
and behaviors or to suppress one identity in favor
of another (Beckstead & Morrow, 2004; Haldeman,
2004; Glassgold, 2008; Mark, 2008). Relief came as
somo soughf roonfnnco from fhoIr sIns, buf ofhors
continued to feel isolated and unacceptable in both
religious and sexual minority communities (Shidlo &
Schroeder, 2002; Yarhouse & Beckstead, 2007). As an
alternative, some with strong religious motivations
and purpose were willing to make sexual abstinence a
goal and to limit sexual and romantic needs in order
to achieve congruence with their religious beliefs (S.
L. Jones & Yarhouse, 2007; Yarhouse et al., 2005;
Yarhouse, 2008). These choices are consistent with
the psychology of religion that emphasizes religious
motivations and purpose (cf. Emmons, 1999; Emmons
& Paloutzian, 2003; Hayduk, Stratkotter, & Rovers,
1997; Roccas, 2005). Success with this choice varied
greatly and appeared successful in a minority of
participants of studies, although not always in the long
term, and both positive and negative mental heath
effects have been reported (Beckstead & Morrow, 2004;
Horlacher, 2006; S. L. Jones & Yarhouse, 2007; Shidlo
& Schroeder, 2002).
Some conservatively religious individuals felt a
need to change their sexual orientation because of the
osIfIvo bonohfs fhnf somo IndIvIdunIs found from
religion (e.g., community, mode of life, values, sense
of purpose) (Beckstead & Morrow, 2004; Borowich,
2008; Glassgold, 2008; Haldeman, 2004; Mark, 2008;
Nicolosi et al., 2000; Yarhouse, 2008). Others hoped that
being heterosexual would permit them to avoid further
negative emotions (e.g., self-hatred, unacceptability,
isolation, confusion, rejection, and suicidality) and
expulsion from their religious community (Beckstead
& Morrow, 2004; Borowich, 2008; Glassgold, 2008;
Haldeman, 2004; Mark, 2008).
The literature on non-Christian religious
denominations is very limited, and no detailed
literature was found on most faiths that differed from
the descriptions cited previously. There is limited
InformnfIon on fho socIhc concorns of obsorvnnf
and Orthodox Jews
39
(e.g., Blechner, 2008; Borowich,
39
Among Jewish traditions, Orthodox Judaism is the most
conservative and does not have a role for same-sex relationships or
sexual orientation identities within its faith (Mark, 2008). Individuals
e oe eoeeceo o,
e|o. oo.o| oooeoeo
ee |o o o|, oo e,
|oce e.o| mo |om oce,
o |oe o. o|o meoe |om
e |o o e, wee oe|ce
|.| oeo oo ooo|,
.wo, o| o|oo .|e e,
coeo e.o| oeoo
2008; Glassgold, 2008; Mark, 2008; Wolowelsky &
WoInsfoIn, l995). ThIs work sfrossos fho conIcfs fhnf
emerge within a communal and insular culture that
values obedience to religious law and separates itself
from mainstream society and other faiths, including
mainstream LGB communities, thus isolating those in
conIcf nnd dIsfross (CInssgoId, 2008; Mnrk, 2008). As
marriage, family, and community are the central units
of life within such a religious context, LGB individuals
do not have a place in Orthodox Judaism and traditional
Jewish society and may fear losing contact with
family and society or bringing shame and negative
consequences to their family if their sexual orientation
is disclosed.
40
Many of the responses and concerns of the
conservative Christian population appear relevant to
those who are Orthodox Jews, especially those that arise
from fho conIcfs of fnIfh nnd soxunI orIonfnfIon, such
as feelings of guilt, doubt, crisis of faith, unworthiness,
and despair (Glassgold, 2008; Mark, 2008).
We found no scholarly psychological literature on
sexual minority Muslims who seek out SOCE. There
is some literature on debates about homosexuality
within Islam and
cuIfurnI conIcfs
for those Muslims
who live in Western
societies with more
progressive attitudes
toward homosexuality
(Halstead & Lewicka,
1998; Hekma, 2002; de Jong & Jivraj, 2002; Massad,
2002; Nahas, 2004). Additionally, there is some
literature on ways in which individuals integrate LGBT
identities with their Muslim faith (Minwalla, Rosser,
IoIdmnn, & Vnrgn, 2005; YI, 2005). Wo dId nof hnd
scholarly articles about individuals from other faiths
who sought SOCE, except for one article (Nicolosi et al.,
2000) that that did not report any separate results for
individuals from non-Christian faiths.
It is important to note that not all sexual minorities
with strong religious beliefs experience sexual
orientation distress, and some resolve such distress
in other ways than SOCE (Coyle & Rafalin, 2000;
Mahaffy, 1996; ONeill & Ritter, 1992; Ritter & ONeill,
1989, 1995; Rodriguez & Ouellette, 2000; Rodriguez,
in other denominations (e.g., Conservative, Reform, Reconstructionist)
mny nof fnco fhIs fyo of conIcf or fhIs dogroo of conIcf.
40
Thoso conIcfs mny nIso bo roIovnnf fo fhoso whoso roIIgIon nnd
community are similarly intertwined and separate from larger society;
see Cates (2007), for instance, regarding an individual from an Old
Amish community.
2006; Yip, 2000, 2002, 2003, 2005). For instance, some
individuals are adherents of more accepting faiths
and thus experience less distress. Some end their
relationship with all religious institutions, although
they may retain the religious and spiritual aspects of
their original faiths that are essential to them. Others
choose another form of religion or spirituality that
Is nfhrmIng of soxunI mInorIfIos (!onso, Horno, &
Noffsinger-Frazier, 2005; Ritter & ONeill, 1989, 1995;
Ritter & Terndrup, 2002; Rodriguez & Ouellette, 2000;
Yip, 2000, 2002, 2003, 2004).
o|c o| |oo.o| ee
\ooe o |e|ooo
There is some indication that some individuals with
same-sex sexual attractions in other-sex marriages or
relationships may request SOCE. Many subjects in the
early studies were married (H. E. Adams & Sturgis,
1977). In the more recent research, some individuals
were married (e.g., Horlacher, 2006; Spitzer, 2003),
and there are clinical reports of experiences of SOCE
among other-sex married people (e.g., Glassgold, 2008;
Isay, 1998). For some, the marriage to another-sex
person was described as based on socialization, religious
views that deny same-sex sexual attractions, lack of
awareness of alternatives, and hopes that marriage
would change them (Gramick, 1984; Higgins, 2006;
Isay, 1998; Malcolm, 2000; Ortiz & Scott, 1994; M.
W. Ross, 1989). Others did not recognize or become
aware of their sexuality, including same-sex sexual
attractions, until after marriage, when they became
sexually active (Bozett, 1982; Carlsson, 2007; Schneider
et al. 2002). Others had attractions to both men and
women (Brownfain, 1985; Coleman, 1989; Wyers, 1987).
For those who experienced distress with their other-
sex relationship, some were at a loss as to how to
docIdo whnf fo do wIfh fhoIr conIcfIng noods, roIos,
and responsibilities and experienced considerable guilt,
shame, and confusion (Beckstead & Morrow, 2004;
Bozett, 1982; Buxton, 1994, 2004, 2007; Gochros, 1989;
Hays & Samuels, 1989; Isay, 1998; Shidlo & Schroeder,
2002; Yarhouse & Seymore, 2006). Love for their spouse
conIcfod wIfh dosIros fo oxIoro or ncf on snmo-sox
romantic and sexual feelings and relationships or to
connect with similar others (Bridges & Croteau, 1994;
Coleman, 1981/1982; Yarhouse & Seymore, 2006).
However, many individuals wished to maintain their
marriage and work at making that relationship last
(Buxton, 2007; Glassgold, 2008; Yarhouse, Pawlowski,
| mooo o oe o o
o|| e.o| moe w o
e|o. oe|e| eoeece
e.o| oeoo oe oo
ome eo|e .c oe
oe wo, o |
& Tan, 2003; Yarhouse & Seymore, 2006). Thus, the
sexual minority individual sometimes felt frustrated
and hopeless in facing feelings of loss and guilt that
result from trying to decide whether to separate from
or remain in the marriage as they balanced hopes
nnd nmbIguIfIos (o.g., fho chnncos of hndIng n snmo-
sex romantic or sexual partner or the possibilities of
experiencing further intimacy with ones heterosexual
spouse) (Hernandez & Wilson, 2007).
Reported Impacts of SOCE
|eceeo |oe o| |
In this section we review the perceptions of individuals
who underwent SOCE in order to examine what may
be perceived as being helpful or detrimental by such
IndIvIdunIs, dIsfIncf from n scIonfIhc ovnIunfIon of fho
ofhcncy or hnrm nssocInfod wIfh soxunI orIonfnfIon
change efforts, as reported in Chapter 4.
Individuals have reported that SOCE provided
sovornI bonohfs: (n) n Inco fo dIscuss fhoIr conIcfs
(Beckstead & Morrow, 2004; Erzen, 2006; Ponticelli,
1999; Wolkomir, 2001); (b) cognitive frameworks that
permitted them to reevaluate their sexual orientation
identity, attractions, and selves in ways that lessened
shame and distress and increased self-esteem (Erzen,
2006; Karten, 2006; Nicolosi et al., 2000; Ponticelli,
1999; Robinson, 1998; Schaeffer et al., 2000; Spitzer,
2003; Throckmorton, 2002); (c) social support and
role models (Erzen, 2006; Ponticelli, 1999; Wolkomir,
2001, 2006); and (d) strategies for living consistently
with their religious faith and community (Beckstead &
Morrow, 2004; Erzen, 2006; Horlacher, 2006; S. L. Jones
& Yarhouse, 2007; Nicolosi et al., 2000; Ponticelli, 1999;
Robinson, 1998; Wolkomir, 2001, 2006; Throckmorton &
Welton, 2005).
Ior Insfnnco, nrfIcInnfs roorfIng bonohcInI
effects in some studies perceived changes to their
sexuality, such as in their sexual orientation, gender
identity, sexual behavior, sexual orientation identity
(Beckstead, 2001; Nicolosi et al., 2000; Schaeffer et
al., 2000; Spitzer, 2003; Throckmorton & Welton,
2005), or improving nonsexual relationships with
men (Karten, 2006). These changes in sexual self-
views were described in a variety of ways (e.g., ex-
gay, heterosexual, heterosexual with same-sex sexual
attractions, heterosexual with a homosexual past) and
with varied and unpredictable outcomes, some of which
were temporary (Beckstead, 2003; Beckstead & Morrow,
2004; Shidlo & Schroeder, 2002). McConaghy (1999)
reported that some men felt they had more control in
their sexual behavior and struggled less with their
attractions after interventions, although same-sex
sexual attractions still existed (cf. Beckstead & Morrow,
2004). Additionally, some SOCE consumers describe
that trying and failing to change their same-sex sexual
orientation actually allowed them to accept their same-
sex attractions (Beckstead & Morrow, 2004; Smith et
al., 2004).
Participants described the social support aspects
of SOCE positively. Individuals reported as positive
that their LMHP accepted their goals and objections
and had similar values (i.e., believing that a gay
or lesbian identity is bad, sick, or inferior and not
supporting same-sex relationships) (Nicolosi et al.,
2000; Throckmorton & Welton, 2005). Erzen (2006),
Ponticelli (1999), and Wolkomir (2001) described
these religiously-oriented ex-gay groups as a refuge
for those who were excluded both from conservative
churches and from their families, because of their same-
sex sexual attractions, and from gay organizations
and social networks, because of their conservative
religious beliefs. In Erzens experiences with these
men, these organizations seemed to provide options for
individuals to remain connected to others who shared
their religious beliefs, despite ongoing same-sex sexual
feelings and behaviors. Wolkomir (2006) found that
ex-gay groups recast
homosexuality as
an ordinary sin,
and thus salvation
was still achievable.
Erzen observed that
such groups built
hope, recovery, and
relapse into an ex-
gay identity, thus expecting same-sex sexual behaviors
and conceiving them as opportunities for repentance
and forgiveness.
Some participants of SOCE reported what they
perceived as other positive values and beliefs
underlying SOCE treatments and theories, such as
supporting celibacy, validating other-sex marriage,
and encouraging and supporting other-sex sexual
behaviors (Beckstead & Morrow, 2004; S. L. Jones &
Yarhouse, 2007; Nicolosi et al., 2000; Throckmorton
& Welton, 2005). For instance, many SOCE theories
and communities focus on supporting clients values
and views, often linked to religious beliefs and
values (Nicolosi et al., 2000; Schaeffer et al., 2000;
Throckmorton & Welton, 2005). Ponticelli (1999)
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eo, oe, . eoec
omee e.o| oeoo
oo coce em o
oooo.e |o eoeoce
oo |oee
described that ex-gay support groups provide alternate
ways of viewing same-sex attractions that permit
individuals to see themselves as heterosexual, which
provided individuals a sense of possibility.
Participants interpretations of their SOCE
experiences and the outcomes of their experiences
appeared to be shaped by their religious beliefs and
by their motivations to be heterosexual. In Schaeffer
et al. (2000), people whose motivation to change was
sfrongIy Inuoncod by
their Christian beliefs
and convictions were
more likely to perceive
themselves as having
a heterosexual sexual
orientation after their
efforts. Schaeffer et al.
also found that those
who were less religious
were more likely to perceive themselves as having an
LGB sexual orientation after the intervention. Some
of the respondents in Spitzers (2003) study concluded
that they had altered their sexual orientation, although
they continued to have same-sex sexual attractions.
Thoso hndIngs undorscoro fho Imorfnnco of fho nnfuro
and strength of participants motivations, as well as the
importance of religious identity in shaping self-reports
of perceived sexual orientation change.
A number of authors (Beckstead & Morrow, 2004;
Ponticelli, 1999; Wolkomir, 2001; Yarhouse et al.,
2005; Yarhouse & Tan, 2004) have found that identity
exploration and reinterpretation were important parts
of SOCE. Beckstead and Morrow (2004) described the
identity development of their research participants who
were or had been members of the Church of Jesus Christ
of Latter-Day Saints and had undergone therapy to
change their sexual orientation to heterosexual. In this
research, those who experienced the most satisfaction
with their lives seemed to undergo a developmental
process that included the following aspects: (a)
becoming disillusioned, questioning authorities, and
reevaluating outside norms; (b) wavering between ex-
gny, ouf gny, hoforosoxunI, or coIIbnfo IdonfIfIos fhnf
depended on cultural norms and fears rather than on
internally self-informed choices; and (c) resolving their
conIcfs fhrough dovoIoIng soIf-nccofnnco, cronfIng
a positive self-concept, and making decisions about
fhoIr roInfIonshIs, roIIgIon, nnd communIfy nfhIInfIons
based on expanded information, self-evaluations, and
priorities. The participants had multiple endpoints,
IncIudIng !CI IdonfIfy, ox-gny IdonfIfy, no soxunI
orientation identity, and a unique self-identity. Some
individuals chose actively to disidentify with a sexual
minority identity so the individuals sexual orientation
identity and sexual orientation may be incongruent
(Wolkomir, 2001, 2006; Yarhouse, 2001; Yarhouse &
Tan, 2004; Yarhouse et al., 2005).
Iurfhor, fho hndIngs suggosf fhnf somo nrfIcInnfs
may have reconceptualized their sexual orientation
identity as heterosexual but not achieved sexual
orientation change, as they still experienced same-
sex sexual attractions and desires (for a discussion of
the distinction between sexual orientation and sexual
orientation identity, see Chapter 3; see also R. L.
Worthington, 2003; R. L. Worthington et al., 2002). For
these individuals, sexual orientation identity may not
roocf undorIyIng nffrncfIons nnd dosIros (Iocksfond,
2003; Beckstead & Morrow, 2004; McConaghy, 1999;
Shidlo & Schroeder, 2002).
|eceeo |eoe o| |
Participants in the studies by Beckstead and Morrow
(2004) and Shidlo and Schroeder (2002) described the
harm they experienced as (a) decreased self-esteem and
authenticity to others; (b) increased self-hatred and
negative perceptions of homosexuality; (c) confusion,
depression, guilt, helplessness, hopelessness, shame,
social withdrawal, and suicidality; (d) anger at and a
sense of betrayal by SOCE providers; (e) an increase
in substance abuse and high-risk sexual behaviors;
(f) a feeling of being dehumanized and untrue to self;
(g) a loss of faith; and (h) a sense of having wasted
time and resources. Interpreting SOCE failures as
individual failures was also reported in this research,
in that individuals blamed themselves for the failure
(i.e., weakness, and lack of effort, commitment, faith, or
worthiness in Gods eyes). Intrusive images and sexual
dysfunction were also reported, particularly among
those who had experienced aversion techniques.
Participants in these studies related that their
relationships with others were also harmed in the
following ways: (a) hostility and blame toward parents
duo fo boIIovIng fhoy cnusod fhoIr homosoxunIIfy;
(b) anger at and a sense of betrayal by SOCE providers;
(c) loss of LGB friends and potential romantic
partners due to beliefs they should avoid sexual
minority people; (d) problems in sexual and emotional
intimacy with other-sex partners, (e) stress due to the
negative emotions of spouses and family members
because of expectations that SOCE would work (e.g.,
disappointment, self-blame for failure of change,
ee |o .oecoe
e moooce o| e o.e
oo e o| oocoo
mooo o we|| o e
moooce o| e|o.
oe, oo e||
eoo o| oeceeo e.o|
oeoo coe
perception of betrayal by partner) (see also J. G. Ford,
2001); (f) guilt and confusion when they were sexually
intimate with other same-sex members of the ex-gay
groups to which they had turned for help in avoiding
their attractions.
Licensed mental health providers working with
former participants in SOCE noted that when
clients who formerly engaged in SOCE consider
adopting an LGB identity or experience same-sex
romantic and sexual relationships later in life, they
hnvo moro dIfhcuIfy wIfh IdonfIfy dovoIomonf duo
to delayed developmental tasks and dealing with
any harm associated with SOCE (Haldeman, 2001;
Isay, 2001). Such treatments can harm some mens
understanding of their masculine identity (Haldeman,
2001; Schwartzberg & Rosenberg, 1998) and obscure
other psychological issues that contribute to distress
(Drescher, 1998a).
Thoso IndIvIdunIs IdonfIhod nsocfs of SOCI
that they perceived as negative, which included (a)
receiving pejorative or false information regarding
sexual orientation and the lives of LGB individuals;
(b) encountering overly directive treatment (told not
to be LGB) or to repress sexuality; (c) encountering
treatments based on unsubstantiated theories or
methods; (d) being misinformed about the likelihood
of treatment outcomes (i.e. sexual orientation
change); (e) receiving inadequate information about
alternative options; and (f) being blamed for lack of
progress of therapy. Some participants in Schroeder
and Shidlos (2001) study reported feeling coerced by
their psychotherapist or religious institution to remain
in treatment and pressured to represent to others
fhnf fhoy hnd nchIovod n succossfuI roorIonfnfIon fo
heterosexuality.
|e|o.|, eeo
\..o| .ooo o.o
Much of fho IIfornfuro dIscussos fho socIhc dynnmIcs
and processes of religiously oriented mutual self-
help groups. A reduction of distress through sexual
orientation identity reconstruction or development
is described in the literature of self-help or religious
groups, both for individuals who reject (Erzen, 2006;
Ponticelli, 1999; Wolkomir, 2001, 2006) and for
individuals who accept a minority sexual orientation
identity (Kerr, 1997; Rodriguez, 2006; Rodriguez &
Ouellette, 2000; Thumma, 1991; Wolkomir, 2006).
Ponticelli (1999) and Wolkomir (2001, 2006) found
several emotional and cognitive processes that
soomod confrnI fo fho soxunI orIonfnfIon IdonfIfy
reconstruction (i.e., recasting oneself as ex-gay,
heterosexual, disidentifying as LGB) (Ponticelli, 1999,
p. 157) that appeared to relieve the distress caused by
conIcfs bofwoon roIIgIous vnIuos nnd soxunI orIonfnfIon
(IonfIcoIII, l999). IonfIcoIII IdonfIhod corfnIn condIfIons
nocossnry for rosoIvIng IdonfIfy conIcfs, IncIudIng (n)
adopting a new discourse or worldview, (b) engaging
in a biographical reconstruction, (c) embracing a new
explanatory model, and (d) forming strong interpersonal
ties. For those rejecting a sexual minority identity, these
chnngos occurrod by nrfIcInnfs fnkIng on ox-gny
cuIfurnI norms nnd Inngungo nnd hndIng n communIfy
that enabled and reinforced their primary religious
beliefs, values, and concerns. For instance, participants
were encouraged to rely on literal interpretations of
the Bible, Christian psychoanalytic theories about
fho cnusos of homosoxunIIfy, nnd ox-gny socInI
roInfIonshIs fo guIdo nnd rodohno fhoIr IIvos.
Interesting counterpoints to the SOCE support
grous nro !CI-nfhrmIng roIIgIous suorf grous.
These groups employ similar emotional and cognitive
sfrnfogIos fo rovIdo omofIonnI suorf, nfhrmIng
ideologies, and identity reconstruction. Further, they
appear to facilitate integration of same-sex sexual
nffrncfIons nnd roIIgIous IdonfIfIos Info !CI-nfhrmIng
identities (Kerr, 1997; Thumma, 1991; Wolkomir, 2001,
2006).
Iofh soxunI-mInorIfy-nfhrmIng nnd ox-gny mufunI
hoI grous ofonfInIIy nonr fo offor bonohfs fo
their participants that are similar to those claimed for
self-help groups, such as social support, fellowship,
role models, and new ways to view a problem through
unique philosophies or ideologies (Levine, Perkins, &
Perkins, 2004).
Mutual help groups philosophy often gives a
normalizing meaning to the individuals situation and
mny ncf ns nn nnfIdofo fo n sonso of dohcIoncy (Anfzo,
1976). New scripts can shape how a member views
and shares her or his life story by replacing existing
personal or cultural scripts with the group ideology
(Humphreys, 2004; Mankowski, 1997, 2000; Maton,
2000). For instance, individuals who are involved
In SOCI or !CI-nfhrmIng grous mny ndof n now
explanation for their homosexuality that permits
reconceptualizing themselves as heterosexual or
acceptable as LGB people (Ponticelli, 1999; Wolkomir,
2001, 2006).
Remaining Issues
Ponticelli (1999) ended her article with the following
quosfIons: Whnf Ionds n orson fo chooso Ixodus
nnd n frnmo fhnf dohnod fhom ns sInfuI nnd In nood
of change? (p. 170). Why do some individuals choose
SOCI ovor soxunI-mInorIfy-nfhrmIng grous, nnd why
nro somo IndIvIdunIs nffrncfod fo nnd nbIo fo hnd roIIof
in a particular ideology or group over other alternatives?
There are some indications that the nature and
type of religious motivation and faith play a role.
In comparing individuals with intrinsic
41
and quest
religious motivations, Tozer and Hayes (2004) proposed
that those with a greater intrinsic religiosity may be
motivated to seek out SOCE more than those with
the quest motivation. However, within both groups
(intrinsic and quest motivation), internalized stigma
Inuoncod who soughf SOCI; fhoso who soughf
SOCE had higher levels of internalized stigma. Tozer
and Hayes (2004) and Mahaffy (1996) found that
individuals in earlier stages of sexual minority identity
development (see, e.g., Cass, 1979; Troiden, 1993) were
more likely to pursue SOCE.
Wolkomir (2001, 2006) found some evidence
that biographical factors may be central to these
choices. Wolkomir (2006) found that motivations for
participation in faith distinguished individuals who
joInod ox-gny grous from soxunI-mInorIfy-nfhrmIng
groups. For instance, men who joined conservative
Christian communities as a solution to lives that had
been lonely and disconnected and those who turned
to faith when they felt overwhelmed by circumstance
were more likely to join ex-gay groups. Wolkomir
hypothesized that these men perceived homosexuality
as a threat to the refuge that conservative faith
provided (cf. Glassgold, 2008).
The other common path to an ex-gay (as well as, to
somo dogroo, fo n soxunI-mInorIfy-nfhrmIng) grou wns
remaining in the community of faith in which one was
raised and meeting the expectations of that faith, such
as heterosexuality. The loss of a personal relationship or
n bofrnynI by n Iovod ono mIghf Inuonco nn IndIvIdunI`s
choice of a group, and the stress of loss and the self-
blame that accompany such a loss may constitute
factors that lead someone to seek SOCE (Wolkomir,
2001, 2006).
Additionally, Wolkomir found that a sense of gender
Inndoquncy (soo nIso gondor roIo sfrnIn; !ovnnf, l992;
41
Internal motivation refers to a motivation that focuses on belief and
values as ends in themselves, and quest sees religion as a process of
exploration.
Pleck, 1995) made groups that embraced traditional
gender roles and gender-based models of homosexuality
appealing to some men. Gender-based internalized
stigma and self-stigma increased distress in these men.
IInnIIy, confrncfunI romIsos fo Cod (WoIkomIr,
2001, p. 332) regarding other concerns (e.g., drug/
alcohol abuse) increased the likelihood that men would
choose ex-gay groups. However, these issues are as yet
underresearched and remain unresolved.
Very little is known about the concerns of other
religious faiths and diverse ethnicities and cultures
(Harper et al., 2004; Miville & Ferguson, 2004). There
are some studies in the empirical and theoretical
IIfornfuro, cIInIcnI cnsos, nnd mnforInI from ofhor hoIds
(e.g., anthropology, sociology) on sexual orientation
among ethnic minorities and in different cultures
and countries. Sexual orientation identity may be
constructed differently in ethnic minority communities
and internationally (Carillo, 2002; Boykin, 1996;
Crawford et al., 2002; Harper et al., 2004; Mays,
Cochran, & Zamudio, 2004; Miville & Ferguson,
2004; Walters, Evans-Campbell, Simoni, Ronquillo,
& Bhuyan, 2006; Wilson & Miller, 2002; Zea, Diaz, &
Reisen, 2003). There is some information that such
ouInfIons oxorIonco dIsfross or conIcfs duo fo
legal discrimination, cultural stigma, and other factors
(McCormick, 2006), and in some other countries,
homosexuality is still seen as a mental disorder or is
illegal (Forstein, 2001; International Gay & Lesbian
Human Rights Commission, n.d.). We did not identify
empirical research on members of these populations
who had sought or participated in SOCE other than as
part of the research already cited.
Summary and Conclusion
Tho roconf IIfornfuro IdonfIhos n ouInfIon of
predominantly White men who are strongly religious
and participate in conservative faiths. This contrasts
with the early research that included nonreligious
individuals who chose SOCE due to the prejudice and
discrimination caused by sexual stigma. Additionally,
there is a lack of research on non-Christian individuals
and limited information on ethnic minority populations,
women, and nonreligious populations.
The religious individuals in the recent literature
report experiencing serious distress, including
depression, identity, confusion, and fear due to the
strong prohibitions of their faith regarding same-
sex sexual orientation, behaviors, and relationships.
These individuals struggle to combine their faiths and
their sexualities in meaningful personal and social
IdonfIfIos. Thoso sfruggIos cnuso fhom sIgnIhcnnf
distress, including frequent feelings of isolation from
both religious organizations and sexual minority
communities. The ensuing struggles with faith,
sexuality and identity lead many individuals to
attempt sexual orientation change through professional
interventions and faith-based efforts.
These individuals report a range of effects from their
efforts to change their sexual orientation, including
bofh bonohfs nnd
hnrm. Tho bonohfs
include social and
spiritual support, a
lessening of isolation,
an understanding
of values and
faith and sexual
orientation identity
reconstruction. The perceived harms include negative
mental health effects (depression and suicidality),
decreased self-esteem and authenticity to others,
increased self-hatred and negative perceptions of
homosexuality; a loss of faith, and a sense of having
wasted time and resources.
MufunI soIf-hoI grous (whofhor nfhrmIng or
rejecting of sexual minorities) may provide a means
fo rosoIvo fho dIsfross cnusod by conIcfs bofwoon
religious values and sexual orientation (Erzen, 2006;
Kerr, 1997; Ponticelli, 1999; Thumma, 1991; Wolkomir,
2001, 2006). Sexual orientation identity reconstruction
found in such groups (Ponticelli, 1999; Thumma, 1991)
and identity work in general may provide reduction
in individual distress (Beckstead & Morrow, 2004).
IndIvIdunIs mny sook ouf soxunI-mInorIfy-nfhrmIng
religious groups or SOCE in the form of ex-gay religious
support groups due to (a) a lack of other sources of social
support; (b) a desire for active coping, including both
cognitive and emotional coping (Folkman & Lazarus,
1980); and (c) access to methods of sexual orientation
identity exploration and reconstruction (Ponticelli,
1999; Wolkomir, 2001).
The limited information provided by the literature on
individuals who experience distress with their sexual
attractions and seek SOCE provides some direction to
!MHI In formuInfIng nfhrmnfIvo InforvonfIons for fhIs
population. The following appear to be helpful to clients:
Finding social support and interacting with others in :
similar circumstances
Experiencing understanding and recognition of the :
importance of religious beliefs and concerns
!ocoIvIng omnfhy for fhoIr vory dIfhcuIf dIIommns :
nnd conIcfs
Being provided with affective and cognitive tools for :
identity exploration and development
Reports of clients perceptions of harm also provide
information about aspects of interventions to avoid:
Overly directive treatment that insists on a particular :
outcome
Innccurnfo, sforoofyIc, or unscIonfIhc InformnfIon or :
lack of positive information about sexual minorities
and sexual orientation
The use of unsound or unproven interventions :
Misinformation on treatment outcomes :
It is important to note that the factors that are
IdonfIhod ns bonohfs nro nof unIquo fo SOCI nnd cnn
bo rovIdod wIfhIn nn nfhrmnfIvo nnd muIfIcuIfurnIIy
competent framework that can mitigate the harmful
aspects of SOCE by addressing sexual stigma while
understanding the importance of religion and social
needs. An approach that integrates the information
IdonfIhod In fhIs chnfor ns hoIfuI Is doscrIbod In nn
nfhrmnfIvo modoI of sychofhorny In Chnfor 6.
\..o| e||e|o o.o
(wee o||m o eec
o| e.o| moe) mo,
oooe o meo o eo|e
e oe co.eo o,
co|c oewee e|o.
o|.e oo e.o| oeoo
O
ur chnrgo wns fo gonornfo n roorf fhnf
IncIudos dIscussIon of fho nrorInfo
nIIcnfIon of nfhrmnfIvo fhornoufIc
interventions for children, adolescents, and adults
who present [themselves for treatment expressing] a
desire to change either their sexual orientation or their
behavioral expression of their sexual orientation. In
fhIs chnfor, wo roorf on nfhrmnfIvo InforvonfIons
for nduIfs. AfhrmnfIvo InforvonfIons for chIIdron nnd
adolescents are reported separately in Chapter 8.
Tho nrorInfo nIIcnfIon of nfhrmnfIvo fhornoufIc
InforvonfIons for nduIfs Is buIIf on fhroo koy hndIngs In
the research:
Our systematic review of the research on SOCE :
found that enduring change to an individuals
sexual orientation as a result of SOCE was unlikely.
Further, some participants were harmed by the
interventions.
What appears to shift and evolve in some individuals :
lives is sexual orientation identity, not sexual
orientation (Beckstead, 2003; Beckstead & Morrow,
2004; Buchanan, Dzelme, Harris, & Hecker, 2001;
Cass, 1983/1984; Diamond, 1998, 2006; McConaghy,
1999; Ponticelli, 1999; Rust, 2003; Tan, 2008;
Throckmorton & Yarhouse, 2006; Troiden, 1988;
Wolkomir, 2001, 2006; R. L. Worthington, 2003,
2004).
Somo nrfIcInnfs In SOCI roorfod bonohfs, buf fho :
bonohfs woro nof socIhc fo SOCI. !nfhor, cIIonfs
orcoIvod n bonohf whon offorod InforvonfIons fhnf
emphasized acceptance, support. and recognition of
important values and concerns.
Tho nrorInfo nIIcnfIon of nfhrmnfIvo sycho-
fhorny Is bnsod on fho foIIowIng scIonfIhc fncfs:
of human sexuality; in other words, they are not
indicators of mental or developmental disorders.
Homosexuality and bisexuality are stigmatized, :
and this stigma can have a variety of negative
consequences (e.g., minority stress) throughout the
life span (DAugelli & Patterson, 1995; DiPlacido,
1998; Herek & Garnets, 2007; Meyer, 1995, 2003).
Same-sex sexual attractions and behavior can occur :
in the context of a variety of sexual orientations and
sexual orientation identities (Diamond, 2006; Hoburg
et al., 2004; Rust, 1996; Savin-Williams, 2005).
Gay men, lesbians, and bisexual individuals can live :
satisfying lives as well as form stable, committed
heterosexual relationships in essential respects
(APA, 2005c; Kurdek, 2001, 2003, 2004; Peplau &
Fingerhut, 2007).
There are no empirical studies or peer-reviewed :
research that support theories attributing same-sex
sexual orientation to family dysfunction or trauma
(Bell et al., 1981; Bene, 1965; Freund & Blanchard,
1983; Freund & Pinkava, 1961; Hooker, 1969;
6. THE APPROPRIATE APPLICATION
OF AFFIRMATIVE THERAPEUTIC INTERVENTIONS
|O| A|u|!S wO S||| SOC|
55 o /,,,.dto /,,.cdt. ' /''dt.vo od,ot.c 'tovot. ' /dt \ oo -
McCord et al., 1962; D. K. Peters & Cantrell, 1991;
Siegelman, 1974, 1981; Townes et al., 1976).
Studies indicated that experiences of felt stigma, such
as self-stigma, isolation and rejection from relationships
and valued communities, lack of emotional support and
nccurnfo InformnfIon, nnd conIcfs bofwoon muIfIIo
identities and between values and attractions, played
a role in creating distress in individuals (Bartoli &
Gillem, 2008; Beckstead & Morrow, 2004; Coyle &
Rafalin, 2000; Glassgold, 2008; Haldeman, 2004; Herek,
2009; Mahaffy, 1996; Mark, 2008; Ponticelli, 1999;
Wolkomir, 2001; Yip, 2000, 2002, 2005). Consequently,
an essential focus of treatment is mitigating the
negative mental health consequences of minority stress
from stigma resulting from age, gender, gender identity,
status (Brown, 2006; Cochran & Mays, 2006; Herek,
2009; Herek & Garnets, 2007; Mays & Cochran,
2001; Russell & Bohan, 2007). For instance, although
many religious individuals desired to live their lives
consistently with their values, primarily their religious
values, we concluded that telic congruence grounded
in self-stigma and shame was unlikely to result in
psychological well-being (Beckstead & Morrow, 2004;
Glassgold, 2008; Gonsiorek, 2004; Haldeman, 2004;
Mark, 2008; Shidlo & Schroeder, 2002).
A Framework for the Appropriate
Aqq||cd|o o| A||ad|ve
Therapeutic Interventions
On fho bnsIs of fho fhroo hndIngs summnrIzod
previously and our comprehensive review of the
research and clinical literature, we developed a
frnmowork for fho nrorInfo nIIcnfIon of nfhrmnfIvo
therapeutic interventions for adults that has the
following central elements: (a) acceptance and support,
(b) assessment, (c) active coping, (d) social support, and
(e) identity exploration and development.
/cceooce oo .ooo
In our review of the research and clinical literature, we
found fhnf fho nrorInfo nIIcnfIon of nfhrmnfIvo
therapeutic interventions for adults presenting
with a desire to change their sexual orientation has
been grounded in a client-centered approach (e.g.,
Astramovich, 2003; Bartoli & Gillem, 2008; Beckstead
& Israel, 2007, Buchanan et al., 2001; Drescher, 1998a;
Glassgold; 2008; Gonsiorek; 2004; Haldeman, 2004,
Lasser & Gottlieb, 2004; Mark, 2008; Ritter & ONeill,
1989, 1995; Tan, 2008; Throckmorton & Yarhouse,
2006; Yarhouse & Tan, 2005a; and Yarhouse, 2008).
The client-centered approach (Rogers, 1957; cf. Brown,
2006) stresses (a) the LMHPs unconditional positive
regard for and congruence and empathy with the client,
(b) openness to the clients perspective as a means to
understanding their concerns, and (c) encouragement
of the clients positive self-concept. This approach
incorporates aspects of the therapeutic relationships
fhnf hnvo boon shown fo hnvo n osIfIvo bonohf In
research literature, such as empathy, positive regard,
and honesty (APA, 2005a, 2005b; Lambert & Barley,
2001; Norcross, 2002; Norcross & Hill, 2004).
This approach consists of empathic attunement to
concerns regarding sexual orientation identity that
acknowledges the role of cultural context and diversity
and allows the different aspects of the evolving
self to be acknowledged, explored, respected, and
potentially rewoven into a more coherent sense of self
that feels authentic to the client (Bartoli & Gillem,
2008; Beckstead &
Morrow, 2004; Brown,
2006; Buchanan et
al., 2001; Glassgold,
2008; Gonsiorek, 2004;
Haldeman, 2004;
Mark, 2008; Miville &
Ferguson, 2004; Tan,
2008; Throckmorton
& Yarhouse, 2006;
Yarhouse, 2008).
The client-centered
therapeutic environment
aspires to be a place of compassionate caring and
respect that facilitates development (Bronfennbrenner,
1979; Winnicott, 1965) by exploring issues without
criticism or condemnation (Bartoli & Gillem,
2008; Beckstead & Morrow, 2004; McMinn, 2005;
Throckmorton & Welton, 2005) and reducing distress
caused by isolation, stigma, and shame (Drescher,
1998a; Glassgold, 2008; Haldeman, 2004; Isay, 2001).
This approach involves empathizing with the clients
desire to change his or her sexual orientation while
understanding that this outcome is unlikely (Beckstead
& Morrow, 2004; Glassgold, 2008; Haldeman, 2004).
Haldeman (2004) cautioned that LMHP who turn down
a clients request for SOCE at the onset of treatment
without exploring and understanding the many
e c|eceeeo
eooe.c eome
ooe o oe o o|oce o|
comooooe co
oo eoec o |oc|oe
oee|oomeo, eo|o
.e wo. ccm
o cooemoo oo
eo.c oe co.eo o,
o|oo mo oo ome
reasons why the client may wish to change may instill
hopelessness in the client, who already may feel at a
loss about viable options. Haldeman emphasized that
before coming to a conclusion regarding treatment
goals, LMHP should seek to validate the clients wish
fo roduco sufforIng nnd normnIIzo fho conIcfs nf fho
root of distress, as well as create a therapeutic alliance
that recognizes the issues important to the client (cf.
Beckstead & Israel, 2007; Glassgold, 2008; Liddle, 1996;
Yarhouse, 2008).
AfhrmnfIvo cIIonf-conforod nronchos consIdor
sexual orientation uniquely individual and inseparable
from an individuals personality and sense of self
(Glassgold, 1995; 2008). This includes (a) being aware
of the clients unique personal, social, and historical
context; (b) exploring and countering the harmful
impact of stigma
and stereotypes
on the clients self-
concept (including
the prejudice related
to age, gender,
gender identity,
race, ethnicity,
culture, national
origin, religion,
sexual orientation,
disability, language,
and socioeconomic
status); and (c)
maintaining a broad
view of acceptable life choices. LMHP who work with
religious clients who are distressed by their sexual
orientation may wish to consult the literature from
the psychology of religion. This literature reminds us
that religion is a complex way of making meaning that
includes not only beliefs and values but also community,
relationships, traditions, family ties, coping, and social
identity (Mark, 2008; Pargament & Mahoney, 2002,
2005; Pargament et al., 2005; Park, 2005).
/eme
therapeutic interventions for adults presenting with
a desire to change their sexual orientation included
comprehensive assessment in order to obtain a fuller
undorsfnndIng of fho muIfIIo Issuos fhnf Inuonco fhnf
clients presentation. Such an assessment allows the
LMHP and client to see the clients sexual orientation
as part of the whole person and to develop interventions
bnsod on nII sIgnIhcnnf vnrInbIos (Iocksfond & IsrnoI,
2007; Gonsiorek, 2004; Haldeman, 2004; Lasser &
Gottlieb, 2004). This comprehensive assessment
includes understanding how a clients distress may
involve (a) psychological disequilibrium from trying
to manage the stressors (e.g., anxiety, depression,
substance abuse and dependence, sexual compulsivity,
posttraumatic stress disorder) and (b) negative effects
from developmental experiences and traumas and
the impact of cultural and family norms. Assessing
fho Inuonco of fncfors such ns ngo, gondor, gondor
religion, disability, language, and socioeconomic status
on the experience and expression of sexual orientation
and sexual orientation identity may aid the LMHP in
understanding the complexity of the clients distress.
The literature indicated that most of the individuals
who are extremely distressed about their same-sex
sexual orientation and who are interested in SOCE have
consorvnfIvo roIIgIous boIIofs. A hrsf sfo fo nddrossIng
fho conIcfs rognrdIng fnIfh nnd soxunI orIonfnfIon Is n
thorough assessment of clients spiritual and religious
beliefs, religious identity and motivations, and spiritual
functioning (Exline, 2002; Hathaway, Scott, & Garver,
2004; Pargament et al., 2005). This helps the LMHP
understand how the current dilemmas impact clients
spiritual functioning (and vice versa) and assess
resources for growth and renewal.
This assessment could include (a) understanding
fho socIhc roIIgIous boIIofs of fho cIIonf; (b) nssossIng
fho roIIgIous nnd sIrIfunI conIcfs nnd dIsfross
experienced by the client (Hathaway et al., 2004);
(c) assessing clients religious goals (Emons &
Paloutzian, 2003) and motivations (e.g., internal,
external, quest, fundamentalism) and positive
and negative ways of coping within their religion
(Pargament, Koenig, Tasakeshwas, & Hahn, 2001;
Pargament & Mahoney, 2005; Pargament et al., 1998);
(d) seeking to understand the impact of religious beliefs
and religious communities on the experience of self-
stigma, sexual prejudice, and sexual orientation identity
(Beckstead & Morrow, 2004; Buchanan et al., 2001;
Fulton et al., 1999; Herek, 1987; Hunsberger & Jackson,
2005; J. P. Schwartz & Lindley, 2005; Schulte & Battle,
2004); (e) developing an understanding of clients
faith identity development (Fowler, 1981, 1991; Oser,
1991; Reich, 1991; Streib, 2005) and its intersection
with sexual orientation identity development (Harris,
Cook, & Kashubeck-West, 2008; Hoffman et al., 2007;
Knight & Hoffman, 2007; Mahaffy, 1996; Yarhouse &
|\| wo wo w e|o.
c|e wo oe oeeo o,
e e.o| oeoo mo,
w o co.| e |eo.e
|om e o,co|o, o| e|o
|eo.e emo . o
e|o o como|e wo, o|
mo meo o c|.oe
o o|, oe|e| oo o|.e o.
o|o comm., e|ooo
ooo |om|, e coo
oo oco| oe,
Tan, 2005a; Yarhouse et al., 2005); and (f) enhancing
with clients, when applicable, the search for meaning,
sIgnIhcnnco, nnd n roInfIonshI wIfh fho dohnIfIons
of the sacred in their lives (Fowler, 2001; Goldstein,
2007; Pargament & Mahoney, 2005; Shafranske, 2000).
Finally, an awareness of the varieties of religious faith,
issues for religious minorities, and the unique role of
religion in ethnic minority communities is important (D.
A. Cook & Wiley, 2000; Zea, Mason, & Muruia, 2000;
Trujillo, 2000).
Some individuals who present with requests for
SOCE may have clinical concerns that go beyond their
soxunI orIonfnfIon conIcfs. Thoso mny IncIudo monfnI
health disorders, personality disorders, or trauma-
roInfod condIfIons fhnf Inuonco fho rosonfnfIon of
soxunI orIonfnfIon conIcfs nnd dIsfross (cf. Irown,
2006; Drescher, 1998a; Glassgold, 2008; Haldeman,
2001; Iwasaki & Ristock, 2007; Lasser & Gottlieb,
2004; Mohr & Fassinger, 2003; S. L. Morrow, 2000;
Pachankis et al., 2008; Schneider et al., 2002; Sherry,
2007; Szymanski & Kashubeck-West, 2008). Such
conditions may require intervention separate from
or in conjunction with the intervention directed at
the sexual orientation distress. For instance, some
clients who seek SOCE may have histories of trauma
(Ponticelli, 1999), and in some individuals sexual abuse
can cause sexual orientation identity confusion and
other sexuality-related concerns (Gartner, 1999). Other
individuals seeking SOCE may make homosexuality the
explanation for all they feel is wrong with their lives
(Beckstead & Morrow, 2004; Erzen, 2006; Ponticelli,
1999; Shidlo & Schroeder, 2002). This displacement of
self-hatred onto homosexuality can be an attempt to
resolve a sense of badness and shame (cf. Brandchaft,
2007; Drescher, 1998a), and clients may thus need
effective interventions to deal with this self-hatred and
shame (Brandchaft, 2007; Linehan, Dimeff, & Koerner,
2007; Zaslav, 1998).
Sexual stigma impacts a clients appraisal of
soxunIIfy, nnd sInco dohnIfIons nnd norms of honIfhy
sexuality vary among individuals, LMHP, and religious
nnd socIofnI InsfIfufIons, ofonfInI conIcfs cnn nrIso
for clients about what a person should do to be sexually
acceptable and healthy. OSullivan, McCrudden,
and Tolman (2006) emphasized that sexuality is an
integral component of psychological health, involving
mental and emotional health, physical health, and
relational health.
42
Initiating sensitive but open and
educated discussions with clients about their views of
and experiences with sexuality may be most helpful,
especially for those who have never had permission or
space to talk about such issues (Schneider et al. 2002).
/ce oo
therapeutic interventions for adults presenting with a
desire to change their
sexual orientation
seeks to increase
clients capacity
for active coping to
mitigate distress.
Coping strategies
refer to the efforts
that individuals use to
resolve, endure, or diminish stressful life experiences,
and active coping strategies are efforts that include
cognitive, behavioral, or emotional responses designed
to change the nature of the stressor itself or how an
individual perceives it (Folkman & Lazarus, 1980).
Research has indicated that active coping is superior
to other efforts, such as passive coping, and that
individuals use both cognitive and emotional strategies
to address stressful events (Folkman & Lazarus, 1980).
These strategies are described in more depth below.
`''v- '/-'-
Research on those individuals who resolve their sexual
orIonfnfIon conIcfs IndIcnfo fhnf cognIfIvo sfrnfogIos
helped to reduce cognitive dissonance (Coyle & Rafalin,
2000; Mahaffy, 1996). One of the dilemmas for many
clients who seek sexual orientation change is that
they see their situation as an eitheror dichotomy. For
instance, their same-sex sexual attractions make them
unworthy or bad, and only if they are heterosexual can
they be worthy (Beckstead & Morrow, 2004; Haldeman,
2001, 2004; Lasser & Gottlieb, 2004; D. F. Morrow,
42
The Pan American Health Organization and the World Health
OrgnnIznfIon (2000) dohnod soxunI honIfh In fho foIIowIng mnnnor:
SoxunI honIfh Is fho ongoIng rocoss of hysIcnI, sychoIogIcnI, nnd
sociocultural well-being in relationship to sexuality. Sexual health can
bo IdonfIhod fhrough fho froo nnd rosonsIbIo oxrossIons of soxunI
capabilities that foster harmonious personal and social wellness,
enriching life within an ethical framework. It is not merely the
nbsonco of dysfuncfIon, dIsonso nnd/or InhrmIfy. Ior soxunI honIfh
to be attained and maintained it is necessary that sexual rights be
recognized and exercised (p. 9).
/ce coo oee oe
e||o o c|.oe coe
oeooo| o emooo|
eooe oeeo o
coe e o.e o| e
eo e|| o ow o
oo.o| oecee
2003; Wolkomir, 2001, 2006). Cognitive strategies can
reduce the all-or-nothing thinking, mitigate self-stigma,
and alter negative self-appraisals (Beckstead & Israel,
2007; Johnson, 2001, 2004; Lasser & Gottlieb, 2004;
Martell et al., 2004). For example, Buchanan et al.
(2001), using a narrative therapy approach, described
a process of uncovering and deconstructing dominant
worIdvIows nnd nssumfIons wIfh conIcfod cIIonfs fhnf
onnbIod fhom fo rodohno fhoIr nffIfudos fownrd fhoIr
spirituality and sexuality (cf. Bright, 2004; Comstock,
1996; Graham, 1997; Yarhouse, 2008). Similarly,
rejection of stereotypes about LGB individuals
was found to be extremely important for increased
psychological well-being in a mixed sample of LGB
individuals (Luhtanen, 2003).
Recent developments in cognitivebehavior
therapy, such as mindfulness-based cognitive therapy,
dialectical behavior therapy, and acceptance and
commitment therapy techniques are especially relevant
(e.g., Hayes, Strosahl, & Wilson, 2003; Linehan et
al., 2007). Acceptance of the presence of same-sex
sexual attractions and sexual orientation paired with
exploring narratives or reframing cognitions, meanings,
or assumptions about sexual attractions have been
reported to be helpful (cf. Beckstead & Morrow, 2004;
Buchanan et al., 2001; Moran, 2007; Rodriguez, 2006;
Tan, 2008; Yarhouse, 2005a, 2005c; Yarhouse &
Beckstead, 2007).
For instance, using
these techniques,
Beckstead and
Morrow (2004)
and Tan (2008)
hoIod conIcfod
clients cope with
their sexual arousal experiences and live with them,
rnfhor fhnn nognfIvoIy judgo or hghf ngnInsf fhom.
Male participants in Beckstead and Morrows (2004)
investigation, regardless of their ultimate sexual
orientation identity, described their ability to accept,
rofrnmo, or surrondor fo fhoIr nffrncfIons ns roducIng
their distress by decreasing their self-judgments and
reducing their fear, anxiety, and shame. However,
acceptance of same-sex sexual attractions and sexual
orientation may not mean the formation of an LGB
sexual orientation identity; alternate identities may
develop instead (Beckstead & Morrow, 2004; Tan, 2008;
Throckmorton & Yarhouse, 2006; Yarhouse, 2008;
Yarhouse et al., 2005).
For clients with strong values (religious or secular),
an LMHP may wish to incorporate techniques that
promote positive meaning-making, an active process
through which people revise or reappraise an event or
series of events (Baumeister & Vohs, 2002; cf. Taylor,
1983) to resolve issues that arise out of crises, loss, and
suffering (cf. Frankl, 1992; Nolen-Hoeksema & Davis,
2002; ONeill & Ritter, 1992; Pargament et al., 2005;
Ritter & ONeill, 1989, 1995). Such new meanings
involve creating a new purpose in life, rebuilding a sense
of mastery, and increasing self-worth (Nolen-Hoeksema
& Davis, 2002; Pargament & Mahoney, 2002).
-''`''-' '/-'-
For those who seek SOCE, the process of addressing
ones sexual orientation can be very emotionally
chnIIongIng, ns fho dosIrod IdonfIfy doos nof hf fho
individuals psychological, emotional, or sexual
predispositions and needs. The experience of
irreconcilability of ones sexual orientation to ones
deeply felt values, life situation, and life goals may
dIsruf ono`s coro sonso of monnIng, uroso, ofhcncy,
and self-worth (Beckstead & Morrow, 2004; Yarhouse,
2008; cf. Baumeister & Vohs, 2002; L. A. King &
SmIfh, 2004) nnd rosuIf In omofIonnI conIcf, Ioss,
and suffering (Glassgold, 2008; ONeill & Ritter, 1992;
Ritter & ONeill, 1989, 1995). Thus, emotion-focused
strategies that facilitate grieving and mourning losses
have reportedly been helpful to some (Beckstead &
Israel, 2007; Glassgold, 2008; ONeill & Ritter, 1992;
Ritter & ONeill, 1989, 1995; Yarhouse, 2008; cf.
Wolkomir, 2001, 2006).
Therapeutic outcomes that have been reported
include (a) coming to terms with the disappointments,
losses, and dissonance between psychological and
emotional needs and possible and impossible selves
(Bartoli & Gillem, 2008; Drescher, 1998a; L.A. King
& Hicks, 2007; ONeill & Ritter, 1992; Ritter &
ONeill, 1989, 1995); (b) clarifying and prioritizing
values and needs (Glassgold, 2008; Yarhouse, 2008);
and (c) learning to tolerate and positively adapt to
fho nmbIguIfy, conIcf, uncorfnInfy, nnd muIfIIIcIfy
(Bartoli & Gillem, 2008; Beckstead & Morrow, 2004;
Buchanan et al., 2001; Corbett, 2001; Drescher, 1998a;
Glassgold, 2008; Halbertal & Koren, 2006; Haldeman,
2002; Miville & Ferguson, 2004).
'-'''' '/-'-
Integrated with other active coping strategies,
psychotherapeutic interventions can focus the client on
positive religious coping (e.g., Ano & Vasconcelles, 2005;
Pargament et al., 2005; Park, 2005; Silberman, 2005; T.
/cceooce o| omee
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oeoo mo, o meo e
|omoo o| o || e.o|
oeoo oe, o|eoe
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B. Smith, McCullough, & Poll, 2003) that may present
the client with alternatives to the concreteness of the
conIcf bofwoon soxunI orIonfnfIon nnd roIIgIous vnIuos.
For instance, several publications indicate that active
engagement with religious texts can reduce identity
conIcfs by roducIng fho snIIonco of nognfIvo mossngos
about homosexuality and increasing self-authority
or understanding
(Brzezinski, 2000;
Comstock, 1996;
Coyle & Rafalin,
2000; Glassgold,
2008; Gross, 2008;
Mahaffy, 1996; Ritter
& ONeill, 1989, 1995;
Rodriguez, 2006;
Rodriguez & Ouellette,
2000; Schnoor, 2006;
Schuck & Liddle,
2001; Thumma, 1991;
Wilcox, 2001, 2002;
Yip, 2002, 2003,
2005). Additionally,
connecting the client to core and overarching values
and virtues, such as charity, hope, forgiveness,
gratitude, kindness, and compassion, may refocus
clients on the more accepting elements of their religion,
which may provide more self-acceptance, direction,
and peace, rather than on their religions rejection
of homosexuality (Lease et al., 2005; McMinn, 2005).
Exploration of how to integrate religious values and
virtues into their sexuality may further development (cf.
Helminiak, 2004).
Altering the meaning of suffering and the burden
of boIng conIcfod ns sIrIfunI chnIIongos rnfhor
than as divine condemnation (Glassgold, 2008; Hall
& Johnson, 2001) and believing that God continues
to love and accept them, because of or despite their
sexual orientation, may be helpful in resolving distress
(Graham, 1997; Ritter & ONeill, 1989, 1995). For some,
reframing spiritual struggles not only as a crisis of faith
but also as an opportunity to increase faith or delve
more deeply into it may be productive (Bartoli & Gillem,
2008; de la Huerta, 1999; Glassgold, 2008; Horne &
ofhsngor-IrnzIor, 2003, !Iffor & Torndru, 2002).
Examining the intersection between mental health
concerns and the presentation of religious beliefs can
be helpful in understanding the client (Johnson, 2001,
2004; Nielsen, 2001; Pargament et al., 2005; Robb,
2001; Shrafranske, 2004). For instance, Johnson (2004)
described a rational emotive behavior therapy case
study that focused on reducing excessive self-criticism,
which lessened the self-stigma surrounding same-sex
sexual attractions. This approach seeks to understand
the core depressive cognitive structures and other
problematic schema that can become associated with the
clients religious values or distort their religious values
(Johnson, 2001, 2004; Nielsen, 2001; Robb, 2001).
oco| .ooo
therapeutic interventions for adults presenting
with a desire to change their sexual orientation
seeks to increase clients access to social support.
As Coyle (1993) and others have noted (e.g., Wright
& Perry, 2006), struggling with a devalued identity
without adequate social support has the potential
to erode psychological well-being. Increasing social
support through psychotherapy, self-help groups, or
welcoming communities (ethnic communities, social
groups, religious denominations) may relieve some
dIsfross. Ior Insfnnco, nrfIcInnfs roorfod bonohfs
from mutual support groups, both sexual-minority-
nfhrmIng nnd ox-gny grous (Korr, l99?; IonfIcoIII,
1999; Rodriguez, 2006; Rodriguez & Ouellette, 2000;
Rodriguez, 2006; Thumma, 1991; Wolkomir, 2001).
These groups counteracted and buffered minority stress,
marginalization, and isolation. Religious denominations
that provide cognitive and affective strategies that aid
in the resolution of cognitive dissonance and increase
religious coping were helpful to religious individuals
as well (Kerr, 1997; Maton, 2000; Ponticelli, 1999;
Rodriguez & Ouellette, 2000: Wolkomir, 2001, 2006).
Licensed mental health providers can provide
clients with information about a wide range of diverse
sexual minority communities and religious and
faith organizations available locally, nationally, or
internationally in person or over the Internet.
43
These
settings can provide contexts in which clients may
oxIoro nnd Infogrnfo IdonfIfIos, hnd roIo modoIs, nnd
reduce self-stigma (Heinz, Gu, Inuzuka, & Zender,
2002; Johnson & Buhrke, 2006; Schneider et al.,
2002). However, some groups may reinforce prejudice
and stigma by providing inaccurate or stereotyped
information about homosexuality, and LMHP may
43
There are growing numbers of communities available that address
unique concerns and identities (see, e.g., www.safraproject.org/ for
Muslim women or http://www.al-fatiha.org/ for LGB Muslims; for
Orthodox Jews, see http://tirtzah.wordpress.com/).
oec e c|e o
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mo, e|oc. c|e o e
moe occeo e|eme
o| e e|o wc
mo, oooe moe e||
occeooce oeco oo
oeoce oe o owe||
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o| omoe.o|,
wish to weigh with clients alternative options in these
circumstances (Schneider et al., 2002).
For those clients who cannot express all aspects
of themselves in the community settings currently
available to them, LMHP can help the client to
consIdor moro oxIbIo nnd sfrnfogIc wnys of oxrossIng
the multiple aspects of self that include managing
self-disclosure and multiple identities (Bing,
2004; Glassgold, 2008; Halbertal & Koran, 2006;
LaFromboise, Coleman, & Gerton, 1993). Social support
mny bo dIfhcuIf fo hnd for cIIonfs whoso communIfIos
stigmatize their sexual orientation identity and other
identities (e.g., ethnic, racial, religious), and these
cIIonfs mny bonohf from consIdorIng fho nIfornnfo
frame that the problem does not lie with the client but
wIfh fho communIfy fhnf Is nof nbIo fo nfhrm fhoIr
sexual orientation or particular identity or meet their
developmental needs (Blechner, 2008; Buchanan et al.,
2001; Lasser & Gottlieb, 2004; Mark, 2008; Tremble,
1989).
Individuals with same-sex attractions in other-sex
marriages may struggle with the loss (or fear of the loss)
of social support and important relationships. Several
authors (e.g., Alessi, 2008; Auerback & Moser, 1987;
Bridges & Croteau, 1994; Brownfain, 1985; Buxton,
1994, 2001, 2004, 2007; Carlsson, 2007; Coleman,
1989; Corley & Kort, 2006; Gochros, 1989; Hernandez
& Wilson, 2007; Isay, 1998; Klein & Schwartz, 2001;
Malcolm, 2000; Schneider et al. 2002; Treyger, Ehlers,
Zajicek, & Trepper, 2008; Yarhouse et al., 2003)
have laid out counseling strategies for individuals in
marriages with the other sex who consider SOCE. These
strategies for individual, couples, and group counseling
do not focus solely on one outcome (e.g., divorce,
marriage) but on exploring the underlying personal and
contextual problems, motivations, realities, and hopes
for being in, leaving, or restructuring the relationship.

|oe, |o|ooo oo |ee|oome
In our review of the research and clinical literature,
we found that identity issues, particularly the ability
to explore and integrate aspects of self, are central to
fho nrorInfo nIIcnfIon of nfhrmnfIvo fhornoufIc
interventions for adults presenting with a desire to
change their sexual orientation. As described in earlier
socfIons of fhIs roorf, conIcfs nmong dIsnrnfo
elements of identity appear to play a major role in
the distress of those seeking SOCE, and identity
exploration and development appear to be ways in
which individuals resolve or avoid distress (e.g., Balsam
& Mohr, 2007; Beckstead & Morrow, 2004; Coyle &
Rafakin, 2000; Drescher, 1998a; Glassgold, 2008; Herek
& Garnets, 2007; Mahaffy, 1996; Yarhouse et al., 2005;
Yip, 2002, 2003, 2005).
Ideally, identity comprises a coherent sense of
ones needs, beliefs, values, and roles, including those
aspects of oneself that are the bases of social stigma,
such as age, gender, race, ethnicity, disability, national
origin, socioeconomic status, religion, spirituality, and
sexuality (G. R. Adams & Marshall, 1996; Bartoli &
Gillem, 2008; Baumeister & Vohs, 2002; LaFramboise
et al., 1993; Marcia, 1966; Meyers et al., 1991; R. L.
Worthington et al., 2002). Marcia (1966) generated
a model in which identity development is an active
process of exploring and assessing ones identity and
establishing a commitment to an integrated identity. R.
L. Worthington et al. (2002) hypothesized that sexual
orientation identity could be conceptualized along
these same lines and advanced a model of heterosexual
identity development based on the assumption that
congruence among the dimensions of individual identity
is the most adaptive status, which is achieved by
active exploration. There is some empirical research
supporting this model (R. L. Worthington, Navarro,
Savoy, & Hampton,
2008). Additionally,
there is some research
illustrating that
resolution of identity
development has
important mental
honIfh bonohfs
for sexual minorities in the formation of a collective
identity that buffers individuals from sexual stigma,
IncronsIng soIf-osfoom nnd IdonfIhcnfIon wIfh n socInI
group (Balsam & Mohr, 2007; Crawford et al., 2002;
Herek & Garnets, 2007).
An nfhrmnfIvo nronch Is suorfIvo of cIIonfs`
identity development without an a priori treatment
goal for how clients identify or live out their sexual
orientation. Sexual orientation identity exploration
can be helpful for those who eventually accept or reject
their same-sex sexual attractions; the treatment does
not differ, although the outcome does. For instance,
the existing research indicates that possible outcomes
of sexual orientation identity exploration for those
distressed by their sexual orientation may be:
LGB identities (Glassgold, 2008; Haldeman, 2004; :
Mahaffy, 1996; Yarhouse, 2008)
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oee|oome wo. o o
oo eome oo| |o ow
c|e oe|, o |e o. e
e.o| oeoo
Heterosexual sexual orientation identity (Beckstead :
& Morrow, 2004)
Disidentifying from LGB identities (e.g., ex-gay) :
(Yarhouse, 2008; Yarhouse & Tan, 2004; Yarhouse et
al., 2005)
Not specifying an identity (Beckstead & Morrow, :
2004; Haldeman, 2004; Tan, 2008)
The research literature indicates that there are
variations in how individuals express their sexual
orientation and label their identities based on ethnicity,
culture, age and generation, gender, nationality,
acculturation, and religion (Boykin, 1996; Carrillo, 2002;
Chan, 1997; Crawford et al., 2002; Denizet-Lewis, 2003;
Kimmel & Yi, 2004; Martinez & Hosek, 2005; Miville &
Ferguson, 2004; Millett, Malebranche, Mason, & Spikes,
2005; Stokes, Miller, & Mundhenk, 1998; Toro-Alfonso,
2007; Weeks, 1995; Yarhouse, 2008; Yarhouse et al.,
2005; Zea et al., 2003). Some authors have provided
analyses of identity that take into account diversity
in sexual identity development and ethnic identity
formation (Helms, 1995; LaFramboise et al., 1993;
Myers et al., 1991; Yi & Shorter-Gooden, 1999), religious
identity (Fowler, 1981, 1991; Oser, 1991; Strieb,
2001), as well as combinations of religious and sexual
orientation identities (Coyle & Rafalin, 2000; Hoffman
et al., 2007; Kerr, 1997; Knight & Hoffman, 2007; Ritter
& ONeill, 1989, 1995; Thumma, 1991; Throckmorton &
Yarhouse, 2006; Yarhouse & Tan 2004).
In some of the literature on SOCE, religious beliefs
nnd IdonfIfy nro rosonfod ns hxod, whorons soxunI
orientation is considered changeable (cf. Rosik, 2003).
Given that there is a likelihood that some individuals
wIII chnngo roIIgIous nfhIInfIons durIng fhoIr IIfofImo
(Pew Forum on Religion and Public Life, 2008) and that
many scholars have found that both religious identity
and sexual orientation identity evolve (Beckstead
& Morrow, 2004; Fowler, 1981; Glassgold, 2008;
Haldeman, 2004; Mahaffy, 1996; Ritter & Terndrup,
2002; Yarhouse & Tan, 2005b), it is important for
LMHP to explore the development of religious identity
and sexual orientation identity (Bartoli & Gillem,
2008). Some authors hypothesize that developmental
awareness or stage of religious or sexual orientation
identity may play a role in identity outcomes (Knight
& Hoffman, 2007; Mahaffy, 1996; cf. Yarhouse & Tan,
2005a). Other authors have described a developmental
process that includes periods of crisis, mourning,
reevaluation, identity deconstruction, and growth
(Comstock, 1996; ONeill & Ritter, 1992; Ritter &
ONeill, 1989, 1995). Others have found that individuals
disidentify or reject LGB identities (Ponticelli, 1999;
Wolkomir, 2001, 2006; Yarhouse et al., 2005). Thus,
!MHI sookIng fo fnko nn nfhrmnfIvo nffIfudo rocognIzo
fhnf IndIvIdunIs wIII dohno soxunI orIonfnfIon IdonfIfIos
in a variety of ways (Beckstead, as cited in Shidlo,
Schroeder, & Drescher, 2002; Diamond, 2003; 2006;
2008; Savin-Williams, 2005; Yarhouse et al., 2005).
Some religious individuals may wish to resolve the
tension between values and sexual orientation by
choosing celibacy (sexual abstinence), which in some
faiths, but not all, may be a virtuous path (Olson, 2007).
We found limited empirical research on the mental
health consequences of that course of action.
44
Some
clinical articles and surveys of individuals indicate
fhnf somo mny hnd such n IIfo fuIhIIIng (S. !. Jonos
& Yarhouse, 2007); however, there are others who
cannot achieve such a goal and might struggle with
depression and loneliness (Beckstead & Morrow, 2004;
Glassgold, 2008; Haldeman, 2001; Horlacher, 2006;
Rodriguez, 2006; Shidlo & Schroeder, 2002). In a similar
way, acting on same-sex sexual attractions may not
bo fuIhIIIng soIufIons for ofhors (Iocksfond & Morrow,
2004; Yarhouse, 2008).
Licensed mental health providers may approach such
a situation by neither rejecting nor promoting celibacy
but attempting to understand how this outcome is part
of the process of exploration, sexual self-awareness, and
understanding of core values and goals. The therapeutic
process could entail exploration of what drives this goal
for clients (assessing cultural, family, personal context
and issues, sexual self-stigma), the possible short-
and long-term consequences/rewards, and impacts on
mental health while providing education about sexual
health and exploring how a client will cope with the
losses and gains of this decision (cf. L. A King & Hicks,
2007; Ritter & ONeill, 1989, 1995).
On the basis of the aforementioned analyses, we
adopted a perspective that recognizes the following:
The important functional aspects of identity (G. R. :
Adams & Marshall, 1996).
The multiplicity inherent in experience and identity, :
including age, gender, gender identity, race, ethnicity,
culture, national origin, religion, sexual orientation,
disability, language, and socioeconomic status
44
Howovor, SIo (l990, 2003) hns survoyod cIorgy nnd found dIfhcuIfy
in maintaining behavior consistent with aspirations. Other studies
indicate that this goal is only achieved for a minority of participants
who choose it (Brzezinski, 2000; Jones & Yarhouse, 2007).
(Bartoli & Gillem, 2008; Miville & Ferguson, 2004;
Myers et al., 1991).
Tho Inuonco of socInI confoxf nnd fho onvIronmonf :
on identity (Baumeister & Muraven, 1996;
Bronfenbrenner, 1979; Meeus, Iedema, Helsen,
& Vollebergh, 1999; Myers et al., 1991; Steenbarger,
1991).
That aspects of multiple identities are dynamic :
nnd cnn bo In conIcf (Iocksfond & Morrow, 2004;
Glassgold, 2008; Mark, 2008; D. F. Morrow, 2003;
Tan, 2008; Yarhouse, 2008).
Identities can be explored, experienced, or integrated :
without privileging or surrendering one or another
at any age (Bartoli & Gillem, 2008; Glassgold, 2008;
Gonsiorek, 2004; Haldeman, 2004; Myers et al., 1991;
Phillips, 2004; Shallenberger, 1996).
Approaches based on models of biculturalism
(LaFromboise et al., 1993) and pluralistic models
of identity, including combining models of ethnic,
sexual orientation, and religious identity that help
individuals develop all aspects of self simultaneously
or some sequentially (Dworkin, 1997; Harris et al.,
2008; Hoffman et al., 2007; Knight & Hoffman, 2007;
Myers et al., 1991; Omer & Strenger, 1992; Ritter &
ONeill, 1989, 1995; Rosario, Schrimshaw, & Hunter,
2004; Rosario, Yali, Hunter, & Gwadz, 2006; Sophie,
1987; Troiden, 1988, 1993), can encourage identity
dovoIomonf nnd synfhosIs rnfhor fhnn IdonfIfy conIcf,
foreclosure, or compartmentalization.
Sexual orientation identity exploration can help
clients create a valued personal and social identity that
provides self-esteem, belonging, meaning, direction,
nnd fufuro uroso, IncIudIng fho rodohnIng of roIIgIous
boIIofs, IdonfIfy, nnd mofIvnfIons nnd fho rodohnIng
of sexual values, norms, and behaviors (Beckstead &
Israel, 2007; Glassgold, 2008; Haldeman, 2004; Mark,
2008; Tan, 2008; Yarhouse, 2008). We encourage LMHP
to support clients in determining their own (a) goals
for their identity process; (b) behavioral expression of
sexual orientation; (c) public and private social roles; (d)
gender role, identity, and expression; (e) sex and gender
of partner; and (f) form of relationship(s).
Understanding gender roles and gender expression
and developing a positive gender identity
45
continue
to be concerns for many individuals who seek SOCE,
especially as nonconformity with social expectations
regarding gender can be a source of distress and stigma
(APA, 2008e; Beckstead & Morrow, 2004; Corbett, 1996,
1998; Wolkomir, 2001). Some SOCE teach men how
to adopt traditional masculine behaviors as a means
of altering their sexual orientation (e.g., Nicolosi,
1991, 1993) despite the absence of evidence that such
interventions affect sexual orientation. Such theoretical
positions have been characterized as products of
stigma and bias that are without an evidentiary basis
and may increase distress (American Psychoanalytic
Association, 2000; Isay, 1987, 1999; Drescher, 1998a;
Haldeman, 1994, 2001). For instance, Haldeman (2001)
emphasized in his clinical work with men who had
participated in SOCE that some men were taught that
their homosexuality made them less masculinea belief
that was ultimately damaging to their self-esteem.
Research on the impact of heterosexism and traditional
gender roles indicates that an individuals adoption
of traditional masculine norms increases sexual self-
stigma and decreases self-esteem and emotional
connection with others, thus negatively affecting mental
health (Szymanski & Carr, 2008).
Advances in the psychology of men and masculinity
provide more appropriate conceptual models for
considering gender
concernsfor instance,
in such concepts as
gender role strain or
gender role stress (cf.
Butler, 2004; Enns,
2008; Fischer &
Good, 1997; Heppner
& Heppner, 2008;
Levant, 1992; Levant
& Silverstein, 2006;
ONeil, 2008; Pleck,
1995; Wester, 2008).
This literature suggests
exploring with clients the role of traditional gender
norms in distress and reconceptualizing gender in ways
that feel more authentic to the client. Such approaches
45
Gender refers to the roles, behaviors, activities, and attributes
that a particular society considers appropriate for men and women.
Condor IdonfIfy Is n orson`s own sychoIogIcnI sonso of IdonfIhcnfIon
as male or female, another gender, or identifying with no gender.
Gender expression is the activities and behaviors that purposely or
inadvertently communicate our gender identity to others, such as
clothing, hairstyles, mannerisms, way of speaking, and social roles.
\o |eo.e oeo
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eoe o o||m o woe
oe o| eoe oe,
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oo |em,
could also reduce the gender stereotypes associated with
same-sex sexual orientation (Corbett, 1998; Haldeman,
2001; Schwartzberg & Rosenberg, 1998). Most literature
in this area suggests that for clients who experience
distress with their gender-role nonconformity, LMHP
provide them with a more complex theory of gender
fhnf nfhrms n wIdor rnngo of gondor dIvorsIfy nnd
oxnnds dohnIfIons nnd oxrossIons of mnscuIInIfy nnd
femininity (Butler, 2004; Corbett, 1996, 1998, 2001;
Haldeman, 2001; Levant & Silverstein, 2006).
Somo womon hnd curronf cnfogorIos for
conceptualizing their sexual orientation and sexual
orientation identity limiting, as concepts in popular
culture and professional literature do not mirror their
oxorIoncos of uIdIfy nnd vnrInfIon In soxunIIfy nnd
relationships (Chivers et al., 2007; Diamond, 2006,
2008; Peplau & Garnets, 2000). Some women, for
example, may experience relationships with others as
important parts of sexuality and may place sexuality,
sexual orientation, and sexual orientation identity
in the context of interpersonal bonds and contexts
(Diamond, 2003, 2006, 2008; Diamond & Savin-
Williams, 2000; Garnets & Peplau, 2000; Kinnish,
Strassberg, & Turner 2005; Kitzinger, & Wilkinson,
1994; Miller, 1991; Morgan & Thompson, 2006; Peplau
& Cnrnofs, 2000; Surroy, l99l). SocIhc sychofhorny
approaches that focus on an understanding of emotional
and erotic interpersonal connections in sexuality rather
than simply on sexual arousal can aide LMHP in
providing a positive framework and goals for therapy
with women (Garnets & Peplau, 2000; Glassgold, 2008;
Miller, 1991; Surrey, 1991).
Ior mnny womon, roIIgIous or cuIfurnI Inuoncos
discourage exploration of sexuality and do not portray
female sexuality as positive or self-directed (Brown,
2006; Espin, 2005; Fassinger & Arseneau, 2006;
Mahoney & Espin, 2008; Moran, 2007; Stone, 2008).
Treatment might involve deconstructing cultural scripts
in order to explore possibilities for religion, sexuality,
sexual orientation, identity, and relationships (Avishai,
2008; Biaggio, Coan, & Adams, 2002; Morgan &
Thompson, 2006; Rose & Zand, 2000).
Conclusion
InforvonfIons fo nduIfs Is buIIf on fhroo koy hndIngs
in the research: (a) An enduring change to an
individuals sexual orientation as a result of SOCE
was unlikely, and some participants were harmed by
the interventions; (b) sexual orientation identity
not sexual orientationappears to change via
psychotherapy, support groups, and life events; and (c)
cIIonfs orcoIvo n bonohf whon offorod InforvonfIons
that emphasize acceptance, support, and recognition of
important values and concerns.
On fho bnsIs of fhoso hndIngs nnd fho cIInIcnI
literature on this population, we suggest client-centered
nronchos groundod on fho foIIowIng scIonfIhc fncfs:
of human sexualityin other words, they are not
indicators of mental or developmental disorders.
Same-sex sexual attractions and behavior can occur :
in the context of a variety of sexual orientations and
sexual orientation identities.
Gay men, lesbians, and bisexual individuals can live :
satisfying lives as well as form stable, committed
heterosexual relationships in essential respects.
No empirical studies or peer-reviewed research :
support theories attributing same-sex sexual
orientation to family dysfunction or trauma.
AfhrmnfIvo cIIonf-conforod nronchos consIdor soxunI
orientation uniquely individual and inseparable from
an individuals personality and sense of self (Glassgold,
1995, 2008). This includes (a) being aware of the clients
unique personal, social, and historical context; (b)
exploring and countering the harmful impact of stigma
and stereotypes on the clients self-concept (including
the prejudice related to age, gender, gender identity,
status); and (c) maintaining a broad view of acceptable
life choices.
We developed a framework for the appropriate
for adults that has the following central elements:
(a) acceptance and support; (b) comprehensive
assessment; (c) active coping; (d) social support; and
(e) identity exploration and development. Acceptance
and support include (a) unconditional positive regard
for and empathy with the client; (b) an openness to the
clients perspective as a means to understanding their
concerns; and (c) encouragement of the clients positive
self-concept.
Client assessment includes an awareness of the
complete person, including mental health concerns that
could impact distress about sexual orientation. Active
coping strategies are
efforts that include
cognitive, behavioral,
or emotional responses
designed to change the
nature of the stressor
itself or how an
individual perceives
it and includes
both cognitive and
emotional strategies.
Psychotherapy, self-help groups, or welcoming
communities (ethnic communities, social groups,
religious denominations) provide social support that can
mitigate distress caused by isolation, rejection, and lack
of role models.
ConIcfs nmong dIsnrnfo oIomonfs of IdonfIfy
Iny n mnjor roIo In fho conIcfs nnd monfnI honIfh
concerns of those seeking SOCE. Identity exploration
is an active process of exploring and assessing
ones identity and establishing a commitment to an
Infogrnfod IdonfIfy fhnf nddrossos fho IdonfIfy conIcfs
without an a priori treatment goal for how clients
identify or live out their sexual orientation. The process
may include a developmental process that includes
periods of crisis, mourning, reevaluation, identity
deconstruction, and growth.
!Iconsod monfnI honIfh rovIdors nddross socIhc
issues for religious clients by integrating aspects of
the psychology of religion into their work, including by
obtaining a thorough assessment of clients spiritual
and religious beliefs, religious identity and motivations,
and spiritual functioning; improving positive religious
coping; and exploring the intersection of religious
and sexual orientation identities. This framework is
consistent with modern multiculturally competent
approaches and evidence-based psychotherapy practices
and can be integrated into a variety of theoretical
systems.
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E
thical concerns relevant to sexual orientation
change efforts (SOCE) have been a major theme
in the literature and a central aspect of the debate
around SOCE (e.g., Benoit, 2005; Cramer et al., 2008;
Davison, 1976, 1978, 1991; Drescher, 1999, 2001,
2002; Gonsiorek, 2004; Haldeman, 1994, 2002, 2004;
Herek, 2003; Lasser & Gottlieb, 2004; Rosik, 2003;
Schreier, 1998; Schroeder & Shidlo, 2001; Sobocinski,
l990; Tozor & McCInnnhnn, l999; WnkohoId, 2003;
Yarhouse, 1998a; Yarhouse & Burkett, 2002; Yarhouse
& Throckmorton, 2002). The major concerns raised
in these publications have been (a) the potential for
harm, (b) the clients right to choose sexual orientation
change efforts and other issues generally related to the
ethical issue of client autonomy, and (c) questions of
how to appropriately balance respect for two aspects
of diversityreligion and sexual orientation. SOCE
presents an ethical dilemma to practitioners because
these publications have urged LMHP to pursue multiple
and incompatible courses of action (cf. Kitchener, 1984).
In 1997 APA adopted the Resolution on Appropriate
Therapeutic Responses to Sexual Orientation. This
resolution highlighted the provisions of the then-
current Ethical Principles for Psychologists and Code of
Conduct (APA, 1992) that APA believed to be relevant
to situations in which clients request treatments to
alter sexual orientation and psychologists provide such
treatments, including the provisions regarding bias
and discrimination, false or deceptive information,
competence, and informed consent to treatment.
46
Ethical concerns for children and adolescents are considered in
Chapter 8.
For a discussion of the resolutions application to
clinical situations, readers are referred to Schneider
of nI. (2002). AIA ronfhrmod (n) Ifs osIfIon fhnf
homosexuality is not a mental disorder; (b) its
opposition to stigma, prejudice, and discrimination
based on sexual orientation; and (c) its concern about
the contribution of the promotion of SOCE to the
continuation of sexual stigma in U.S. culture.
Tho AIA`s chnrgo fo fho fnsk forco IncIudod fo
review and update the APA Resolution on Appropriate
Therapeutic Responses to Sexual Orientation. In
fho rocoss of fuIhIIIng fhIs nsocf of our chnrgo, wo
considered the possibility of recommending revisions
fo fho l99? rosoIufIon fo udnfo If wIfh fho socIhc
principles and standards of the 2002 APA Ethics Code.
Ultimately, we decided against a revision,
47
because the
relevant concepts in the two versions of the principles
and code are similar. Instead, this chapter examines the
relevant sections of the 2002 APA Ethical Principles for
Psychologists and Code of Conduct [hereafter referred to
as the Ethics Code] in light of current debates regarding
ethical decision making in this area.
48
We build
our discussion on the concepts outlined in the 1997
47
As fho hnnI chnfor of fhIs roorf rovonIs, wo hnvo dovoIood n now
resolution that we recommend APA adopt.
48
This section is for descriptive and educational purposes. It is not
designed to interpret the APA (2002b) Ethics Code. The APA Ethics
Committee alone has the authority to interpret the APA (2002b)
Ethics Code and render decisions about whether a course of treatment
is ethical. Furthermore, this section is not intended to provide
guidelines or standards for practice. Guidelines and standards for
rncfIco nro cronfod fhrough n socIhc rocoss fhnf Is oufsIdo fho
purview of the task force.
7. |!|CA| CONC||NS AN| ||C|S|ON 'A||NC
IN PSYCHOTHERAPY WITH ADULTS
46

resolution and discuss some of the ethical controversies
in light of the newer APA Ethics Code (2002b) and of
the systematic research review presented in Chapters
3 and 4 of this report. Although many of the principles
and standards in the Ethics Code are potentially
pertinent,
49
the principles and standards most relevant
to this discussion are (in alphabetical order):
Insos for ScIonfIhc nnd IrofossIonnI Judgmonfs 1.
(Standard 2.04) and Competence (e.g. 2.01a, 2.01b)
50
IrIncIIo A: Ionohconco nnd onmnIohconco 2.
Principle D: Justice 3.
Principle E: Respect for Peoples Rights and Dignity 4.
bdses |o Sc|e||c dd
Professional Judgments
and Competence
Many of the standards of the Ethics Code are derived
from the ethical and valuative foundations found in
the principles (Knapp & VandeCreek, 2004). Two of
the more important standards are competence and
fho bnsos for scIonfIhc nnd rofossIonnI judgmonfs.
These standards are linked, as competence is based on
knowIodgo of fho scIonfIhc ovIdonco roIovnnf fo n cnso
(Glassgold & Knapp, 2008). When practicing with those
who seek sexual orientation change for themselves
or for others, commentators on ethical practice have
recommended that the practitioner understand the
scIonfIhc rosonrch on soxunI orIonfnfIon nnd SOCI
(Glassgold & Knapp, 2008; Schneider et al., 2002). It
is obviously beyond the task forces scope to provide
a systematic review of the whole body of research
on sexual orientation, but we have tried to provide a
systematic review of the research on SOCE in Chapters
3 and 4. From this review, we have drawn two key
conclusions.
49
The following are some of the pertinent standards: 2. Competence,
2.01 Boundaries of Competence, 2.03 Maintaining Competence, 2.04
Insos for ScIonfIhc nnd IrofossIonnI Judgmonfs; 3. Humnn !oInfIons,
3.01 Unfair Discrimination, 3.03 Other Harassment, 3.04 Avoiding
Harm, 3.10 Informed Consent; 5.01 Avoidance of False and Deceptive
Statements, 5.04 Media Presentations; 7.01 Design of Education
and Training Programs; 8.02 Informed Consent to Research; 10.01
Informed Consent to Therapy; 10.02 Therapy Involving Couples or
Families.
50
Knapp and VandeCreek (2004) proposed that 2. Competence is
dorIvod from IrIncIIo A Ionohconco & onmnIohconco, ns If Is moro
IIkoIy fhnf nn !MHI cnn rovIdo bonohf If ho or sho Is comofonf;
however, for our purposes, this chapter will discuss these issues
sequentially.
Tho hrsf hndIng from our rovIow Is fhnf there is
ineuf[cien/ etiJence /lo/ SOC1 ore ef[cocioue for
changing sexual orientation. Furthermore, there is some
evidence that such efforts cause harm. On the basis
of this evidence,
we consider it
inappropriate for
psychologists and
other LMHP to foster
or support in clients
the expectation that
they will change their
sexual orientation
if they participate
in SOCE. We believe that among the various types of
SOCE, the greatest level of ethical concern is raised by
SOCE that presuppose that same-sex sexual orientation
is a disorder or a symptom of a disorder.
51
Treatments
based on such assumptions raise the greatest level of
ethical scrutiny by LMHP because they are inconsistent
wIfh fho scIonfIhc nnd rofossIonnI consonsus fhnf
homosexuality per se is not a mental disorder. Instead,
we counsel LMHP to consider other treatment
options when clients present with requests for sexual
orientation change.
Tho socond koy hndIng from our rovIow Is fhnf fhoso
who participate in SOCE, regardless of the intentions
of these treatments, and those who resolve their distress
through other means, may evolve during the course of
their treatment in such areas as self-awareness, self-
concept, and identity. These changes may include (a)
sexual orientation identity, including changes in private
nnd ubIIc IdonfIhcnfIon, grou momborshI, nnd
nfhIInfIon; (b) omofIonnI ndjusfmonf, IncIudIng roducIng
self-stigma and shame; and (c) personal beliefs, values,
and norms, including changes in religious and moral
beliefs and behaviors and motivations (Buchanon et
al., 2001; Diamond, 1998, 2006; Rust, 2003; Savin-
Williams, 2004; R. L. Worthington, 2002, 2004, 2005;
Yarhouse, 2008). These areas become targets of LMHP
InforvonfIons In ordor fo roduco IdonfIfy conIcfs nnd
distress and to explore and enhance the clients identity
integration.
Because a large number of individuals who seek
SOCE are from conservative faiths and indicate that
religion is very important to them, research on the
psychology of religion can be integrated into treatment.
For instance, individual religious motivations can be
51
See, e.g., Socarides (1968), Hallman (2008), and Nicolosi
(1991); these theories assume homosexuality is always a sign of
developmental defect or mental disorder.
e oo o| eoece
we cooe ooooooe
|o o,co|o oo oe
|\| o |oe o .ooo
c|e e eoecoo o
e, w|| coe e e.o|
oeoo | e, oocooe
|
examined, positive religious coping increased, and
religious identity and sexual orientation identity
explored and integrated (Beckstead & Israel, 2007;
Fowler, 1981; Glassgold, 2008; Haldeman, 2004; Knight
& Hoffman, 2007; ONeill & Ritter, 1992; Yarhouse &
Tan, 2005a, 2005b). This is consistent with advances in
the understanding of human diversity that place LGB-
nfhrmnfIvo nronchos wIfhIn curronf muIfIcuIfurnI
perspectives that include age, gender, gender identity,
status (e.g., Bartoli & Gillem, 2008; Brown, 2006;
Fowers & Davidov, 2006), consistent with Principle D
(Justice) and Principle E (Respect for Peoples Rights
and Dignity).
However, in some of the debates on these issues,
there are tensions between conservative religious
orsocfIvos nnd nfhrmnfIvo nnd scIonfIhc orsocfIvos
(Haldeman, 2002; Rosik, 2003; Throckmorton & Welton,
2005; Yarhouse, 1998a; Yarhouse & Burkett, 2002;
Yarhouse & Throckmorton, 2002). Although there are
fonsIons bofwoon roIIgIous nnd scIonfIhc orsocfIvos,
the task force and other scholars do not view these
perspectives as mutually exclusive (Bartoli & Gillem,
2008; Haldeman, 2004; S. L. Morrow & Beckstead, 2004;
Yarhouse, 2005b). As we noted in the introduction,
in its Resolution on Religious, Religion-Related, and/
or Religion-Derived
Prejudice, APA
(2008a) delineates
a perspective that
nfhrms fho Imorfnnco
of science in exploring
and understanding
human behavior while
respecting religion as
an important aspect of
humnn dIvorsIfy. ScIonfIhc hndIngs from fho sychoIogy
of religion can be incorporated into treatment, thus
respecting all aspects of diversity while providing
fhorny fhnf Is consIsfonf wIfh scIonfIhc rosonrch.
Most important, respecting religious values does not
require using techniques that are unlikely to have an
effect. We proposed an approach that respects religious
values and welcomes all of the clients actual and
ofonfInI IdonfIfIos by oxIorIng conIcfs nnd IdonfIfIos
without preconceived outcomes. This approach does
not prioritize one identity over another and may aide
a client in creating a sexual orientation identity with
religious values (see Chapter 6) (Bartoli & Gillem, 2008;
Beckstead & Israel, 2007; Glassgold, 2008; Gonsiorek,
2004; Haldeman, 2004; Tan, 2008; Yarhouse, 2008).
bee| dd da
IrIncIIo A of fho AIA IfhIcs Codo, Ionohconco nnd
onmnIohconco, osfnbIIshos fhnf sychoIogIsfs nsIro
fo rovIdo sorvIcos fhnf mnxImIzo bonohf nnd mInImIzo
harm (APA, 2002b). Many ethicists and scholars
consider the avoidance of harm to be the priority of
modern health care and medical ethics (Beauchamp &
Childress, 2008; Herek, 2003; S. L. Morrow, 2000). The
literature on effective treatments and interventions
stresses that effective interventions do not have serious
negative side effects (Beutler, 2000; Flay et al., 2005).
When applying this principle in the context of providing
interventions, LMHP assess the risk of harm, weigh
fhnf rIsk wIfh fho ofonfInI bonohfs, nnd communIcnfo
this to clients through informed consent procedures
that aspire to provide the client with an understanding
of ofonfInI rIsks nnd bonohfs fhnf nro nccurnfo nnd
unbiased. Some of the published considerations of
ethical issues related to SOCE have focused on the
IImIfod ovIdonco for Ifs ofhcncy, fho ofonfInI for cIIonf
harm, and the potential for misrepresentation of these
issues by proponents of SOCE (Cramer et al., 2008;
Haldeman, 1994, 2002, 2004; Herek, 2003; Schroeder
& Shidlo, 2001; Shidlo & Schroeder, 2002). Other
discussions focus on other harms of SOCE, such as
reinforcing bias, discrimination, and stigma against
LGB individuals (Davison, 1976, 1978, 1991; Drescher,
1999, 2001, 2002; Gonsiorek, 2004).
In woIghIng fho hnrm nnd bonohf of SOCI, !MHI
can review with clients the evidence presented in
this report. Research on harm from SOCE is limited,
and some of the research that exists suffers from
methodological limitations that make broad and
dohnIfIvo concIusIons dIfhcuIf. InrIy woII-dosIgnod
experiments that used aversive and behavioral
interventions did cause inadvertent and harmful mental
health effects such as increased anxiety, depression,
suicidality, and loss of sexual functioning in some
participants. Additionally, client dropout rate is
sometimes an indication of harmful effects (Lilienfeld,
2007). Early studies with aversive procedures are
characterized by very high dropout rates, perhaps
indicating harmful effects, and substantial numbers
of clients unwilling to participate further. Other
perceptions of harm mentioned by recipients of SOCE
include increased guilt and hopelessness due to the
/|/ (...oo) oe|eoe
o oeoece o
o||m e moooce o|
cece eo|o oo
.oeoo .mo
oeoo w|e eoec
e|o o o mooo
ooec o| .mo oe,
failure of the intervention, loss of spiritual faith, and a
sense of personal failure and unworthiness (Beckstead
& Morrow, 2004; Haldeman, 2001, 2004; Shidlo &
Schroeder, 2002). Other indirect harms from SOCE
include the time, energy, and cost of interventions
fhnf woro nof bonohcInI (Iocksfond & Morrow, 2004;
Lilienfeld, 2007; Smith et al., 2004).
Wo found IImIfod rosonrch ovIdonco of bonohfs from
SOCE. There is qualitative research that describes
clients positive perceptions of such efforts, such as
experiencing empathy and a supportive environment
to discuss problems and share similar values, which
seemed to reduce their stress about their same-
sex sexual attractions (Beckstead & Morrow, 2004;
Ponticelli, 1999; Wolkomir, 2001). The literature on
SOCE support groups, for instance, illustrates results
sImIInr fo fhoso found for !CI-nfhrmIng grous nnd
mutual help groups in general (e.g., Kerr, 1997; Levine
et al., 2004; Thumma, 1991). The positive experiences
clients report in SOCE are not unique. Rather, they are
bonohfs fhnf hnvo boon found In sfudIos of fhornoufIc
relationships and
support groups in a
number of different
contexts (Levine et
al., 2004; Norcross,
2002; Norcross &
Hill, 2004). Thus,
fho bonohfs roorfod
by participants in SOCE may be achieved through
treatment approaches that do not attempt to change
sexual orientation.
Perceptions of risks and rewards of certain courses
of ncfIon Inuonco fho IndIvIdunI`s docIsIons, dIsfross,
and process of exploration in psychotherapy. The
cIIonf nnd !MHI mny dohno fhoso rIsks nnd rownrds
dIfforonfIy, IondIng fo dIfforonf orcofIons of bonohf
and harm. Recognizing, understanding, and clarifying
these different perceptions of risks and rewards are
crucial for a thorough ethical analysis of each clients
unique situation and are aspects of client-centered
approaches. For instance, an LMHP may attempt
to provide information to the client to reduce sexual
stigma and increase life options by informing the client
about the research literature on same-sex couples. Such
relationships may be threatening to the client when
such a life course is perceived as being inconsistent
with existing religious beliefs and motivations
and potentially having negative repercussions on
existing relationships with religious communities.
Yet, discussing positive coping resources with clients
regarding how to manage such inconsistencies, stigma,
and negative repercussions may provide the client with
more informed and empowered solutions from which
fo chooso, fhus IncronsIng bonohf nnd nufonomy nnd
reducing harm.
Justice and Respect
for Rights and Dignity
In this section, we focus on two concepts, Justice
(Principle D) and Self-Determination (Principle E,
!osocf for IooIo`s !Ighfs nnd IgnIfy). Tho hrsf
considers justice, both distributive and procedural
justice (Knapp & VandeCreek, 2004), and the second
focuses on recognizing diversity and maximizing a
clients ability to choose. The APA Ethics Code uses the
term self-determination to encompass the meanings for
which many ethicists have used the term autonomy;
wo dohno soIf-doformInnfIon ns fho rocoss by whIch
a person controls or determines the course of her
or his own life (Oxford American Dictionary, n.d.).
Client self-determination encompasses the ability
to seek treatment, consent to treatment, and refuse
treatment. The informed consent process is one of the
ways by which self-determination is maximized in
psychotherapy.
Informed consent and self-determination cannot be
considered without an understanding of the individual,
community, and social contexts that shape the lives of
sexual minorities. By understanding self-determination
ns confoxf-socIhc nnd by workIng fo Incronso cIIonfs`
nwnronoss of fho Inuoncos of confoxf on fhoIr
decision making, the LMHP can increase clients self-
determination and thereby increase their ability to
make informed life choices (Beckstead & Israel, 2007;
Glassgold, 1995; 2008; Haldeman, 2004). For instance,
some have suggested that social stigma and prejudice
are fundamental reasons for sexual minorities desire
to change their sexual orientation (Davison, 1976,
1978, 1982, 1991; Haldeman, 1994; Silverstein, 1991;
G. Smith et al., 2004; Tozer & Hayes, 2004). As stigma,
prejudice, and discrimination continue to be prevalent,
52

52
For instance, the criminalization of certain forms of same-sex sexual
behavior between consenting adults in private was constitutional
in the United States until 2003 (see Lawrence v. Texas, 2003). The
federal government and most U.S. states do not provide civil rights
protections to LGB individuals and their families (National Gay
and Lesbian Task Force, n.d.). In some other countries, homosexual
behavior is still illegal and subject to extreme consequences, even
death (e.g., Human Rights Watch, 2008; International Gay & Lesbian
Human Rights Commission (IGLHRC), n.d.; Wax, 2008). In extremely
repressive environments, sexual orientation conversion efforts are
e oee| eooeo
o, oocoo |
mo, oe oceeo o.
eome oooooce o
oo o oemo o coe
e.o| oeoo
we recommend that LMHP strive to understand their
clients request for SOCE in the context of sexual
stigma and minority stress (e.g., DiPlacido, 1998;
Meyer, 2001). We further recommend that providers
explore with their clients the impact of these factors
on their clients decision making in order to assess the
extent to which self-determination is compromised (cf.
G. Smith et al., 2004).
For instance, repressive, coercive, or invalidating
cuIfurnI, socInI, oIIfIcnI, nnd roIIgIous Inuoncos cnn
limit autonomous expression of sexual orientation,
including the awareness and exploration of options for
expression of sexual orientation within an individual
life (e.g., Glassgold, 2008; Mark, 2008; McCormick,
2006; G. Smith et al., 2004; Wax, 2008). We recommend
that LMHP consider the impact of discrimination and
stigma on the client and themselves (e.g., Beckstead &
Israel, 2007; Haldeman, 2001, 2002). This consideration
can become quite complex when the client or the
community of the client or the LMHP believes that
homosexuality is sinful and immoral (see Beckstead &
Israel, 2007). Further exploration of religious beliefs
and the cognitive assumptions underlying those beliefs
may be helpful in understanding the clients beliefs and
perception of choices (Buchanan et al., 2001; Fischer
& DeBord, 2007; Johnson, 2004; Yarhouse, 2008; Yip,
2000, 2002, 2005).
The issue of self-determination and autonomy
has become controversial, and some have suggested
that SOCE be offered in the spirit of maximizing
client autonomy
53
so that clients have access to a
treatment they request (e.g., Rosik, 2003; Yarhouse &
Throckmorton, 2002). Others have cautioned against
providing interventions that have very limited evidence
of offocfIvonoss, run counfor fo curronf scIonfIhc
knowledge, and have the potential for harm, despite
client requests (Drescher, 1999, 2002; Forstein, 2001;
Gonsiorek, 2004; Haldeman, 2002; Herek, 2003). With
rognrd fo cInIms fhnf cIIonf nufonomy Is fho dohnIng
concern in treatment decision making, elevating one
aspect of ethical reasoning, such as autonomy, above
all others is not consistent with the current framework
of the APA Ethics Code or medical ethics that focus on
the interrelatedness of ethical principles (Beauchamp &
Childress, 2008; Knapp & VandeCreek, 2004).
provided in a coercive manner and have been the subject of human
rights complaints (e.g., IGLHRC, 2001).
53
The APA Ethics Code does not use the word autonomy; rather it
uses self-determination, whIch Is dohnod horo ns fho rocoss by whIch
a person controls their own life (Oxford American Dictionary, n.d.).
For instance, current ethics guidance focuses on the
interrelatedness of ethical principles and understanding
a clinical situation fully so as to appropriately
balance the various pertinent principles (e.g., Knapp
& VandeCreek, 2004). Self-determination and
autonomy can vary in degree due to interpersonal and
intrapersonal concerns and can be considered in relation
to other ethical principles, such as providing services
fhnf (n) nro IIkoIy fo rovIdo bonohf, (b) nro nof offocfIvo,
or (c) have the potential for harm.
We believe that simply providing SOCE to clients
who request it does not necessarily increase self-
determination but rather abdicates the responsibility
of LMHP to provide
competent assessment
and interventions that
have the potential for
bonohf wIfh n IImIfod
risk of harm. We also
believe that LMHP
are more likely to
maximize their clients
self-determination
by providing effective
psychotherapy
that increases a
clients abilities to
cope, understand,
acknowledge, explore,
and integrate sexual
orientation concerns
into a self-chosen life in which the client determines
the ultimate manner in which he or she does or does
not express sexual orientation (Bartoli & Gillem, 2008;
Beckstead & Israel, 2007; S. L. Morrow & Beckstead,
2004; Haldeman, 2004; Tan, 2008; Throckmorton &
Yarhouse, 2006; Yarhouse, 2008).
|e|ooo| |.e eome
Ideal or desired outcomes may not always be possible,
nnd nf fImos, fho cIIonf mny fnco dIfhcuIf docIsIons fhnf
require different types and degrees of disappointment,
dIsfross, nnd sncrIhco, ns woII ns bonohfs, fuIhIImonf,
and rewards (Beckstead & Morrow, 2004; Glassgold,
2008; Haldeman, 2004; Yarhouse, 2008). LMHP may
face strong emotions regarding the limits of their ability
fo rovIdo roIIof from such dIfhcuIf docIsIons or fhoIr
consequences. Such emotions are understandable in
this complex area, yet acting on such emotions within
treatment has the potential to be harmful to the client
\e o|o oe|ee o
|\| oe moe |e|, o
momze e c|e e||
oeemoo o, ooo
e||ece o,coeoo, o
ceoe o c|e oo|e
o cooe .oeoo
ocow|eoe eo|oe oo
eoe e.o| oeoo
coce o o e||coe
||e wc e c|e
oeeme e .|moe
moe wc e o e
ooe o ooe o eoe
e.o| oeoo
(Knapp & VandeCreek, 2004; Pope & Vasquez, 2007).
In these situations, in order to aid the client, the LMHP
may have to address his or her own emotional reactions
to the clients dilemmas. As the client must address
regrets, losses (such as impossible and possible selves;
soo !. A. KIng & HIcks, 200?), nnd dohnIfIons of whnf Is
n fuIhIIIng nnd worfhwhIIo IIfo, fho !MHI musf nddross
his or her own values and beliefs about such issues. The
LMHPs self-awareness, self-care, and judicious use of
consultation can be helpful in these circumstances (Pope
& Vasquez, 2007; Porter, 1995).
Moreover, LMHP may have their own internalized
assumptions about sexual orientation, sexual
orientation identity, sexuality, religion, race, ethnicity,
and cultural issues (APA, 2000, 2002b; Garnets et al.,
1991; McIntosh, 1990; Pharr, 1988; Richards & Bergin,
2005). The ethical principles of justice and respect
for peoples rights and dignity encourage LMHP to be
aware of discrimination and prejudice so as to avoid
condoning or colluding with the prejudices of others,
including societal prejudices. As a way to increase
awareness of their assumptions and promote the
rosoIufIon of fhoIr own conIcfs, !. !. WorfhIngfon,
Dillon, and Becker-Schutte (2005) advised LMHP to
develop their own competence surrounding sexual
orientation, sexual minorities, and heterosexual
rIvIIogo. Such comofonco roquIros soIf-roocfIon,
contact with diverse sexual minority communities, and
self-management of biases and sexual prejudice (cf.
Israel, Ketz, Detrie, Burke, & Shulman, 2003).
Several authors (e.g., Faiver & Ingersoll, 2005;
Lomax, Karff, & McKenny, 2002; Richards & Bergin,
2005; Yarhouse & Tan, 2005a; Yarhouse & VanOrman,
1999) have described potential ethical concerns related
to working with religious clients. LMHP can strive to be
aware of how their
own religious values
affect treatment
and can aspire to
focus on the clients
perspective and
aspire to become
informed about the
importance and
confonf of socIhc
religious beliefs and the psychology of religion (Bartoli,
2007; Yarhouse & VanOrman, 1999; Yarhouse &
Fisher, 2002). Yet, for LMHP, the goal of treatment
is determined by mental health concerns rather
than directed by religious values (Gonsiorek, 2004).
Although LMHP strive to respect religious diversity
and to be aware of the importance of religion to clients
worIdvIows, !MHI focus on scIonfIhc ovIdonco nnd
professional judgment in determining mental health
interventions (APA, 2008a; Beckstead, 2001; Glassgold,
2008; Haldeman, 2004; Yarhouse & Burkett, 2002).
Summary
The principles and standards of the 2002 Ethical
Principles for Psychologists and Code of Conduct most
relevant to working with sexual minorities who seek to
nIfor fhoIr soxunI orIonfnfIon nro (n) Insos for ScIonfIhc
and Professional Judgments (Standard 2.04) and
Comofonco (2.0l); (b) Ionohconco nnd onmnIohconco
(Principle A); (c) Justice (Principle D); and (d) Respect
for Peoples Rights and Dignity (Principle E). The key
scIonfIhc hndIngs roIovnnf fo fho ofhIcnI concorns fhnf
are important in the area of SOCE are the limited
ovIdonco of ofhcncy or bonohf nnd fho ofonfInI for
harm. LMHP are cautioned against promising sexual
orientation change to clients. LMHP are encouraged
fo consIdor nfhrmnfIvo fronfmonf ofIons whon cIIonfs
present with requests for sexual orientation change.
Such options include the therapeutic approaches
included in Chapter 6 and focus on supporting a clients
exploration and development of sexual orientation
identity, which provide realistic opportunities for
maximizing self-determination. These approaches
balance an understanding of the role of sexual stigma
and respect other aspects of diversity in a clients
exploration and maximize client self-determination.
/|o. |\| e o
eoec e|o. oe, oo
o oe owoe o| e moooce
o| e|o o c|e wo|oew
|\| |oc. o ce|c
eoece oo oo|eoo|
.ome oeem meo|
eo| eeo
71 'o ' .do /docot dd o. 'd..o
Task Force Charge
and Its Social Context
T
he task force was asked to report on three issues
for children and adolescents:
Tho nrorInfo nIIcnfIon of nfhrmnfIvo fhornoufIc 1.
interventions for children and adolescents who
present a desire to change either their sexual
orientation
54
on their behavioral expression of their
sexual orientation, or both, or whose guardian
expresses a desire for the minor to change.
The presence of adolescent inpatient facilities 2.
sexual orientation.
55

Recommendations regarding treatment protocols that 3.
promote stereotyped gender-normative behavior to
54
In fhIs roorf, wo dohno ndoIosconfs ns IndIvIdunIs bofwoon fho
ages of 12 and 18 and children as individuals under age 12. The age
of 18 was chosen because many jurisdictions in the United States use
this age as the legal age of majority, which determines issues such as
consent to treatment and other relevant issues.
55
Wo dohno coorcIvo fronfmonfs ns rncfIcos fhnf comoI or
manipulate a child or adolescent to submit to treatment through
the use of threats, intimidation, trickery, or some other form of
pressure or force. The threat of future harm leads to the cooperation
or obedience. Threats of negative consequences can be physical
or emotional, such as threats of rejection or abandonment from
or disapproval by family, community, or peer-group; engendering
feelings of guilt/obligation or loss of love; exploiting physical,
emotional, or spiritual dependence.
mitigate behaviors that are perceived to be indicators
that a child will develop a homosexual orientation in
adolescence and adulthood.
ThIs chnrgo roocfs roconf ovonfs nnd curronf socInI
context. Advocacy groups, both for and against sexual
orientation change efforts (SOCE), law journals, and
the media have reported on involuntary SOCE among
adolescents (Goishi, 1997; Morey, 2006; Sanchez, 2007;
Weithorn, 1998; Williams, 2005).
56
Publications by
LMHP directed at parents and outreach from religious
organizations advocate SOCE for children and youth
as interventions to prevent adult same-sex sexual
orientation (Cianciotto & Cahill, 2006; Kennedy &
Cianciotto, 2006; Nicolosi & Nicolosi, 2002; Rekers,
1982; Sanchez, 2007).
Reports by LGB advocacy groups (e.g., Cianciotto
& Cahill, 2006; Kennedy & Cianciotto, 2006) have
claimed that there has been an increase in attention
to youths by religious organizations that believe
that homosexuality is a mental illness or an adverse
developmental outcome. These reports further suggest
that there has been an increasing in outreach to
youths that portrays homosexuality in an extremely
negative light and uses fear and shame to fuel this
message. These reports expressed concern that such
efforts have a negative impact on adolescents and
their parents perceptions of their sexual orientation
56
Wo dohno InvoIunfnry fronfmonf ns fhnf whIch Is orformod
without the individuals consent or assent and may be contrary to
his or her expressed wishes. Unlike coercive treatment, no threats or
intimidation are involved.
8. ISSUES FOR CHILDREN,
ADOLESCENTS, AND THEIR FAMILIES
or potential sexual orientation, increase the perception
that homosexuality and religion are incompatible, and
increase the likelihood that some adolescents will be
exposed to SOCE without information about evidence-
based treatments.
One aspect of these concerns expressed by LGB
advocacy groups has been the presence of residential
programs in which adolescents have been placed by
their parents, in some cases with reported lack of
assent from the adolescent (e.g., Cianciotto & Cahill,
2006; Kennedy & Cianciotto, 2006). In addition, a
longstanding concern raised by advocacy groups for
both LGB people and transgender people has been the
alleged use of residential psychiatric commitment and
gender-normative behavioral treatments for children
and adolescents whose expression of gender or sexuality
violates gender norms (Goishi, 1997; Morey, 2006;
Weithorn, 1988).
To fuIhII our chnrgo, wo rovIowod fho IIfornfuro on
SOCI In chIIdron nnd ndoIosconfs nnd nfhrmnfIvo
psychotherapy for children, adolescents, and their
families. We considered the literature on best practices
in child and adolescent treatment, inpatient treatment,
and legal issues regarding involuntary or coercive
treatments and consent to and refusal of treatment.
We also reviewed the literature on the development of
sexual orientation in children and adolescents.
Literature Review
|eo.e o |oe
There is a lack of published research on SOCE among
children. Research on sexuality in childhood is limited
and seldom includes sexual orientation or sexual
orientation identity (Perrin, 2002). Although LGB
adults and others with same-sex sexual attractions
often report emotional and sexual feelings and
attractions from their childhood or early adolescence
and recall a sense of being different even earlier in
childhood (Beckstead & Morrow, 2004; Bell et al., 1981;
DAugelli & Hershberger, 1993; Diamond & Savin-
Williams, 2000; Troiden, 1989), such concerns have not
been studied directly in young children (cf. Bailey &
Zucker, 1995; Cohen & Savin-Williams, 2004).
There is no published research suggesting that
children are distressed about their sexual orientation
per se. Parental concern or distress about a childs
behavior, mental health, and possible sexual orientation
plays a central role in referrals for psychotherapy
(Perrin, 2002; Ryan & Futterman, 1997). Parents
may be concerned about behaviors in the child that
are stereotypically associated with a same-sex sexual
orientation (e.g., affection directed at another child
of the same sex, lack of interest in the other sex, or
behaviors that do not conform to traditional gender
norms) (American Academy of Pediatrics [AAP],
1999; Haldeman, 2000). This situation contrasts with
the condition of gender dysphoria in childhood and
adolescence, for which there is clear evidence that some
children and adolescents experience distress regarding
their assigned sex, and some experience distress with
the consequences of their gender and biological sex (i.e.,
youth struggling with social discrimination and stigma
surrounding gender nonconformity) (APA, 2008e;
Menveille, 1998; Menveille & Tuerk, 2002; R. Green,
1986, 1987; Zucker & Bradley, 1995).
Childhood interventions to prevent homosexuality
have been presented in non-peer-reviewed literature
(see Nicolosi & Nicolosi, 2002; Rekers, 1982).
57
These
interventions are based on theories of gender and
soxunI orIonfnfIon fhnf connfo sforoofyIc gondor roIos
or interests with heterosexuality and homosexuality
or that assume that certain patterns of family
relationships cause same-sex sexual orientation.
These treatments focus on proxy symptoms (such
as nonconforming gender behaviors), since sexual
orientation as it is usually conceptualized does not
emerge until puberty with the onset of sexual desires
and drives (see APA, 2002a; Perrin, 2002). These
interventions assume a same-sex sexual orientation
is caused by certain family relationships that form
gender identity and assume that encouraging gender
stereotypic behaviors and certain family relationships
will alter sexual orientation (Burack & Josephson, 2005;
see, e.g., Nicolosi & Nicolosi, 2002; Rekers, 1979, 1982).
The theories on which these interventions are based
hnvo nof boon conhrmod by omIrIcnI sfudy (IorrIn,
2002; Zucker, 2008; Zucker & Bradley, 1995). Although
retrospective research indicates that some gay men
and lesbians recall gender nonconformity in childhood
(Bailey & Zucker, 1995; Bem, 1996; Mathy & Drescher,
57
The only peer-reviewed literature is on children who exhibited
nonconformity with gender roles or gender identity disorder and did
not focus on sexual orientation (e.g., Rekers, 1979, 1981; Rekers,
Bentler, Rosen, & Lovaas, 1977; Rekers, Kilgus, & Rosen, 1990;
Rekers & Lovaas, 1974). However, the relevance of such work to
this topic is limited, as none of these children reported experiencing
same-sex sexual attractions or were followed into adulthood. Gender
nonconformity differs from gender identity disorder, and children
with gender identity disorder are not necessarily representative of
the larger population of those children who will experience same-sex
sexual attractions in adulthood (Bailey & Zucker, 1995; Bradley &
Zucker, 1998; Zucker, 2008).
2008), there is no research evidence that childhood
gender nonconformity and adult homosexuality are
identical or are necessarily sequential developmental
phenomena (Bradley & Zucker, 1998; Zucker, 2008).
Theories that certain patterns of family relationships
cause same-sex sexual orientation have been discredited
(Bell et al., 1981; Freund & Blanchard, 1983; R. R.
Green, 1987; D. K. Peters & Cantrell, 1991).
The research that has been attempted to determine
whether interventions in childhood affect adult sexual
orIonfnfIon oxIsfs onIy wIfhIn fho socIhc ouInfIon
of children with gender identity disorder (GID). R.
Green (1986, 1987) and Zucker and Bradley (1995)
(to a limited degree) examined prospectively whether
sychofhorny In chIIdron wIfh CI Inuoncod nduIf
or adolescent sexual orientation and concluded that
it did not (for a review of the issues for children with
GID, see APA, 2009, Report of the Task Force on Gender
Identity and Gender Variance). Thus, we concluded that
there is no existing research to support the hypothesis
that psychotherapy in children alters adult sexual
orientation.
|eo.e o /oo|ece
We found no empirical research on adolescents who
request SOCE, but there were a few clinical articles
reporting cases of psychotherapy with religious
adolescents (Cates, 2007; Yarhouse, 1998b; Yarhouse
& Tan, 2005a; Yarhouse et al., 2005) who expressed
confusion regarding their sexual orientation and
conIcfs bofwoon roIIgIous vnIuos nnd soxunI
orientation. In some of these cases, the adolescents or
their families sought SOCE or considered SOCE (Cates,
2007; Yarhouse
& Tan, 2005a;
Yarhouse et al.,
2005). The general
body of research
on adolescents who
identify themselves
as same-sex oriented
does not suggest
that the normal
development of a
same-sex sexual
orientation in adolescence is typically characterized by
distress that results in requests for sexual orientation
change (e.g., DAugelli, 2002; Garofalo & Harper, 2003;
Savin-Williams & Cohen, 2004).
The absence of evidence for adolescent sexual
orientation distress that results in requests for SOCE
and the few studies in the literature on religious
adolescents seeking psychotherapy related to sexual
orientation suggest that such distress is most likely
to occur among adolescents in families for whom
a religion that views homosexuality as sinful and
undesirable is important. Yarhouse (1998b) and
colleagues (Yarhouse & Tan, 2005a; Yarhouse, Brooke,
Pisano, & Tan, 2005) discussed clinical examples of
dIsfross cnusod by conIcfs bofwoon fnIfh nnd soxunI
orientation surrounding the incompatibility between
religious beliefs and LGB identities. For instance, a
female adolescent client struggled with guilt and shame
and fears that God would not love her, and a male
ndoIosconf oxorIoncod n conIcf bofwoon boIIovIng
God created him with same-sex feelings and believing
that God prohibited their expression (Yarhouse &
Tan, 2005a). Cates (2007) described three cases of
Caucasian males who were referred by schools, courts,
or parents for concerns that included their sexual
orientation. All three youths perceived that within
their faith community and family, an LGB identity was
unacceptable and would probably result in exclusion
and rejection (Cates, 2007). Because of the primacy
of religious beliefs, the adolescents or their families
requested religiously based therapy or SOCE. For
instance, Cates described the treatment of an adolescent
who belonged to the Old Amish Community and who
requested SOCE. The young man perceived that there
was no place for him in his faith community as a gay
man and did not want to leave that community.
|eeoc o |oe oce
/oo. e |oe e.o| eoo
Wo dId nof hnd socIhc rosonrch on fho chnrncforIsfIcs
of parents who bring their children to SOCE. Thus,
we do not know whether this population is similar
to or different from the more general population
of parents who may have concerns or questions
regarding their childrens sexual orientation or future
sexual orientation. We cannot conclude that parents
who present to LMHP with a request for SOCE are
motivated by factors that cause distress in other parents
of adolescents with emerging LGB identities.
In the small samples represented by articles on case
studies and clinical papers, parents religious beliefs
appear to be factors in their request of SOCE for their
children. For instance, in clinical case discussions and
e eeo| ooo, o| eeoc
o ooo|ece wo oe|,
eme|e o omee
oeeo ooe o .e o
e omo| oee|oome o| o
omee e.o| oeoo
ooo|ecece ,oco||,
coocezeo o, oe o
e.| eo.e |o e.o|
oeoo coe
psychotherapy articles, Cates (2007), Yarhouse (1998b),
Yarhouse and Tan (2005a), and Yarhouse et al. (2005)
IdonfIhod n ouInfIon of nronfs who hnvo sfrong
conservative religious beliefs that reject LGB identities
and perceive homosexuality as sinful.
Other reports suggest that parents of adolescents with
emerging same-sex sexual orientation and conservative
religious beliefs that perceive homosexuality negatively
nonr fo bo Inuoncod by roIIgIous nufhorIfIos nnd
LMHP who promote SOCE. For instance, Burack and
Josephson (2005) and Cianciotto and Cahill (2006)
reported that fear and stereotypes appeared to be
contributing factors in parents who resort to residential
SOCE or other related coercive treatment on youth.
Cianciotto and Cahill found that some advocacy groups
do outreach to parents that encourages commitment
to SOCE residential programs even if the children do
not assent. These programs also appear to provide
information to parents that stresses that sexual
orientation can be changed (Burack & Josephson, 2005;
Cianciotto & Cahill, 2006), despite the very limited
empirical evidence for that assertion.
|eoeo| oo |ooe ece
Wo woro nskod fo roorf on fho rosonco of ndoIosconf
inpatient facilities that offer coercive treatment
designed to change sexual orientation or the behavioral
expression of sexual orientation. We performed a
thorough review of the literature on these programs.
Upon completion of this review, we decided that the
best way to address this task was to evaluate issues of
the appropriateness of these programs for adolescents
In IIghf of Issuos of hnrm nnd bonohf bnsod on fho
literature on adolescent development, standards for
inpatient and residential treatment, and ethical issues
such as informed consent.
There are several accounts of inpatient and
residential treatment, sometimes involuntary or
coorcod, for ndoIosconfs who woro !CI-IdonfIhod,
confused or questioning their sexual orientation, gender
nonconforming, or transgender (Arriola, 1998; Burack &
Josephson, 2005; Goishi, 1997; Molnar, 1997; Weithorn,
1988). These incidents mostly occurred because the
parent or guardian was distressed regarding the childs
actual sexual orientation or potential and perceived
sexual orientation. An account of an adolescent boy who
was placed in a program sponsored by Love in Action,
a religious-based program, was reported widely in the
press (Williams, 2005). This program was reported
to focus on religious approaches to SOCE as well as
approaches that stress conformity to traditional gender
roles and behaviors.
Concerns have arisen over the conduct of some
private psychiatric hospitals that use alternative
diagnosessuch as GID, conduct disorders, oppositional
dohnnf dIsordors, or bohnvIors IdonfIhod ns soIf-
defeating or self-destructiveto justify hospitalization
of LGB and questioning youth and expose adolescents
to SOCE (Arriola, 1998; Morey, 2006). Data on these
issues are incomplete, as each state has different
reporting requirements for public and private hospitals,
nnd Inws rognrdIng conhdonfInIIfy undorsfnndnbIy
protect client information.
/''--` '' `-`
'-/'-`
In researching involuntary treatment, we reviewed the
recent literature on the growing movement to increase
adolescents rights to
consent to outpatient
and inpatient mental
health treatment so as
to reduce involuntary
hospitalization
(Mutcherson, 2006;
Redding, 1993). It
is now recognized that adolescents are cognitively
able to participate in some health care treatment
decisions, and such participation is helpful (Hartman,
2000, 2002; Mutcherson, 2006; Redding, 1993). The
APA Guidelines for Psychotherapy for Lesbian, Gay,
and Bisexual Clients (2000) and the APA Ethics Code
(2002b) encourage professionals to seek the assent
of mInor cIIonfs for fronfmonf. WIfhIn fho hoId of
adolescent mental health and psychiatry, there are
developmental assessment models to determine an
adolescents competence to assent or consent to and
potentially refuse treatment (Forehand & Ciccone, 2004;
Redding, 1993; Rosner, 2004a, 2004b). Some states now
permit adolescents some rights regarding choosing or
refusing inpatient treatment, participating in certain
interventions, and control over disclosure of records
(Koocher, 2003).
'`'/'-` '-/'-`
The use of inpatient and residential treatments for
SOCE is inconsistent with the recommendations of the
hoId. Ior Insfnnco, fho AmorIcnn Acndomy of ChIId
and Adolescent Psychiatry (1989) recommended that
inpatient treatment, when it does occur, be of the
| ow ecozeo o
ooo|ece oe coe|,
oo|e o oocooe
ome eo| coe eome
oeco oo .c
oocooo e|o|.|
shortest possible duration and reserved for the most
serious psychiatric illnesses, such as those of a psychotic
nature or where there is an acute danger to self or
others. For less serious mental health conditions, the
Academy recommended that inpatient hospitalization
occur only after less restrictive alternatives (i.e.,
outpatient and community resources) are shown to
be ineffective. In Best Practice Guidelines: Serving
LGBT Youth in Out-of-Home Care (Wilber, Ryan, &
Marksamer, 2006), the Child Welfare League of America
recommended that, if necessary, hospitalization or
residential substance abuse treatment for adolescents
be in a setting that provides mental health treatments
fhnf nro nfhrmnfIvo of !CI ooIo nnd for whIch fho
staff is competent to provide such services. Further, in
a review of the psychiatric literature, Weithorn (1988)
concluded that the deprivation of normal social contacts
and prevention of attendance at school and other normal
social settings can be harmful as well as punitive.
'''/' \' '-'''' /'''''/'`
Programs sponsored by religious groups, such as Love
in Actions program, Refuge,
58
provide religiously
based interventions that claim to change sexual
orientation, control sexual behavior, or prevent the
development of same-sex sexual orientation. The
interventions have been marketed to parents in this
way (Burack & Josephson, 2005; Sanchez, 2007;
Williams, 2005). Because they are religious in nature
and are not explicitly mental health facilities,
59
many
of these programs are not licensed or regulated by
state authorities. Burack and Josephson reported
that there was effort by religious organizations and
sponsors of these programs to communicate to parents
that homosexuality is abnormal and sinful and could
be changed.
60
Such religious organizations, according
to the authors of the report, encouraged parents to
seek treatment for their children. Based on anecdotal
accounts of current and past residents, these programs,
fo Inuonco ndoIosconfs` IIfo docIsIons, nIIogodIy usod
fear and even threats about negative spiritual, health,
and life consequences and thus are viewed as coercive
(Burack & Josephson, 2005; Sanchez, 2007).
58
Tho rogrnm !ofugo, dIrocfod nf ndoIosconfs, wns cIosod In 200?
and is no longer advertised. However, Love in Action still sponsors
residential programs for adults.
59
Thoso rogrnms ndvorfIso hoIIng wIfh nddIcfIon, nognfIvo soIf-
talk and irrational belief systems, and behavior change (see www.
loveinaction.org/default.aspx?pid=91).
60
See www.loveinaction.org/default.aspx?pid=122
To provide an overview of the issues with residential
programs for youth, we reviewed information gathered
by the APA (2002a) Committee on Children, Youth, and
Families in collaboration with the APA State Advocacy
Ofhco nnd fho fosfImony nnd subsoquonf ubIIshod
report by members of the U.S. General Accounting
Ofhco boforo fho CommIffoo on IducnfIon nnd !nbor of
the U.S. House of Representatives (Kutz & OConnell,
2007). These reports and testimony evaluated some
current problems in adolescent residential mental
health care. There are a large number of unlicensed and
unregulated programs marketed to parents struggling
fo hnd bohnvIornI or monfnI honIfh rogrnms for fhoIr
adolescent children. Although many of these programs
avoid regulation by not identifying themselves as
mental health programs, they do advertise mental
health, behavioral, and/or educational goals, especially
for those youth perceived as troubled by their parents.
Many of these programs are involuntary and coercive
and use seclusion or isolation and escort services to
transport unwilling youth to program locations (Kutz &
OConnell, 2007). The testimony and report described
the negative mental health impacts of these programs
and expressed grave concerns about them, including
questions about quality of care and harm caused by
coercive or involuntary measures (Kutz & OConnell,
2007).
Thus, residential and outpatient programs that
are involuntary and coercive and provide inaccurate
scIonfIhc InformnfIon nbouf soxunI orIonfnfIon or nro
excessively fear-
based pose both
clinical and ethical
concerns, whether
or not they are
based on religious
doctrine. Although
religious doctrines
themselves are
not the purview of
psychologists, how
religious doctrine
is inculcated
through educational
and socialization
practices is a
psychological issue
and an appropriate subject of psychological examination,
especially if there are concerns regarding substantiation
of bonohf or hnrm, unIIconsod nnd unroguInfod fncIIIfIos,
and coercive and involuntary treatment.
/|o. e|o. ooce
eme|e oe o e o.ew
o| o,co|o ow e|o.
ooce c.|coeo o.
eo.cooo| oo oco|zoo
oocce o o,co|oco|
.e oo o ooooooe
.oec o| o,co|oco|
eomoo eoeco||, |
ee oe coce eoo
.oooo o| oee| o om
.|ceeo oo .e.|oeo
|oc|e oo coece oo
o|.o, eome
As nofod onrIIor, wo dohno coorcIvo fronfmonfs ns
practices that compel or manipulate an individual
to submit to treatment through the use of threats,
intimidation, manipulation, trickery, or some other
form of pressure, including threats of future harm.
Harm can be physical or psychological. Harmful
psychological consequences include disapproval; loss of
love; rejection or abandonment by family, community, or
peer group; feelings of guilt/obligation; and exploitation
of physical, emotional, or spiritual dependence.
Coercive and involuntary treatment present ethical
dilemmas for providers working with many clients
(APA, 2002b; Beauchamp & Childress, 2008; Davis,
2002); however, with children and adolescents, such
concerns are heightened (Molnar, 1997; Weithorn,
1988). Children and adolescents are more vulnerable to
such treatments because of the lack of legal rights and
cognitive and emotional maturity and emotional and
physical dependence on parents, guardians, and LMHP
(Molnar, 1997; Weithorn, 1988). The involuntary nature
of particular programs raises issues similar to those
of other involuntary mental health settings; however,
because they are religious programs, not mental health
programs, they pose complex issues for licensure and
regulation (Williams, 2005). Given ethical imperatives
that stress maximizing autonomous decision making
and self-determination (APA, 2002b; Beauchamp &
Childress, 2008), LMHP should strive to maximize
autonomous decision making and self-determination
and avoid coercive and involuntary treatments.
Appropriate Application of
A||ad|ve |eve|o w|'
Children and Adolescents
\.|c.|.o| oo |eeeeo
/ooooce |o /oo|ece
A number of researchers and practitioners have
advised LMHP that when working with children or
adolescents and their families, they should address
concerns regarding sexual orientation and base their
interventions on the current developmental literature
on children and adolescents and the scholarly literature
on parents responses to their childs sexual orientation
(e.g., Ben-Ari, 1995; Bernstein, 1990; Holtzen &
Agriesti, 1990; Mattison & McWhirter, 1995; Perrin,
2002; Ryan, Huebner, Diaz, & Sanchez, 2009; Salzburg,
2004, 2007; Yarhouse & Tan, 2005a).
61
This literature
recommends that LMHP learn about the law and
scholarship on developmental factors in informed
consent and take steps to ensure that minor clients
have a developmentally appropriate understanding
of treatment, are afforded complete information
about their rights, and are provided treatment in the
least restrictive environment. LMHP can review the
recommendations for assent to treatment recommended
in the Guidelines for Psychotherapy for Lesbian,
Gay, and Bisexual Clients (APA, 2000) and can seek
an adolescents consent consistent with evolving
considerations of developmental factors (Forehand &
Ciccone, 2004; Redding, 1993; Rosner, 2004a, 2004b).
APA policies (APA, 1993, 2000) and the vast majority
of current publications on therapy for LGB and
questioning adolescents who are concerned about their
sexual orientation recommend that LMHP support
adolescents exploration of identity by
accepting homosexuality and bisexuality as normal :
and positive variants of human sexual orientation,
accepting and supporting youths as they address the :
stigma and isolation of being a sexual minority,
using person-centered approaches as youths :
explore their identities and experience important
developmental milestones (e.g., exploring sexual
values, dating, and socializing openly),
ameliorating family and peer concerns (e.g., APA, :
2000, 2002a; DAugelli & Patterson, 2001; Floyd &
Stein, 2002; Fontaine & Hammond, 1996; Hart &
Heimberg, 2001; Hetrick & Martin, 1987; Lemoire
& Chen, 2005; Mallon, 2001; Martin, 1982; Perrin,
2002; Radkowsky & Siegel, 1997; Ryan, 2001; Ryan
et al., 2009; Ryan & Diaz, 2005; Ryan & Futterman,
1997; Schneider, 1991; Slater, 1988; Wilber, Ryan &
Marksamer, 2006; Savin-Williams & Cohen, 2004;
Yarhouse & Tan, 2005a).
When sexual minority and questioning youth require
residential or inpatient treatment for mental health,
behavioral, or family issues, it has been recommended
that such treatment be safe from discrimination and
rojudIco nnd nfhrmIng of soxunI orIonfnfIon dIvorsIfy
61
Due to the limited research on children, adolescents, and families
who sook SOCI, our rocommondnfIons for nfhrmnfIvo fhorny
for children, youth, and their families distressed about sexual
orientation are based on general research and clinical articles
nddrossIng fhoso nnd ofhor Issuos, nof on rosonrch socIhc fo fhoso
who socIhcnIIy roquosf SOCI. Wo ncknowIodgo fhnf IImIfnfIon In
our recommendations.
by staff who are knowledgeable about LGB identities
and life choices (Mallon, 2001; Wilber et al., 2006).
Other aspects of human diversity, such as age,
gender, gender identity, race, ethnicity, culture,
national origin, religion, disability, language, and
socioeconomic status, may be relevant to an adolescents
identity development, and these differences may
intersect with sexual orientation identity (Diamond
& Savin-Williams, 2000; Rosario, Rotheram-Borus,
& Reid, 1996; Rosario, Scrimshaw, & Hunter, 2004;
Rosario, Schrimshaw, Hunter, & Braun, 2006). Some
ndoIosconfs nro moro comforfnbIo wIfh uId or oxIbIo
identities due to gender differences and generational or
developmental concerns, and their sexual orientation
identities may not be exclusive or dichotomous
(Diamond, 2006; Morgan & Thompson, 2006; Savin-
Williams, 2005).
OnIy n fow nrfIcIos nddrossod fho socIhc conIcfs
between religious identities and sexual orientation
identities among youth (Cates, 2007; Yarhouse, 1998b;
Yarhouse & Tan, 2005a). For instance, Yarhouse and
Tan proposed solutions that respect religious beliefs
and emphasized nondirective exploration of religious
and sexual orientation identity that do not advocate
a particular sexual orientation identity outcome. As
adolescents may experience a crisis of faith and distress
linked to religious and spiritual beliefs, the authors
explored interventions that integrate the psychology
of religion into interventions that stress improving the
clients positive religious coping and relationship with
the sacred (e.g., Exline, 2002; Pargament & Mahoney,
2005; Pargament et al., 1998, 2005). Cates (2007), from
a more secular frame, emphasized a client-centered
approach that stresses the LMHPs unconditional
acceptance of the client and client choices even if the
client cannot accept his or her own sexual orientation.
The ethical issues outlined in Chapter 7 are also
relevant to children and adolescents; however, working
with adolescents presents unique ethical dilemmas to
LMHP (Koocher, 2003). Children and adolescents are
often unable to anticipate the future consequences of
n courso of ncfIon nnd nro omofIonnIIy nnd hnnncInIIy
dependent on adults. Further, they are in the midst of
developmental processes in which the ultimate outcome
is unknown. Efforts to alter that developmental path
may have unanticipated consequences (Perrin, 2002).
LMHP should strive to be mindful of these issues,
particularly as these concerns affect assent and consent
to treatment and goals of treatment (Koocher, 2003;
Rosner, 2004a, 2004b; Sobocinski, 1990). Possible
nronchos IncIudo oon-ondod nnd scIonfIhcnIIy bnsod
age-appropriate exploration with children, adolescents,
and parents regarding these issues.

\.|c.|.o| oo |eeeeo
/ooooce |o |oe oo |om|e
InronfnI nffIfudos nnd bohnvIors Iny n sIgnIhcnnf roIo
in childrens and adolescents adjustment (Radkowsky
& Siegel, 1997; Ryan & Diaz, 2005; Ryan et al., 2009;
Savin-Williams,
1989b, 1998;
Wilber et al., 2006;
Yarhouse, 1998b).
One retrospective
research study of
adults indicated
that LGB children are more likely to be abused by
their families than by nonrelated individuals (Corliss,
Cochran, & Mays, 2002). Another found that family
rejection is a key predictor of negative health outcomes
in White and Latino LGB young adults (Ryan,
Huebner, Diaz, & Sanchez, 2009). Reducing parental
rejection, hostility, and violence (verbal or physical)
may contribute to the mental health and safety of the
adolescent (Remafedi et al., 1991; Ryan et al., 2009;
Savin-Williams, 1994; Wilber et al., 2006). Further, to
Imrovo nronfs` rosonsos, !MHI nood fo hnd wnys
to ameliorate parents distress about their childrens
sexual orientation. Exploring parental attributions
and values regarding same-sex sexual orientation is
especially important in order to facilitate engagement in
treatment, resolution of ethical dilemmas, and increase
of ofonfInI bonohfs of sychofhorny (MorrIsoy-Knno &
Prinz, 1999; Sobocinski, 1990).
Family therapy for families who are distressed
by their childs sexual orientation may be helpful
in facilitating dialogues, increasing acceptance
and support, reducing rejection, and improving
mnnngomonf of conIcfs or mIsInformnfIon fhnf
may exacerbate an adolescents distress (Mattison &
McWhirter, 1995; Ryan et al., 2009; Salzburg, 2004,
2007). Such therapy can include family psychoeducation
to provide accurate information and teach coping
skills and problem-solving strategies for dealing more
effectively with the challenges sexual minority youth
may face and the concerns the families and caretakers
may have (Ben-Ari, 1995; Perrin, 2002; Ryan & Diaz,
2005; Ryan & Futterman, 1997; Ryan et al., 2009;
Salzburg, 2004, 2007; Yarhouse, 1998b). Ryan and
Futterman (1997) termed this anticipatory guidance:
|eo.c ooeo| eeco
o|, oo o|ece (eoo|
o o,co|) mo, coo.e o
e meo| eo| oo o|e,
o| e ooo|ece
the LMHP provides family members with accurate
information regarding same-sex sexual orientation
and dispels myths regarding the lives, health, and
psychological well-being of LGB individuals.
Perrin (2002) recommended that when working
with families of preadolescent children, LMHP
counsel parents who are concerned that their young
children may grow up to be lesbian or gay to tolerate
the ambiguity inherent in the limited knowledge of
development. In addition, Perrin suggested a two-
prong approach: (a) Provide information to reduce
heterosexism within the family and increase the
familys capacity to provide support and (b) introduce
information about LGB issues into family discussions to
aid the childs own self-awareness and self-acceptance
and to counter stigma. For adolescents, Ryan et al.
(2009) recommended that LMHP assess family reactions
fo !CI youfh, socIhcnIIy fho rosonco of fnmIIy
rejection. Further, the authors advocated attempting
to modify highly rejecting behaviors, providing
anticipatory guidance to families that includes
recommendations for support on the part of the family,
and explaining the link between family rejection and
negative health problems in children and adolescents.
Families with strong religious beliefs that condemn
homosexuality may struggle with a childs same-sex
sexual orientation (Cates, 2007; Yarhouse, 1998b;
Yarhouse & Tan, 2005a). Yarhouse and Tan (2005a)
suggested that family therapy reframe the religious
beliefs to focus on aspects of faith that encourage love
and acceptance of their child rather than on a religions
prohibitions. The authors stressed that these positive
elements of faith can lay a constructive foundation for
communication and problem solving and reduce family
discord and rejection (Yarhouse & Tan, 2005a, p. 534).
Providing anticipatory guidance to parents to address
their unique personal concerns can be helpful (Ryan
& Futterman, 1997). The LMHP can help the parents
Inn In nn nfhrmnfIvo wny for fho unIquo IIfo chnIIongos
that they may face as parents of a sexual minority child.
Parents must deal with their own unique choices and
rocoss of comIng ouf nnd rosoIvo fonrs of onncfod
stigma if they risk disclosure within their communities,
at work, and to other family members (Bernstein, 1990).
Further, the LMHP can address other stresses, such as
managing life celebrations and transitions and coping
with feelings of loss, and aid parents in advocating for
their children in school situationsfor example, when
they face bullying or harassment. Multiple family
groups led by LMHP might be helpful to counter the
isolation that many parents experience (Menveille &
Tuerk, 2002).
omm., /ooooce |o |oe
/oo|ece oo |om|e
Research has illuminated the potential that school-
based and community interventions have for increasing
safety and tolerance of sexual minorities, preventing
distress and negative mental health consequences,
and increasing the psychological well-being and health
of sexual minority youth (APA, 1993; DAugelli &
Patterson, 2001; Goodenow, Szalacha, & Westheimer,
2006; Harper, Jamil, & Wilson, 2007; Kosciw & Diaz,
2006; A. J. Peters, 2003; Roffman, 2000; Safren &
Heimberg, 1999; Schneider, 1991; Treadway & Yoakum,
1992). For instance, sexual minority adolescents in
schools with support groups for LGB students reported
lower rates of suicide attempts and victimization
than those without such groups (Goodenow et al.,
2006; Kosciw & Diaz, 2006; Szalacha, 2003). Kosciw
and Diaz (2006) found that such support groups were
related to improved academic performance and college
attendance. The support groups that were examined in
fho rosonrch rovIdod nccurnfo nfhrmnfIvo InformnfIon
and social support, and the groups presence was also
related to increased school tolerance and safety for LGB
youth (Goodenow et al., 2006; Kosciw & Diaz, 2006;
Szalacha, 2003). School policies that increased staff
support and positive school climate have been found
to moderate suicidality and to positively affect sexual
minority youth school achievement and mental health
(Goodenow et al., 2006).
School and community interventions have the
potential for introducing other sources of peer and adult
support that may buffer children and adolescents from
rejection that may occur in certain family, community,
and religious contexts. These school and community
interventions may provide alternative sources of
information regarding LGB identities and lives.
However, such school and community interventions are
unlikely to directly affect the core attitudes and beliefs
of the religious institutions and communities in which
sexual orientation distress and family rejection might
occur. These programs may have an indirect effect on
communities and religious institutions because of their
potential to change the general social context in which
fnmIIIos donI wIfh conIcfs bofwoon fhoIr chIIdron`s
emerging sexual orientations and identities. We hope
that such change will reduce the level of psychological
dIsfross fhnf such conIcfs bofwoon roIIgIon nnd
sexuality create and reduce the level of hostility and
punitiveness to which some children and adolescents
are exposed as a result of their sexual orientation.
For families, groups such as Parents, Families,
and Friends of Lesbians and Gays (PFLAG) and the
Straight Spouse Network may also provide a safe,
nonjudgmental space in which to discuss their concerns,
receive accurate information, reduce isolation, and
reduce feelings of perceived stigma (Goldfried &
Goldfried, 2001). PFLAG offers extensive literature for
nronfs bnsod on nfhrmnfIvo nronchos fo snmo-sox
sexual attractions as well as a nationwide network of
support groups. Such groups, by providing alternative
sources of information, could reduce the distress for
parents and increase family support of their sexual
minority children, thus positively affecting sexual
minority youth and children whose families are
concerned about their future sexual orientation.
Inronfs who nro roIIgIous mny bonohf from hndIng
support through religious organizations and groups.
One concern is that some groups may provide parents
with information that presents same-sex sexual
orIonfnfIon In n nognfIvo IIghf (o.g., dofocfIvo, brokon),
which could increase stigma and rejection of children
and adolescents; thus, such groups should rarely
be considered. Alternatively, some groups provide
rosourcos fhnf nro bofh !CI nfhrmIng nnd roIIgIous.
62

Conclusion
We were asked to report on three issues for children
and adolescents. First, we were asked to provide
recommendations regarding treatment protocols that
attempt to prevent homosexuality in adulthood by
promoting stereotyped gender-normative behavior in
children to mitigate behaviors that are perceived to
be indicators that a child will develop a homosexual
orientation in adolescence and adulthood. We found
no empirical evidence that providing any type of
therapy in childhood can alter adult same-sex sexual
orientation. Some advocates of these treatments see
homosexuality as a mental disorder, a concept that has
been rejected by the mental health professions for more
than 35 years. Further, the theories that such efforts
nro bnsod on hnvo nof boon corrobornfod by scIonfIhc
evidence or evaluated for harm. Thus, we recommend
62
Soo, o.g., InmIIy IoIIowshI (www.IdsfnmIIyfoIIowshI.org/) for
parents who belong to the Church of Jesus Christ of Latter-Day
Saints. The Institute of for Sexual Orientation and Judaism also lists
resources: www.huc.edu/ijso/.
that LMHP avoid
such efforts and
provide instead
multicultural,
client-centered,
nnd nfhrmnfIvo
treatments
that are
developmentally appropriate (Perrin, 2002).
Second, we were asked to comment on the presence
of adolescent inpatient facilities that offer coercive
treatment designed to change sexual orientation or
the behavioral expression of sexual orientation. We
found that serious questions are raised by involuntary
and coercive interventions and residential centers
for adolescents due to their advocacy of treatments
fhnf hnvo no scIonfIhc bnsIs nnd ofonfInI for hnrm
due to coercion, stigmatization, inappropriateness of
treatment level and type, and restriction of liberty.
Although the prevalence of these treatment centers is
unknown, we recommend that some form of oversight
be established for such youth facilities, such as
licensure and monitoring, especially as a means of
reporting abuse or neglect.
States have different requirements and standards
for obtaining informed consent to treatment for
adolescents; however, it is recognized that adolescents
are cognitively able to participate in some health care
treatment decisions and that such participation is
helpful. We recommend that when it comes to treatment
that purports to have an impact on sexual orientation,
LMHP assess the adolescents ability to understand
treatment options, provide developmentally appropriate
informed consent to treatment that is consistent with
the adolescents level of understanding, and, at a
minimum, obtain the youths assent to treatment. SOCE
that focus on negative representations of homosexuality
and lack a theoretical or evidence base provide no
documonfod bonohfs nnd cnn oso hnrm fhrough
increasing sexual stigma and providing inaccurate
information. We further concluded that involuntary or
coercive residential or inpatient programs that provide
SOCE to children and adolescents may pose serious
rIsk of hnrm, nro ofonfInIIy In conIcf wIfh ofhIcnI
imperatives to maximize autonomous decision making
and client self-determination, and have no documented
bonohfs. Thus, wo rocommond fhnf nronfs, gunrdInns,
or youth not consider such treatments.
Finally, we were asked to report on the appropriate
for children and adolescents who present a desire to
ome ooocoe o| ee
eome ee omoe.o|, o
o meo| oooe o coceo
o o oee eeceo o, e
meo| eo| oo|eo |o
moe o ,eo
change their sexual orientation or their behavioral
expression of their sexual orientation, or both, or whose
guardian expresses a desire for the minor to change.
We recommend
that LMHP provide
multiculturally
competent and
client-centered
therapies
to children,
adolescents, and their families rather than SOCE. Such
approaches include an awareness of the interrelatedness
of multiple identities in individual development as
well an understanding of cultural, ethnic, and religious
vnrInfIon In fnmIIIos. SocIhc nronchos cnn IncIudo (n)
supporting children and youth in their developmental
processes and milestones, (b) reducing internalized
stigma in children and sexual stigma in parents, and
(c) rovIdIng nfhrmnfIvo InformnfIon nnd oducnfIon
on LGB identities and lives. These approaches would
support children and youth in identity exploration and
development without seeking predetermined outcomes.
Interventions that incorporate knowledge from the
psychology of religion and that increase acceptance,
love, and understanding among individuals, families,
and communities are recommended for populations
for whom religion is important. Family therapy that
provides anticipatory guidance to parents to increase
their support and reduce rejection of children and
youth addressing these issues is essential. School and
community interventions are also recommended to
reduce societal-level stigma and provide information
and social support to children and youth.
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81 Summary and Conclusions
A
PAs charge to the task force included three major
tasks that this report addresses. First, the task
force was asked to review and update the 1997
resolution on Appropriate Therapeutic Responses to
Sexual Orientation (APA, 1998). Second, the task force
was asked to report on the following:
Tho nrorInfo nIIcnfIon of nfhrmnfIvo fhornoufIc :
interventions for children and adolescents who
present a desire to change either their sexual
orientation or their behavioral expression of their
sexual orientation, or both, or whose guardian
expresses a desire for the minor to change.
Tho nrorInfo nIIcnfIon of nfhrmnfIvo fhornoufIc :
interventions for adults who present a desire to
change their sexual orientation or their behavioral
expression of their sexual orientation, or both.
The presence of adolescent inpatient facilities :
sexual orientation.
Education, training, and research issues as they :
Recommendations regarding treatment protocols that :
promote stereotyped gender-normative behavior to
mitigate behaviors that are perceived to be indicators
that a child will develop a homosexual orientation in
adolescence and adulthood.
Third, the task force was asked to inform APAs
response to groups that promote treatments to change
sexual orientation or its behavioral expression and
fo suorf ubIIc oIIcy fhnf furfhors nfhrmnfIvo
therapeutic interventions.
The substance of the second task has been achieved
in the preceding chapters of this report. In Chapters 3
nnd 4, wo rovIowod fho body of rosonrch on fho ofhcncy
and safety of sexual orientation change effort (SOCE).
In Chapter 5 we addressed the nature of distress and
IdonfIhod conIcfs In nduIfs fhnf rovIdo fho bnsIs of
our rocommondnfIons for nfhrmnfIvo nronchos for
psychotherapy practice that are described in Chapter 6.
Chapter 7 discusses ethical issues in SOCE for adults.
In Chapter 8, we considered the more limited body of
research on children and adolescents, including a review
of SOCI wIfh chIIdron nnd ndoIosconfs nnd nfhrmnfIvo
approaches for psychotherapy.
In fhIs hnnI chnfor, wo summnrIzo fho roorf nnd
address those two tasksone and threethat have not
been addressed in the report so far. With regard to the
policy, we recommend that the 1997 policy be retained
and that a new policy be adopted to complement it. The
new policy that we propose is presented in Appendix A.
With regard to APAs response to groups that advocate
for SOCE, we provide those recommendations at the
end of this chapter in the section on policy.
To achieve the charge given by APA, we decided to
conduct a systematic review of the empirical literature
on SOCE. This review covered the peer-reviewed

9. SUMMARY AND CONCLUSIONS
journal articles in English from 1960 to 2007.
63
The
review is reported in Chapters 3 and 4: Chapter 3
addresses methodological issues in the research and
Chapter 4 addresses the outcomes, such as safety,
ofhcncy, bonohf, nnd hnrm of fho SOCI.
We also reviewed the recent literature on the
psychology of sexual orientation. There is a growing
body of literature that concludes that social stigma,
known socIhcnIIy ns soxunI sfIgmn, mnnIfosfod ns
prejudice and discrimination directed at same-sex
sexual orientations and identities, is a major source
of stress for sexual minorities. This stress, known as
minority stress, is a major cause of the mental health
disparities of sexual minorities. On the basis of this
literature, we recommend that all interventions and
policy for these populations include efforts to mitigate
minority stress and reduce stigma.
Further, we found that religious individuals with
beliefs that homosexuality is sinful and morally
unacceptable are prominent in the population that
currently undergoes SOCE. These individuals seek
SOCE because the disapproving stance of their faiths
fownrd homosoxunIIfy roducos conIcfs nmong fhoIr
beliefs and values and their sexual orientation. These
conIcfs rosuIf In sIgnIhcnnf dIsfross duo fo cIIonfs`
perceptions that they are unable to integrate their faith
and sexual orientation. To respond as well as possible to
this population, we included in our review some of the
empirical and theoretical literature from the psychology
of religion, recently adopted APA policies on religion
nnd scIonco, nnd socIhc InforvonfIons fhnf hnvo boon
proposed in the literature for religious populations.
SOCE has been quite controversial, and the
controversy has
at times become
polemical because
of clashes between
differing political
viewpoints
about LGB
individuals and
communities and the differing values between some
fnIfh-bnsod orgnnIznfIons nnd scIonfIhc nnd rofossIonnI
organizations (Drescher, 2003; Zucker, 2008).
Psychology, as a science, and various faith traditions, as
theological systems, can acknowledge and respect their
63
The articles in English include material on populations outside
the United States, including Canada, Mexico, Western Europe, and
some material on Middle Eastern, South Asian, and East Asian
populations. No articles based on new research have been published
since 2007. One article published in 2008 is a restatement of Schaeffer
et al. (2000).
profoundly different methodological and philosophical
vIowoInfs. Tho AIA hns nfhrmod fhnf rovon mofhods
of scIonfIhc InquIry nro fho bosf mofhods fo oxIoro
and understand human behavior and are the basis
for the associations policies (APA, 2007a, 2008a). The
AIA nfhrms fhnf dIscrImInnfIon dIrocfod nf roIIgIons
and their adherents or derived from religious beliefs
is unacceptable and that religious faith should be
respected as an aspect of human diversity (APA, 2008a).
Summary of the Systematic
Review of the Literature
To fuIhII fho chnrgo gIvon by AIA, wo undorfook n
systematic review to address the key questions: What
nro fho oufcomos of SOCI nnd fhoIr ofonfInI bonohfs
and harms? What is the evidence on whether SOCE
Is offocfIvo or snfo Tho hrsf sfo wns fo ovnIunfo fho
research to determine if such conclusions could be
drawn from the researchin other words, was the
research performed with the appropriate degree of
methodological rigor to provide such answers? The next
question was to determine, if such research existed,
what answers it provided.
|||coc, oo o|e,
Wo found fow scIonfIhcnIIy rIgorous sfudIos fhnf couId
be used to answer the questions regarding safety,
ofhcncy, bonohf, nnd hnrm (o.g., IIrk of nI., l9?l; S.
James, 1978; McConaghy, 1969, 1976; McConaghy et
al., 1972; Tanner, 1974, 1975). Few studies could be
considered true experiments or quasi-experiments that
would isolate and control the factors that might effect
change (see the list of studies in Appendix B). These
studies were all conducted in the period from 1969 to
1978 and used aversive or other behavioral methods.
Recent SOCE differ from those interventions
explored in the early research studies. The recent
nonreligious interventions are based on the assumption
that homosexuality and bisexuality are mental
dIsordors or dohcIfs nnd nro bnsod on oIdor dIscrodIfod
psychoanalytic theories (e.g., Socarides, 1968; see
American Psychoanalytic Association, 1991, 1992, 2000;
Drescher, 1998a; Mitchell, 1978, 1981). Some focus on
increasing behavioral consistency with gender norms
and stereotypes (e.g., Nicolosi, 1991). None of these
nronchos Is bnsod on n crodIbIo scIonfIhc fhoory,
as these ideas have been directly discredited through
evidence or rendered obsolete. There is longstanding
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meoo o| ce|c o., oe
e oe meoo o eo|oe
oo .oeoo .mo oeoo
oo oe e oo |o e
oocoo oo|ce
scIonfIhc ovIdonco fhnf homosoxunIIfy or so Is nof n
mental disorder (American Psychiatric Association,
1973; Bell & Weinberg, 1978; Bell et al., 1981; Conger,
1975; Gonsiorek, 1991; Hooker, 1957), and there are
a number of alternate theories of sexual orientation
and gender consistent with this evidence (Bem, 1996;
Butler, 2004; Chivers et al., 2007; Corbett, 1996, 1998,
2001; Diamond, 1998, 2006; Drescher, 1998a; Enns,
2008; Heppner & Heppner, 2008; Levant & Silverstein,
2006; Mustanksi et al., 2002; ONeil, 2008; Peplau &
Garnets, 2000; Pleck, 1995; Rahman & Wilson, 2005;
Wester, 2008).
Other forms of recent SOCE are religious, are not
bnsod on fhoorIos fhnf cnn bo scIonfIhcnIIy ovnIunfod,
and have not been subjected to rigorous examination
of ofhcncy nnd snfofy. Thoso nronchos nro bnsod
on religious beliefs that homosexuality is sinful and
immoral and, consequently, that identities and life
paths based on same-sex sexual orientation are not
religiously acceptable. The few high-quality studies of
SOCE conducted from 1999 to 2004 are qualitative (e.g.,
Beckstead & Morrow, 2004; Ponticelli, 1999; Wolkomir,
2001) and these, due to the research questions explored,
aid in understanding the population that seeks sexual
orientation change but do not provide the kind of
InformnfIon noodod for dohnIfIvo nnswors fo quosfIons
of fho snfofy nnd ofhcncy of SOCI.
Thus, we concluded that the early evidence, though
extremely limited, is the best basis for predicting what
would be the outcome of psychological interventions.
ScIonfIhcnIIy rIgorous oIdor work In fhIs nron (o.g., IIrk
et al., 1971; S. James, 1978; McConaghy, 1969, 1976;
McConaghy et al., 1973; Tanner, 1974, 1975) shows that
enduring change to an individuals sexual orientation
is uncommon and
that a very small
number of people
in these studies
show any credible
evidence of reduced
same-sex sexual
attraction, though
some show lessened physiological arousal to all sexual
stimuli. Compelling evidence of decreased same-sex
sexual behavior and increased sexual attraction to
and engagement in sexual behavior with the other
sex was rare. Few studies provided strong evidence
that any changes produced in laboratory conditions
translated to daily life. Many individuals continued to
experience same-sex sexual attractions following SOCE
nnd soIdom roorfod sIgnIhcnnf chnngo fo ofhor-sox
sexual attractions. Thus, we concluded the following
nbouf SOCI: Tho rosuIfs of scIonfIhcnIIy vnIId rosonrch
indicate that it is unlikely that individuals will be able
to reduce same-sex sexual attractions or increase other-
sex attractions through SOCE.
The few early research investigations that were
conducfod wIfh scIonfIhc rIgor rnIso concorns nbouf
the safety of SOCE, as some participants suffered
unintended harmful side effects from the interventions.
These negative side effects included loss of sexual
feeling, depression, suicidality, and anxiety. The high
dropout rate in these studies may indicate that some
research participants may have experienced these
treatments as harmful and discontinued treatment
(!IIIonfoId, 200?). Thoro nro no scIonfIhcnIIy rIgorous
studies of recent SOCE that would enable us to make a
dohnIfIvo sfnfomonf nbouf whofhor roconf SOCI Is snfo
or harmful and for whom.
|oo.o| \o ee |
oo e |oeece
AIfhough scIonfIhc ovIdonco shows fhnf SOCI Is nof
likely to produce its intended outcomes and can produce
harm for some of its participants, there is a population
of consumers who present to LMHP seeking SOCE.
To address the questions of appropriate application of
nfhrmnfIvo InforvonfIons for fhIs ouInfIon, whIch wns
a major aspect of APAs charge to the task force, we
returned to the research literature on SOCE, expanding
beyond the scope of the systematic review to include
other literature in order to develop an understanding of
the current population that seeks SOCE. The research
does reveal something about those individuals who
seek SOCE, how they evaluate their experiences,
and why they undergo SOCE, even if the research
does not indicate whether SOCE has anything to do
with the changes some clients perceive themselves
to have experienced. We sought this information
to be as comprehensive as possible and to develop
an information base that would serve as a basis for
consIdorIng nfhrmnfIvo InforvonfIons.
SOCI rosonrch IdonfIhos n ouInfIon of IndIvIdunIs
who oxorIonco conIcfs nnd dIsfross roInfod fo snmo-
sex sexual attractions. The population of adults
included in recent SOCE research is highly religious,
participating in faiths that many would consider
traditional or conservative (e.g., the Church of Jesus
Christ of Latter-Day Saints [Mormon], evangelical
Christian, or Orthodox Jewish). Most of the participants
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eeoc ocoe o
.|e|, o oo.o| w|| oe
oo|e o eo.ce omee e.o|
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in recent studies are White men who report that their
religion is extremely important to them (Nicolosi et
al., 2000; Schaeffer et al., 2000; Shidlo & Schroeder,
2002; Spitzer, 2003). These recent studies include a
small number of participants who identify as members
of ethnic minority groups. Recent studies include more
women than in early studies, and two qualitative
studies are exclusively female (i.e., Moran, 2007;
Ponticelli, 1999). Most of the individuals studied tried
a variety of methods to change their sexual orientation,
including psychotherapy, support groups, and religious
efforts. Many of the individuals studied were recruited
from groups endorsing SOCE. The body of literature
overall is based on convenience samples; thus, the
relationship between the characteristics of these
individuals compared with to the entire population of
people who seek SOCE is unknown.
Comparisons of the early and recent research indicate
changes in the demographics of those who seek SOCE.
The individuals who participated in early research
on SOCE were also predominantly White males, but
those studies included men who were court-referred to
treatment, men who were referred to treatment for a
range of psychiatric and sexual concerns, and men who
were fearful of criminal or legal sanctions, in addition
to men who were distressed by their sexual attractions.
There are no data on the religious faith beliefs of
those in the early studies. As noted previously, the
individuals in recent studies indicated that religion is
very important to them.
We concluded that some of the controversy
surrounding SOCE can be explained by different
understandings of the nature of sexual orientation
and sexual orientation identity. Recent research in
fho hoId of soxunI orIonfnfIon IndIcnfos n rnngo of
sexual attractions and desires, sexual orientations,
and multiple ways of self-labeling and self-identifying
(e.g., Carrillo, 2002; Diamond, 1998, 2006, 2008; Fox,
1995; Hoburg et al., 2004; Savin-Williams, 2005).
Some researchers have found that distinguishing the
constructs of sexual orientation and sexual orientation
identity adds clarity to an understanding of the
variability inherent in reports of these two variables (R.
L. Worthington & Reynolds, 2009). Sexual orientation
refers to an individuals patterns of sexual, romantic,
and affectional arousal and desire for other persons
based on those persons gender and sex characteristics.
Sexual orientation is tied to physiological drives and
biological systems that are beyond conscious choice and
InvoIvo rofound omofIonnI fooIIngs such ns fnIIIng
in love and emotional attachment. Other dimensions
commonly attributed to sexual orientation (e.g., sexual
behavior with men and/or women; sexual values,
norms, nnd mofIvnfIons; socInI nfhIInfIons wIfh !CI or
heterosexual individuals and communities; emotional
attachment preferences for men or women; gender role
and identity; lifestyle choices) are potential correlates
of sexual orientation rather than principal dimensions
of the construct. Sexual orientation identity refers to
recognition and internalization of sexual orientation
nnd roocfs soIf-nwnronoss, soIf-rocognIfIon, soIf-
InboIIng, grou momborshI nnd nfhIInfIon, cuIfuro,
and self-stigma. Sexual orientation identity is a key
element in determining relational and interpersonal
decisions, as it creates a foundation for the formation of
community, social support, role models, friendship, and
partnering (APA, 2003; Jordan & Deluty, 1998; McCarn
& Fassinger, 1996; Morris, 1997).
Recent studies of SOCE participants frequently
do not distinguish between sexual orientation and
sexual orientation
identity. We
concluded that
the failure to
distinguish
these aspects of
human sexuality
has led SOCE
research to obscure
understanding of
what aspects of
human sexuality
might and might
not change through intervention. The available
evidence, from both early and recent studies, suggests
that although sexual orientation is unlikely to change,
somo IndIvIdunIs modIhod fhoIr soxunI orIonfnfIon
identity (i.e., individual or group membership and
nfhIInfIon, soIf-InboIIng) nnd ofhor nsocfs of soxunIIfy
(i.e., values and behavior). They did so in a variety of
ways and with varied and unpredictable outcomes, some
of which were temporary (Beckstead, 2003; Beckstead &
Morrow, 2004; Shidlo & Schroeder, 2002). For instance,
in recent research, many individuals claim that through
participating in SOCE, they became skilled in ignoring
or tolerating their attractions or limiting the impact of
their attractions on their sexual behavior (Beckstead &
Morrow, 2004; McConaghy, 1976; Shidlo & Schroeder,
2002). Early nonexperimental case studies described
individuals who reported that they went on to lead
outwardly heterosexual lives, including, for some,
developing a sexual relationship with another-sex
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partner and adopting a heterosexual identity (Birk,
1974; Larson, 1970). Some of these individuals reported
heterosexual experience prior to treatment. People
whose sexual attractions were initially limited to people
of the same sex report much lower increases (if any)
in other-sex attractions compared to those who report
initial attractions to both men and women (Barlow et
nI., l9?5). Howovor, fho Iow dogroo of scIonfIhc rIgor In
these studies makes any conclusion tentative.
Recent research indicates that former participants in
SOCE report diverse evaluations of their experiences.
Somo IndIvIdunIs orcoIvo fhnf fhoy hnvo bonohfod from
SOCE, while other individuals perceive that they have
been harmed by SOCE (Beckstead & Morrow, 2004;
Nicolosi et al., 2000; Schroeder & Shidlo, 2001; Shidlo
& Schroeder, 2002). Across studies, it is unclear what
socIhc IndIvIdunI chnrncforIsfIcs nnd dIngnosfIc crIforIn
would prospectively distinguish those individuals
who will later perceive that they have succeeded and
bonohfod from SOCI from fhoso who wIII Infor orcoIvo
that they have failed or been harmed.
Some individuals who participated in the early
research reported negative side effects such as loss of
sexual arousal, impotence, depression, anxiety, and
relationship dysfunction. Individuals who participated
in recent research and who failed to change sexual
orientation, while believing they should have changed
with such efforts, described their experiences as a
sIgnIhcnnf cnuso of omofIonnI dIsfross nnd nognfIvo
self-image (Beckstead & Morrow, 2004; Shidlo &
Schroeder, 2002). Overall, those in this recent research
who indicated that they were harmed reported feelings
of distress, anxiety, depression, suicidal ideation, self-
blame, guilt, and loss of hope among other negative
feelings. Those who experienced religious interventions
and perceived them negatively said that they felt
disillusioned with faith and a sense of failure in the
eye of divine being (Beckstead & Morrow, 2004; Shidlo
& Schroeder, 2002). Indirect harm from the associated
costs (time, energy, effort, money, disillusionment
with psychotherapy) spent in ineffective treatment is
sIgnIhcnnf. Iofh fho onrIy nnd roconf rosonrch rovIdo
little clarity on the associations between claims to
modify sexual orientation from same-sex to other-sex
and subsequent improvements or harm to mental
health.
Other individuals reported that they perceived
SOCE to be helpful by providing a place to discuss
fhoIr conIcfs, roduco IsoInfIon, nnd rocoIvo suorf
(Beckstead & Morrow, 2004; Jones & Yarhouse, 2007;
Nicolosi et al., 2000; Ponticelli, 1999; Shidlo
& Schroeder, 2002; Spitzer, 2003; Wolkomir, 2001,
2006). Some reported that SOCE helped them view
their sexual orientation in a different light that
permitted them to live in a manner consistent with
their faith, which they perceived as positive (Nicolosi et
nI., 2000). Somo IndIvIdunIs doscrIbod hndIng n sonso
of support and community through SOCE and valued
having others with whom they could identify (Beckstead
& Morrow, 2004; Ponticelli, 1999; Wolkomir, 2001).
These effects mirror those provided by mutual support
grous for n rnngo of robIoms. And fho osIfIvo bonohfs
reported by participants in SOCE, such as reduction
of isolation, change of meaning, and stress reduction,
nro consIsfonf wIfh fho hndIngs of socInI suorf
IIfornfuro (!ovIno of nI., 2004). CIvon fho hndIngs
of IImIfod ofhcncy of chnngo of soxunI orIonfnfIon, If
Is unIIkoIy fhnf SOCI rovIdos nny unIquo bonohfs
other than those documented for the social support
mechanisms of mutual help groups (Levine et al., 2004).
For those in psychotherapy, the positive perceptions
doscrIbod nonr fo roocf fho documonfod offocfs of
the supportive function of psychotherapy relationships
(e.g., Norcross, 2002). For instance, providing emotional
support, empathy, support, and compassion can reduce
distress.
|eo.e o |oe oo /oo|ece
The task force was asked to report on the following: (a)
fho nrorInfo nIIcnfIon of nfhrmnfIvo fhornoufIc
interventions for children and adolescents who present
a desire to change either their sexual orientation or
their behavioral expression of their sexual orientation,
or both, or whose guardian expresses a desire for the
minor to change; (b) the presence of adolescent inpatient
facilities that offer coercive treatment designed to
change sexual orientation or the behavioral expression
of sexual orientation; and (c) recommendations
regarding treatment protocols that promote stereotyped
gender-normative behavior to mitigate behaviors that
are perceived to be indicators that a child will develop a
homosexual orientation in adolescence and adulthood.
We reviewed the limited research on child and
adolescent issues and drew the following conclusions:
There is no research demonstrating that providing
SOCE to children or adolescents has an impact on
adult sexual orientation. The few studies of children
with gender identity disorder found no evidence that
psychotherapy provided to those children had an
impact on adult sexual orientation (R. Green, 1986,
1987; Zucker, 2008; Zucker & Bradley, 1995). There
is currently no evidence that teaching or reinforcing
stereotyped gender-normative behavior in childhood
or adolescence can alter sexual orientation (Mathy
& Drescher, 2008). We are concerned that such
interventions may increase the self-stigma, minority
stress, and ultimately the distress of children and
adolescents. We have serious concerns that the coercive
or involuntary treatment of children or adolescents has
the potential to be harmful and may potentially violate
current clinical and practice guidelines, standards for
ethical practice, and human rights.
Recommendations
and Future Directions
/||moe |,coeoo, \ /o.|
interventions with adults is built on three key
hndIngs In fho rosonrch: (n) nn ondurIng chnngo fo nn
individuals sexual orientation as a result of SOCE is
unlikely, and some participants were harmed by the
interventions; (b) sexual orientation identity, not sexual
orientation, appears to change via psychotherapy,
suorf grous, or IIfo ovonfs; nnd (c) cIIonfs bonohf
from approaches that emphasize acceptance, support,
and recognition of important values and concerns.
On fho bnsIs of fhoso hndIngs nnd fho cIInIcnI
literature on this population, we suggest client-
centered, multiculturally competent approaches
groundod In fho foIIowIng scIonfIhc fncfs: (n) snmo-
sex sexual attractions, behavior, and orientations
per se are normal and positive variants of human
sexualityin other words, they are not indicators
of mental or developmental disorders; (b) same-sex
sexual attractions and behavior can occur in the
context of a variety of sexual orientations and sexual
orientation identities; (c) gay men, lesbians, and
bisexual individuals can live satisfying lives and form
stable, committed relationships and families that are
equivalent to those of heterosexual individuals in
essential respects; and (d) no empirical studies or peer-
reviewed research supports theories attributing same-
sex sexual orientation to family dysfunction or trauma.
Insod on fhoso hndIngs summnrIzod nbovo nnd
our comprehensive review of the research and
clinical literature, we developed a framework for the
nrorInfo nIIcnfIon of nfhrmnfIvo fhornoufIc
interventions for adults that has the following central
elements:
Acceptance and support :
Comprehensive assessment :
Active coping :
Social support :
Identity exploration and development :
Acceptance and support include (a) unconditional
positive regard for and empathy with the client, (b)
openness to the clients perspective as a means to
understanding their concerns, and (c) encouragement of
the clients positive self-concept.
A comprehensive assessment considers sexual
orientation uniquely individual and inseparable from an
individuals personality and sense of self. This includes
(a) being aware of the clients unique personal, social,
and historical context and (b) exploring and countering
the harmful impact of stigma and stereotypes on the
clients self-concept (including the prejudice related to
age, gender, gender identity, race, ethnicity, culture,
language, and socioeconomic status).
Active coping strategies are efforts that include
cognitive, behavioral, or emotional responses designed
to change the nature of the stressor itself or how an
individual perceives it and include both cognitive and
emotional strategies. These may include cognitive
sfrnfogIos fo rofrnmo conIcfs nnd omofIonnI sfrnfogIos
to manage potential losses.
Psychotherapy, self-help groups, or welcoming
communities (ethnic communities, social groups,
religious denominations) provide social support that
can mitigate distress caused by isolation, rejection, and
Inck of roIo modoIs. ConIcfs nmong dIsnrnfo oIomonfs
of IdonfIfy Iny n mnjor roIo In fho conIcfs nnd monfnI
health concerns of those seeking SOCE.
Identity exploration is an active process of exploring
and assessing ones identity and establishing a
commitment to an integrated identity that addresses
IdonfIfy conIcfs wIfhouf nn n rIorI fronfmonf gonI for
how clients identify or live out their sexual orientation.
The process may include a developmental process that
includes periods of crisis, mourning, reevaluation,
identity deconstruction, and growth.
Treatments that are based on assumptions that
homosexuality or same-sex sexual attractions are, a
priori, a mental disorder or psychopathology or based on
inaccurate stereotypes regarding LGB people are to be
avoided because they run counter to empirical data and
because reports of harm suggest that such treatments
can reinforce restricting stereotypes, increase
internalized stigma, and limit a clients development
(Beckstead & Morrow, 2004; Haldeman, 2001; Shidlo &
Schroeder, 2002; Smith et al., 2004; see Lilienfeld, 2007,
for information on psychotherapy harms).
|,coeoo, \ |oe
oo /oo|ece
We were asked to report on the appropriate application
of nfhrmnfIvo fhornoufIc InforvonfIons for chIIdron
and adolescents who present a desire to change either
their sexual orientation or the behavioral expression
of their sexual orientation, or both, or whose guardian
expresses a desire for the minor to change. Consistent
wIfh fho curronf scIonfIhc ovIdonco, fhoso workIng
with children and adolescents should strive to have a
developmentally appropriate perspective that includes
a client-centered multicultural perspective to reduce
self-stigma and mitigate minority stress. This includes
interventions that (a) reduce stigma and isolation, (b)
support the exploration and development of identity,
(c) facilitate achievement of developmental milestones,
and (d) respect age-appropriate issues regarding self-
determination. Such services are ideally provided in the
least restrictive setting and with, at a minimum, the
assent of the youth. However, LMHP are encouraged to
acquire developmentally appropriate informed consent
to treatment.
AfhrmnfIvo nronchos oncourngo fnmIIIos fo roduco
rejection and increase acceptance of their child and
adolescent (Perrin, 2002; Ryan et al., 2009). Parents
who are concerned or distressed by their childrens
sexual orientation can be provided accurate information
about sexual orientation and sexual orientation identity
and offered anticipatory guidance and psychotherapy
that supports family reconciliation (e.g., communication,
understanding, and empathy) and maintenance of their
childs total health and well-being. Interventions that
increase family, school, and community acceptance and
safety of sexual minority children and youth appear
particularly helpful. Such interventions are offered in
ways that are consistent with aspects of diversity such
as age, gender, gender identity, race, ethnicity, culture,
language, and socioeconomic status.
oeco| oce o|
|e|o. |oo.o| oo |om|e
Mnny roIIgIous soxunI mInorIfIos oxorIonco sIgnIhcnnf
sychoIogIcnI dIsfross nnd conIcf duo fo fho dIvorgonco
between their sexual orientation and religious beliefs.
To support clients who have these concerns, LMHP
can provide
psychological
acceptance,
support, and
recognition of the
importance of faith
to individuals
and communities
while recognizing
the science of
sexual orientation. LMHP working with religious
individuals and families can incorporate research
from the psychology of religion into the client-centered
multicultural framework summarized above. The
goal of treatment is for the client to explore possible
life paths that address the reality of their sexual
orientation while considering the possibilities for a
religiously and spiritually meaningful and rewarding
life. Such psychotherapy can enhance clients search
for monnIng, sIgnIhcnnco, nnd n roInfIonshI wIfh fho
sacred in their lives (e.g., Pargament & Maloney, 2005).
Such an approach would focus on increasing positive
religious coping, understanding religious motivations,
integrating religious and sexual orientation identities,
and reframing sexual orientation identities to reduce or
eliminate self-stigma.
|co| ooeoo
!MHI sfrIvo fo rovIdo InforvonfIons fhnf bonohf
clients and avoid harm, consistent with current
professional ethics. Psychologists aspire to provide
treatment that is consistent with the APA Ethical
Principles of Psychologists and Code of Conduct (APA,
2002b) and relevant APA guidelines and resolutions
(e.g., APA, 2000, 2002c, 2004, 2005a, 2007b) with a
socInI focus on ofhIcnI rIncIIos such ns Ionohf nnd
Harm; Justice; and Respect for Peoples Rights and
Dignity (including self-determination). LMHP reduce
ofonfInI hnrms nnd Incronso ofonfInI bonohfs by
basing their professional judgments and actions on the
mosf curronf nnd vnIId scIonfIhc ovIdonco, such ns fhnf
provided in this report (see APA, 2002b, Standard 2.04,
Insos for ScIonfIhc nnd IrofossIonnI Judgmonfs).
e oo| o| eome |o e
c|e o eo|oe ooo|e ||e
oo o oooe e eo|,
o| e e.o| oeoo w|e
cooe e ooo|e
|o o e|o.|, oo o.o||,
meo|.| oo ewoo ||e
LMHP enhance principles of social justice when they
strive to understand and mitigate the effects of sexual
stigma, prejudice, and discrimination on the lives of
individuals, families, and communities. Further, LMHP
aspire to respect diversity in all aspects of their work,
disability, and socioeconomic status.
Self-determination is the process by which a
person controls or determines the course of her or his
own life (Oxford American Dictionary, n.d.). LMHP
maximize self-determination by (a) providing effective
psychotherapy that explores the clients assumptions
and goals, without preconditions on the outcome; (b)
providing resources to manage and reduce distress; and
(c) permitting the client herself or himself to decide
the ultimate goal of how to self-identify and live out
her or his sexual orientation. We were not persuaded
by some accounts that suggest that providing SOCE
increases self-determination, because these suggestions
encourage LMHP
to offer treatment
that (a) has not
provided evidence
of ofhcncy; (b) hns
the potential to be
harmful; and (c)
delegates important
rofossIonnI docIsIons fhnf shouId bo bnsod on qunIIhod
expertise and trainingsuch as diagnosis and the type
of intervention. Rather, therapy that increases the
clients ability to cope, understand, acknowledge, and
integrate sexual orientation concerns into a self-chosen
life is the measured approach.
|o.coo o oo |eeoc
We were asked to provide recommendations for
education, training, and research as they pertain to
such nfhrmnfIvo InforvonfIons. Wo oxnmIno fhoso
areas separately.
-''/'` /`' '/'`'`
|o|eoo| eo.coo oo o
TrnInIng of !MHI fo rovIdo nfhrmnfIvo, ovIdonco-
based, and multicultural interventions with individuals
distressed by their same-sex sexual attractions is
critical. Research on LMHP behaviors indicates a range
of interventions, some of which are based on attitudes
and beliefs rather than evidence, especially as some
LMHP may have been educated during the period when
homosexuality was pathologized (cf. Bartlett, King,
& Phillips, 2001; Beutler, 2000; M. King et al., 2004;
Liszcz & Yarhouse, 2005). We recommend that LMHP
increase their awareness of their own assumptions and
attitudes toward sexual minorities (APA, 2000; R. L.
Worthington et al., 2005). This occurs by increasing
knowledge about the diversity of sexual minorities
(e.g., age, gender, gender identity, race, ethnicity,
disability, language, and socioeconomic status), as
well as the management of the LMHPs own biases
in order to avoid colluding with clients internalized
stigma and with the negating environments in which
clients and LMHP live (APA, 2000; Dillon et al., 2004;
Israel & Hackett, 2004; R. L. Worthington et al., 2005).
Wo rocommond fhnf frnInIng In nfhrmnfIvo, ovIdonco-
based, and multiculturally informed interventions for
sexual minorities be offered at all graduate schools and
postgraduate training programs.
An important resource for LMHP is the APA (2000)
Guidelines for Psychotherapy With Lesbian, Gay,
and Bisexual Clients,
64
which advises LMHP to be
competent in a variety of domains, including knowledge
of the impact of stigma on mental health, the unique
issues facing same-sex relationships and families, and
the range of diversity concerns for sexual minority
individuals. We recommend that several areas in which
LMHP working with clients seeking SOCE obtain
additional knowledge and skills include: (a) sexuality,
sexual orientation, and sexual identity development;
(b) the psychology of religion and spirituality, including
models of faith development, religious coping, and the
positive psychology of religion; (c) identity development
models, including those that integrate multiple
IdonfIfIos nnd fncIIIfnfo IdonfIfy conIcf rosoIufIon; nnd
(d) adaptive ways to manage stigma, minority stress,
and multiple aspects of identity. We also recommend
that practitioners review publications that explicate
the above-mentioned topics and evidence-based,
!CI-nfhrmnfIvo, nnd muIfIcuIfurnI nronchos fo
psychological interventions (APA, 2000, 2002a, 2002c,
2004, 2005b, 2006, 2007b, 2008a; Bartoli & Gillem,
2008; Brown, 2006; Fowers & Davidov, 2006; Schneider
et al., 2002).
Those less familiar with religious perspectives can
broaden their views on religion and religious individuals
and reduce their potential biases by seeking relevant
information on religious faith and the psychology of
64
These guidelines are being revised, and a new version will be
available in 2010.
eoo, o ceoe
e c|e oo|, o cooe
.oeoo ocow|eoe oo
eoe e.o| oeoo
coce o o e||coe ||e
e meo.eo oooooc
religion (e.g., Ano & Vasconcelles, 2005; Exline, 2002;
Emmons, 1999; Emmons & Paloutzian, 2003; Fowler,
2001; Goldstein, 2007; Pargament & Mahoney, 2005;
Pargament et al., 1998, 2005). Training programs for
practitioners can increase competencies in these areas
by including comprehensive material on religion and
spirituality (Bartoli, 2007; Hage, 2006; Hathaway et al.,
2004; Yarhouse & Fisher, 2002; Yarhouse & VanOrman,
1999) and on ways to incorporate religious approaches
into psychotherapy (see, e.g., Richards & Bergin,
2000, 2004; Sperry & Shafranske, 2004). Additionally,
ubIIcnfIons fhnf IIIusfrnfo nfhrmnfIvo InfogrnfIon nnd
resolution of religious and sexual minority identity are
helpful (Astramovich, 2003; Beckstead & Israel, 2007;
Glassgold, 2008; Haldeman, 2004; Ritter & ONeil,
1989, 1995).
Conservative religious practitioners can increase
their compassionate and understanding responses to
sexual minorities. For instance, recent publications
provide insight into techniques that address negative
attitudes toward sexual minorities by focusing
on increasing compassionate responses toward or
positive attitudes of sexual minorities by conservative
religious students or individuals (Bassett et al., 2005;
Benoit, 2005; Fischer & DeBord, 2007; McMinn, 2005;
Yarhouse, Burkett, & Kreeft, 2001; Zahniser & Boyd,
2008; Zahniser & Cagle, 2007). This research includes
exploring the evolution of positive attitudes toward
sexual minorities of LMHP who hold conservative
religious values (E. Adams, Longoria, Hitter, & Savage,
2009). These perspectives are based on established
social psychology research, such as the contact
hypothesis, where increasing personal contact with
members of minority groups of equal status reduces
bias, including attitudes toward sexual minorities (e.g.,
Herek & Capitanio, 1996; Herek & Glunt, 1993; Pew
Forum on Religion and Public Life, 2003).
Finally, although this report has limited information
regarding sexual minorities in other countries, the
research review and practice recommendations may be
helpful to professionals. We recommend dissemination of
this report to international mental health organizations
and LGBT advocacy groups.
We recommend the following steps be taken by the
APA to educate LMHP and support training programs
in providing education:
Disseminate this report to accredited doctoral 1.
programs, internships, and other postdoctoral
programs in psychology both in the United States
and other countries to encourage the incorporation
of this report and other relevant material on LGBT
issues into graduate school training programs and
internship sites.
Disseminate information to faculty in psychology 2.
departments in community colleges, colleges, and
university programs as information and for use in
curriculum development.
Maintain the currently high standards for APA 3.
approval of continuing professional education
providers and programs.
Offer symposia and continuing professional education 4.
workshops at APAs annual convention that focus on
treatment of individuals distressed by their same-sex
sexual attractions, especially those who struggle to
integrate religious and spiritual beliefs with sexual
orientation identity.
Pursue the publication of a version of this report in 5.
an appropriate journal or other publication.
|.o|c eo.coo
The information available to the public about SOCE
and sexual orientation is highly variable and can
be confusing. In those information sources that
encourage SOCE, the portrayals of homosexuality and
sexual minorities tend to be negative and at times
to emphasize inaccurate and misleading stereotypes
(Kennedy & Cianciotto, 2006; SPLC, 2005). Sexual
minorities, individuals aware of same-sex sexual
attractions, families, parents, caregivers, policymakers,
roIIgIous Iondors, nnd socIofy nf Inrgo cnn bonohf from
nccurnfo scIonfIhc InformnfIon nbouf soxunI orIonfnfIon
and about appropriate interventions for individuals
distressed by their same-sex sexual attractions both in
the United States and internationally. We recommend
that APA:
Create informational materials for sexual minority 1.
individuals, families, parents, and other stakeholders
on appropriate multiculturally competent and client-
centered interventions for those distressed by their
sexual orientation and who may seek SOCE.
Create informational materials on sexual orientation, 2.
sexual orientation identity, and religion for all
stakeholders, including the public and institutions
of faith.
Create informational materials focused on the 3.
integration of ethnic, racial, national origin and
cultural issues, and sexual orientation and sexual
orientation identity.
Integrate the conclusions of this report into existing 4.
APA public information resources, including print,
media, and the Internet.
Collaborate with other relevant organizations, 5.
especially religious organizations, to disseminate
this information.
RESEARCH
Our systematic review of research has highlighted the
methodological problems pervasive in recent research
on SOCE. This raises two issues: (a) the publication of
poorly designed research and (b) whether more research
on SOCE should be conducted to pursue questions
of bonohf, hnrm, nnd snfofy. Thoso fwo Issuos nro
addressed separately.
Much of the recent research on SOCE has had serious
methodological problems. Although this research
area presents serious challenges (e.g., obtaining a
rorosonfnfIvo snmIo, hndIng nrorInfo monsuros,
and using evidence-based constructs), many of the
problems were avoidable. Many of the problems
in published SOCE research indicate the need for
improvement in the journal review process, for instance.
Problems included: (a) violations of statistical measures,
(b) measures that were not evaluated prior to use, and
(c) inappropriate conclusions drawn from data.
Hunt and Carlson (2007) have argued that studies
with immediate social relevance that have an impact on
social policy or social issues should be held to a higher
standard because this literature has the potential to
Inuonco oIIcymnkors nnd fho ubIIc, nnd IncomIofo
or misleading information has serious costs. Whether
a higher standard is necessary is not clear; however,
research published on SOCE needs to meet current
best-practice research standards. It is recommended
fhnf rofossIonnI nnd scIonfIhc journnIs rofnIn rovIowors
and editors with expertise in this area to maintain the
standards of published research.
We concluded that research on SOCE (psychotherapy,
mutual self-help groups, religious techniques) has
not answered basic questions of whether it is safe or
effective and for whom. Any future research should
conform to best-practice standards for the design of
ofhcncy rosonrch. AddIfIonnIIy, rosonrch Info hnrm
and safety is essential. Certain key issues are worth
highlighting. Future research must use methods
that are prospective and longitudinal, allow for
concIusIons nbouf cnuso nnd offocf fo bo conhdonfIy
drawn, and employ sampling methods that allow
proper generalization.
65
Future research should also
IncIudo nrorInfo monsuros In forms of socIhcIfy
of measurement of sexual orientation, sexual
orientation identity and outcomes, and psychometric
adequacy. Mixed-method research, in which
methods and measures with offsetting weaknesses
are simultaneously employed, may be especially
advantageous. Alternative physiological means of
measuring sexual orientation objectively may also be
helpful. Recent research has used alternatives to genital
gauges for the assessment of sexual orientation in men
and women, such as functional magnetic resonance
imaging (Ponseti et al., 2006). Physiological measures
often use visual portrayals of nude individuals
fhnf somo roIIgIous IndIvIdunIs mny hnd mornIIy
unacceptable. Jlang, Costello, Fang, Huang, and He
(2006) have explored the use of invisible images and
have measured selective inattention/attention as an
alternative to assess sexual arousal. Such methods
or the development of methods that are less intrusive
and are more consistent with religious values would be
helpful to develop for this population.
Additionally, preexisting and co-occurring conditions,
mental health problems, participants need for
monitoring self-impression, other interventions, and
life histories would have to be given appropriate
consideration so that research can better account
for and test competing explanations for any changes
obsorvod In sfudy nrfIcInnfs ovor fImo. SocIhc
conceptual and methodological challenges exist in
research related to sexual minority populations, such
as the conceptualization of sexual orientation and
sexual orientation identity and obtaining representative
samples. Researchers would be advised to consider
and compensate for the unique conceptual and
65
A published study that appeared in the grey literature in 2007
(Jones & Yarhouse, 2007) has been described by SOCE advocates
and its authors as having successfully addressed many of the
mofhodoIogIcnI robIoms fhnf nffocf ofhor roconf sfudIos, socIhcnIIy
the lack of prospective research. The study is a convenience sample of
self-referred populations from religious self-help groups. The authors
claim to have found a positive effect for some study respondents
in different goals such as decreasing same-sex sexual attractions,
increasing other-sex attractions, and maintaining celibacy. However,
upon close examination, the methodological problems described in
Chapter 3 (our critique of recent studies) are characteristic of this
work, most notably the absence of a control or comparison group and
the threats to internal, external, construct, and statistical validity.
Best-practice analytical techniques were not performed in the study,
nnd fhoro nro sIgnIhcnnf dohcIoncIos In fho nnnIysIs of IongIfudInnI
data, use of statistical measures, and choice of assessment measures.
Tho nufhors` cInIm of hndIng chnngo In soxunI orIonfnfIon Is
unpersuasive due to their studys methodological problems.
methodological challenges in this area (Meyer & Wilson,
2009; Moradi, Mohr, Worthington, Fassinger, 2009).
Safety issues continue to be important areas of
study. As noted previously, early research indicates
that aversive techniques have been found to have very
IImIfod bonohfs ns woII ns ofonfInIIy hnrmfuI offocfs.
These documented harms were serious. An additional
hndIng Is fhnf fhoso fronfmonfs hnd oxfromoIy hIgh
dropout rates, which has been linked to adverse effects.
Some individuals report harm from recent nonaversive
fochnIquos, nnd somo IndIvIdunIs roorf bonohfs.
Indeed, some have raised the concern about both
research and practice in this area due to the limited
examination of safety (Davison, 1976, 1991; Herek,
2003), as it is still unclear which techniques or methods
may or may not be harmful. Assessing the safety
of recent practices is a high priority given that this
research is the least rigorous. Given that types of harm
can be multiple (Lilienfeld, 2007), outcome studies
with measures capable of assessing deterioration
in mental health, appearance of new symptoms,
heightened concern regarding existing symptoms,
excessive dependency on the LMHP, and reluctance
to seek out new treatment are important to include in
future research (Lilienfeld, 2007). Other areas to assess
are types of harm to others (e.g., some individuals
have noted that advocating other-sex marriage or
promising sexual orientation change may negatively
affect spouses, potential spouses, and children)
(Buxton, 1994, 2007; Wolkomir, 2006). Finally, LMHP
must be mindful of the indirect harms of SOCE, such
ns fho oorfunIfy cosfs (!IIIonfoId, 200?) nnd fho
time, energy, effort, and expense of interventions that
offor IImIfod bonohf nnd hnvo fho ofonfInI fo cnuso
disillusionment in psychotherapy. However, as concerns
regarding harm have been raised, addressing risks to
research participants and concerns regarding voluntary
participation (see Standard 8.02 in APA, 2002b) must
be carefully considered in any future research.
!osonrch fhnf moofs fhoso scIonfIhc sfnndnrds nnd
nddrossos ofhcncy nnd snfofy mIghf hoI fo cInrIfy fho
Issuos. Ivon so, scIonfIhc rosonrch mny nof hoI fo
resolve the issues unless it can better account for the
complexity of the concerns of the current population.
The results of current research are complicated by the
belief system of many of the participants whose religious
faith and beliefs may be intricately tied to the possibility
of change. Future research will have to better account
for the motivations and beliefs of participants in SOCE.
ImorgIng rosonrch rovonIs fhnf nfhrmnfIvo
interventions show promise for alleviating the distress
of children, adolescents, and families around sexual
orientation and identity concerns (DAugelli, 2002,
2003; Goodenow et al., 2006; Perrin, 2002; Ryan et
al., 2009). However, sexual minority adolescents
are underrepresented in research on evidence-based
approaches, and sexual orientation issues in children
nro vIrfunIIy unoxnmInod (AIA, 2008d). SocIhc
research on sexual minority adolescents and children
hns IdonfIhod fhnf sfIgmn cnn bo roducod fhrough
community interventions, supportive client-centered
approaches, and family reconciliation techniques
that focus on strengthening the emotional ties of
family members to each other, reducing rejection, and
increasing acceptance (DAugelli, 2003; Goodenow et al.,
2006; Ryan et al., 2009).
Finally, we presented a framework for therapy
with this population. Although this model is based on
accepted principles of psychotherapy and is consistent
with evidence-based approaches to psychotherapy, it
hns nof boon ovnIunfod for snfofy nnd ofhcncy. Such
studies would have to be conducted in the same manner
as research on SOCE and in ways that are consistent
with current standards (see, e.g., Flay et al., 2005).
|ecommeooo |o ooc eeoc
To ndvnnco knowIodgo In fho hoId nnd Imrovo fho IIvos
of individuals distressed by same-sex sexual attractions
who seek SOCE, it is recommended that researchers,
research-funding organizations, and other stakeholders,
including those who establish funding priorities, work
together to improve our knowledge of sexuality, sexual
orientation, and sexual orientation identity in the
following areas:
The nature and development of sexuality, sexual 1.
orientation, sexual orientation identity across the
life span and the correlates to these variables,
incorporating differences brought about by age,
gender, gender identity, race, ethnicity, culture,
language, and socioeconomic status.
Religious identity and faith development (inclusive of 2.
all world religions) and their intersection with other
aspects of human life and identity, such as sexual
orientation, sexual orientation identity, and the
multiple social identity statuses related to privilege
and stigma.
Identity integration, reduction in distress, and 3.
positive mental health for populations of religious
sexual minorities and ethnic minority populations.
Culture, gender, religion, and race/ethnicity in the 4.
experience and construction of sexual orientation and
sexual orientation identity.
Mental health outcomes of those who choose not to 5.
act on their sexual orientation by living celibately or
in relationships with other-sex partners.
|ecommeooo |o eeoc o,coeoo,
We recommend that researchers and practitioners
rigorously investigate multiculturally competent and
nfhrmnfIvo ovIdonco-bnsod fronfmonfs for soxunI
minorities and those distressed by their sexual
orientation that do not aim to alter sexual orientation
but rather focus on sexual orientation identity
exploration, development, and integration without
prioritizing one outcome over another, for the following
populations:
Sexual minorities who have traditional religious 1.
beliefs
Sexual minorities who are members of ethnic 2.
minority and culturally diverse communities both in
the United States and internationally
Children and adolescents who are sexual minorities 3.
or questioning their sexual orientation
Parents who are distressed by their childrens 4.
perceived future sexual orientation
Populations with any combination of the above 5.
demographics
|o|c,
We were asked to make recommendations to APA
to inform the associations response to groups that
promote treatments to change sexual orientation or its
behavioral expression and to support public policy that
The debate surrounding SOCE has become mired
in ideological disputes and competing political
agendas (Drescher, 2003; Drescher & Zucker, 2006).
Some organizations opposing civil rights for LGBT
individuals advocate SOCE (SPLC, 2005). Other policy
concerns involve religious or socially conservative
ngondns whoro Issuos of roIIgIous mornIIfy conIcf wIfh
scIonfIhc-bnsod concofIons of osIfIvo nnd honIfhy
development. We encourage APA to continue its
advocacy for lesbian, gay, bisexual, and transgender
individuals and families and to oppose prejudice against
sexual minorities (APA, 2003, 2005, 2006, 2008b). We
encourage collaborative activities in pursuit of shared
prosocial goals between psychologists and religious
communities when such collaboration can be done in
a mutually respectful manner that is consistent with
sychoIogIsfs` rofossIonnI nnd scIonfIhc roIos. Thoso
collaborative relationships can be designed to integrate
humanitarian perspectives and professional expertise
(Tyler, Pargament, & Gatz, 1983).
Thus, the task force urges APA to:
Actively oppose the distortion and selective use of 1.
scIonfIhc dnfn nbouf homosoxunIIfy by IndIvIdunIs
nnd orgnnIznfIons sookIng fo Inuonco ubIIc oIIcy
and public opinion and take a leadership role in
responding to such distortions.
Suorf fho dIssomInnfIon of nccurnfo scIonfIhc nnd 2.
professional information about sexual orientation
in order to counteract bias that is based on lack of
scIonfIhc knowIodgo nbouf soxunI orIonfnfIon.
Incourngo ndvocncy grous, oIocfod ofhcInIs, 3.
policymakers, religious leaders, and other
organizations to seek accurate information and
avoid promulgating inaccurate information about
sexual minorities.
Seek areas where collaborationwith religious leaders, 4.
institutions, and organizations can promote the well-
being of sexual minorities through the use of accurate
scIonfIhc dnfn rognrdIng soxunI orIonfnfIon nnd
sexual orientation identity.
Encourage the Committee onLesbian, Gay, Bisexual, 5.
and Transgender Concerns to prioritize initiatives
that address religious and spiritual concerns and the
concerns of sexual minorities from conservative faiths.
Adopt a new resolution: the Resolution on 6.
ArorInfo AfhrmnfIvo !osonsos fo SoxunI
Orientation Distress and Change Efforts (see
Appendix A).
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119 Appendix A
Research Summary
T
he longstanding consensus of the behavioral
and social sciences and the health and mental
health professions is that homosexuality per se
is a normal and positive variation of human sexual
orientation (Bell, Weinberg & Hammersmith, 1981;
Bullough, 1976; Ford & Beach 1951; Kinsey, Pomeroy,
& Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard,
1953). Homosexuality per se is not a mental disorder
(APA, 1975). Since 1974, the American Psychological
Association (APA) has opposed stigma, prejudice,
discrimination, and violence on the basis of sexual
orientation and has taken a leadership role in
supporting the equal rights of lesbian, gay, and bisexual
individuals (APA, 2005).
APA is concerned about ongoing efforts to
mischaracterize homosexuality and promote the
notion that sexual orientation can be changed and
about the resurgence of sexual orientation change
efforts (SOCE).
A1
SOCE has been controversial due
to tensions between the values held by some faith-
based organizations, on the one hand, and those held
by lesbian, gay, and bisexual rights organizations
nnd rofossIonnI nnd scIonfIhc orgnnIznfIons, on fho
other (Drescher, 2003; Drescher & Zucker, 2006).
A1
APA uses the term sexual orientation change efforts to describe
all means to change sexual orientation (e.g., behavioral techniques,
psychoanalytic techniques, medical approaches, religious and
spiritual approaches). This includes those efforts by mental health
professionals, lay individuals, including religious professionals,
religious leaders, social groups, and other lay networks such as self-
help groups.
Some individuals and groups have promoted the idea
of homosexuality as symptomatic of developmental
defects or spiritual and moral failings and have argued
that SOCE, including psychotherapy and religious
efforts, could alter homosexual feelings and behaviors
(Drescher & Zucker, 2006; Morrow & Beckstead, 2004).
Many of these individuals and groups appeared to be
embedded within the larger context of conservative
religious political movements that have supported the
stigmatization of homosexuality on political or religious
grounds (Drescher, 2003; Drescher & Zucker, 2006;
Southern Poverty Law Center, 2005). Psychology, as
a science, and various faith traditions, as theological
systems, can acknowledge and respect their profoundly
different methodological and philosophical viewpoints.
The APA concludes that psychology must rely on proven
mofhods of scIonfIhc InquIry bnsod on omIrIcnI dnfn,
on whIch hyofhosos nnd roosIfIons nro conhrmod or
dIsconhrmod, ns fho bnsIs fo oxIoro nnd undorsfnnd
human behavior (APA, 2008a; 2008c).
In response to these concerns, APA appointed the
Task Force on Appropriate Therapeutic Responses to
Sexual Orientation to review the available research
on SOCE and to provide recommendations to the
association. The task force reached the following
hndIngs.
Recent studies of participants in SOCE identify
a population of individuals who experience serious
distress related to same sex sexual attractions. Most
of these participants are Caucasian males who report
that their religion is extremely important to them
(Beckstead & Morrow, 2004; Nicolosi, Byrd, & Potts,
A|||N||X A. ||SO|u!|ON ON A|||O|||A!|
AFFIRMATIVE RESPONSES TO SEXUAL
ORIENTATION DISTRESS AND CHANGE EFFORTS
2000; Schaeffer, Hyde, Kroencke, McCormick, &
Nottebaum, 2000; Shidlo & Schroeder, 2002, Spitzer,
2003). These individuals report having pursued a
variety of religious and secular efforts intended to help
them change their sexual orientation. To date, the
research has not fully addressed age, gender, gender
disability, language, and socioeconomic status in the
population of distressed individuals.
Thoro nro no sfudIos of ndoqunfo scIonfIhc rIgor fo
conclude whether or not recent SOCE do or do not work
fo chnngo n orson`s soxunI orIonfnfIon. ScIonfIhcnIIy
rigorous older work in this area (e.g., Birk, Huddleston,
Miller, & Cohler, 1971; James, 1978; McConaghy, 1969,
1976; McConaghy, Proctor, & Barr, 1972; Tanner,
1974, 1975) found that sexual orientation (i.e., erotic
attractions and sexual arousal oriented to one sex or
the other, or both) was unlikely to change due to efforts
designed for this purpose. Some individuals appeared to
learn how to ignore or limit their attractions. However,
this was much less likely to be true for people whose
sexual attractions were initially limited to people of the
same sex.
Although sound data on the safety of SOCE are
extremely limited, some individuals reported being
harmed by SOCE. Distress and depression were
exacerbated. Belief in the hope of sexual orientation
change followed by the failure of the treatment was
IdonfIhod ns n sIgnIhcnnf cnuso of dIsfross nnd nognfIvo
self-image (Beckstead & Morrow, 2004; Shidlo &
Schroeder, 2002).
AIfhough fhoro Is InsufhcIonf ovIdonco fo suorf
the use of psychological interventions to change sexual
orIonfnfIon, somo IndIvIdunIs modIhod fhoIr soxunI
orientation identity (i.e., group membership and
nfhIInfIon), bohnvIor, nnd vnIuos (IcoIosI of nI., 2000).
They did so in a variety of ways and with varied and
unpredictable outcomes, some of which were temporary
(Beckstead & Morrow, 2004; Shidlo & Schroeder,
2002). Based on the available data, additional claims
nbouf fho monnIng of fhoso oufcomos nro scIonfIhcnIIy
unsupported.
On fho bnsIs of fho fnsk forco`s hndIngs, fho AIA
encourages mental health professionals to provide
assistance to those who seek sexual orientation change
by ufIIIzIng nfhrmnfIvo muIfIcuIfurnIIy comofonf
(Bartoli & Gillem, 2008; Brown, 2006) and client-
centered approaches (e.g., Beckstead & Israel, 2007;
Glassgold, 2008; Haldeman, 2004; Lasser & Gottlieb,
2004) that recognize the negative impact of social
stigma on sexual minorities (Herek, 2009; Herek &
Garnets, 2007)
A2
and balance ethical principles of
bonohconco nnd nonmnIohconco, jusfIco, nnd rosocf for
peoples rights and dignity (APA, 1998, 2002; Davison,
1976; Haldeman, 2002; Schneider, Brown, & Glassgold,
2002).
Resolution
WHEREAS, The American Psychological Association
oxrossIy oosos rojudIco (dohnod brondIy)
and discrimination based on age, gender, gender
religion, sexual orientation, disability, language, or
socioeconomic status (APA, 1998, 2000, 2002, 2003,
2005, 2006, 2008c);
takes a leadership role in opposing prejudice and
discrimination (APA, 2008b, 2008c), including
prejudice based on or derived from religion or
spirituality, and encourages commensurate
consideration of religion and spirituality as diversity
variables (APA, 2008c);
WHEREAS, Psychologists respect human diversity
disability, language, and socioeconomic status (APA,
2002) and psychologists strive to prevent bias from
their own spiritual, religious, or non-religious beliefs
from taking precedence over professional practice
nnd sfnndnrds or scIonfIhc hndIngs In fhoIr work ns
psychologists (APA, 2008c);
WHEREAS, Psychologists are encouraged to recognize that
it is outside the role and expertise of psychologists,
as psychologists, to adjudicate religious or spiritual
tenets, while also recognizing that psychologists
can appropriately speak to the psychological
implications of religious/spiritual beliefs or practices
whon roIovnnf sychoIogIcnI hndIngs nbouf fhoso
implications exist (APA, 2008c);
WHEREAS, Those operating from religious/spiritual
traditions are encouraged to recognize that it
is outside their role and expertise to adjudicate
omIrIcnI scIonfIhc Issuos In sychoIogy, whIIo
A2
We use the term sexual minority (cf. Blumenfeld, 1992; McCarn &
Fassinger, 1996; Ullerstam, 1966) to designate the entire group of
IndIvIdunIs who oxorIonco sIgnIhcnnf orofIc nnd romnnfIc nffrncfIons
to adult members of their own sex, including those who experience
attractions to members of both their own and the other sex. This term
is used because we recognize that not all sexual minority individuals
adopt an LGB bisexual identity.
121 Appendix A
also recognizing they can appropriately speak to
theological implications of psychological science (APA,
2008c);
encourages collaborative activities in pursuit of
shared prosocial goals between psychologists and
religious communities when such collaboration
can be done in a mutually respectful manner that
is consistent with psychologists professional and
scIonfIhc roIos (AIA, 2008c);
WHEREAS, Societal ignorance and prejudice about a
same-sex sexual orientation places some sexual
minorities at risk for seeking sexual orientation
chnngo duo fo orsonnI, fnmIIy, or roIIgIous conIcfs,
or lack of information (Beckstead & Morrow,
2004; Haldeman, 1994; Ponticelli, 1999; Shidlo &
Schroeder, 2002; Wolkomir, 2001);
WHEREAS, Some mental health professionals advocate
treatments based on the premise that homosexuality
is a mental disorder (e.g., Nicolosi, 1991; Socarides,
1968);
WHEREAS, Sexual minority children and youth are
especially vulnerable populations with unique
developmental tasks (Perrin, 2002; Ryan &
Futterman, 1997) who lack adequate legal protection
from involuntary or coercive treatment (Arriola, 1998;
Burack & Josephson, 2005; Molnar, 1997) and whose
parents and guardians need accurate information to
make informed decisions regarding their development
and well-being (Cianciotto & Cahill, 2006; Ryan &
Futterman, 1997); and
WHEREAS, Research has shown that family rejection
is a predictor of negative outcomes (Remafedi,
Farrow, & Deisher, 1991; Ryan, Huebner, Diaz, &
Sanchez, 2009; Savin-Williams, 1994; Wilber, Ryan,
& Marksamer, 2006) and that parental acceptance
and school support are protective factors (DAugelli,
2003; DAugelli, Hershberger, & Pilkington, 1998;
Goodenow, Szalacha, & Westheimer, 2006; Savin-
Williams, 1989) for sexual minority youth;
THEREFORE, BE IT RESOLVED, That the American
IsychoIogIcnI AssocInfIon nfhrms fhnf snmo-sox
sexual and romantic attractions, feelings, and
behaviors are normal and positive variations of
human sexuality regardless of sexual orientation
identity;
BE IT FURTHER RESOLVED, That the American
IsychoIogIcnI AssocInfIon ronfhrms Ifs osIfIon fhnf
homosexuality per se is not a mental disorder and
opposes portrayals of sexual minority youths and
adults as mentally ill due to their sexual orientation;
Psychological Association concludes that there
Is InsufhcIonf ovIdonco fo suorf fho uso of
psychological interventions to change sexual
orientation;
Psychological Association encourages mental health
rofossIonnIs fo nvoId mIsrorosonfIng fho ofhcncy
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;
IsychoIogIcnI AssocInfIon concIudos fhnf fho bonohfs
reported by participants in sexual orientation change
efforts can be gained through approaches that do not
attempt to change sexual orientation;
Psychological Association concludes that the
omorgIng knowIodgo on nfhrmnfIvo muIfIcuIfurnIIy
competent treatment provides a foundation for an
appropriate evidence-based practice with children,
adolescents and adults who are distressed by or seek
to change their sexual orientation (Bartoli & Gillem,
2008; Brown, 2006; Martell, Safren & Prince, 2004;
Norcross, 2002; Ryan & Futterman, 1997);
Psychological Association advises parents, guardians,
young people, and their families to avoid sexual
orientation change efforts that portray homosexuality
as a mental illness or developmental disorder and to
seek psychotherapy, social support and educational
services that provide accurate information on sexual
orientation and sexuality, increase family and school
support, and reduce rejection of sexual minority
youth;
Psychological Association encourages practitioners
to consider the ethical concerns outlined in the 1997
APA Resolution on Appropriate Therapeutic Response
to Sexual Orientation (APA, 1998), in particular the
foIIowIng sfnndnrds nnd rIncIIos: scIonfIhc bnsos
for rofossIonnI judgmonfs, bonohf nnd hnrm, jusfIco,
and respect for peoples rights and dignity;
Psychological Association encourages practitioners
to be aware that age, gender, gender identity, race,
ethnicity, culture, national origin, religion, disability,
language, and socioeconomic status may interact with
sexual stigma, and contribute to variations in sexual
orientation identity development, expression, and
experience;
Psychological Association opposes the distortion and
soIocfIvo uso of scIonfIhc dnfn nbouf homosoxunIIfy
by IndIvIdunIs nnd orgnnIznfIons sookIng fo Inuonco
public policy and public opinion and will take a
leadership role in responding to such distortions;
Psychological Association supports the dissemination
of nccurnfo scIonfIhc nnd rofossIonnI InformnfIon
about sexual orientation in order to counteract bias
that is based in lack of knowledge about sexual
orientation; and
Psychological Association encourages advocacy
grous, oIocfod ofhcInIs, monfnI honIfh rofossIonnIs,
policy makers, religious professionals and
organizations, and other organizations to seek areas
of collaboration that may promote the wellbeing of
sexual minorities.
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JS 44 (Rev. 12/12)
CIVIL COVER SHEET
The JS 44 civil cover sheet and the inIormation contained herein neither replace nor supplement the Iiling and service oI pleadings or other papers as required by law, except as
provided by local rules oI court. This Iorm, approved by the Judicial ConIerence oI the United States in September 1974, is required Ior the use oI the Clerk oI Court Ior the
purpose oI initiating the civil docket sheet. (SEE INSTRUCTIONS ON NEXT PAGE OF THIS FORM.)
I. (a) PLAINTIFFS DEFENDANTS
(b) County oI Residence oI First Listed PlaintiII County oI Residence oI First Listed DeIendant
(EXCEPT IN U.S. PLAINTIFF CASES) (IN U.S. PLAINTIFF CASES ONLY)
NOTE: IN LAND CONDEMNATION CASES, USE THE LOCATION OF
THE TRACT OF LAND INVOLVED.

(c) Attorneys (Firm Name, Address, Email and Telephone Number) Attorneys (If Known)
II. BASIS OF JURISDICTION (Place an 'X` in One Box Onlv) III. CITIZENSHIP OF PRINCIPAL PARTIES (Place an 'X` in One Box for Plaintiff
(For Diversitv Cases Onlv) and One Box for Defendant)
1 U.S. Government 3 Federal Question PTF DEF PTF DEF
PlaintiII (U.S. Government Not a Partv) Citizen oI This State 1 1 Incorporated or Principal Place 4 4
oI Business In This State
2 U.S. Government 4 Diversity Citizen oI Another State 2 2 Incorporated and Principal Place 5 5
DeIendant (Indicate Citi:enship of Parties in Item III) oI Business In Another State
Citizen or Subject oI a 3 3 Foreign Nation 6 6
Foreign Country
IV. NATURE OF SUIT (Place an 'X` in One Box Onlv)
CONTRACT TORTS FORFEITURE/PENALTY BANKRUPTCY OTHER STATUTES
110 Insurance PERSONAL INJURY PERSONAL INJURY 625 Drug Related Seizure 422 Appeal 28 USC 158 375 False Claims Act
120 Marine 310 Airplane 365 Personal Injury - oI Property 21 USC 881 423 Withdrawal 400 State Reapportionment
130 Miller Act 315 Airplane Product Product Liability 690 Other 28 USC 157 410 Antitrust
140 Negotiable Instrument Liability 367 Health Care/ 430 Banks and Banking
150 Recovery oI Overpayment 320 Assault, Libel & Pharmaceutical PROPERTY RIGHTS 450 Commerce
& EnIorcement oI Judgment Slander Personal Injury 820 Copyrights 460 Deportation
151 Medicare Act 330 Federal Employers` Product Liability 830 Patent 470 Racketeer InIluenced and
152 Recovery oI DeIaulted Liability 368 Asbestos Personal 840 Trademark Corrupt Organizations
Student Loans 340 Marine Injury Product 480 Consumer Credit
(Excludes Veterans) 345 Marine Product Liability LABOR SOCIAL SECURITY 490 Cable/Sat TV
153 Recovery oI Overpayment Liability PERSONAL PROPERTY 710 Fair Labor Standards 861 HIA (1395II) 850 Securities/Commodities/
oI Veteran`s BeneIits 350 Motor Vehicle 370 Other Fraud Act 862 Black Lung (923) Exchange
160 Stockholders` Suits 355 Motor Vehicle 371 Truth in Lending 720 Labor/Management 863 DIWC/DIWW (405(g)) 890 Other Statutory Actions
190 Other Contract Product Liability 380 Other Personal Relations 864 SSID Title XVI 891 Agricultural Acts
195 Contract Product Liability 360 Other Personal Property Damage 740 Railway Labor Act 865 RSI (405(g)) 893 Environmental Matters
196 Franchise Injury 385 Property Damage 751 Family and Medical 895 Freedom oI InIormation
362 Personal Injury - Product Liability Leave Act Act
Medical Malpractice 790 Other Labor Litigation 896 Arbitration
REAL PROPERTY CIVIL RIGHTS PRISONER PETITIONS 791 Employee Retirement FEDERAL TAX SUITS 899 Administrative Procedure
210 Land Condemnation 440 Other Civil Rights Habeas Corpus: Income Security Act 870 Taxes (U.S. PlaintiII Act/Review or Appeal oI
220 Foreclosure 441 Voting 463 Alien Detainee or DeIendant) Agency Decision
230 Rent Lease & Ejectment 442 Employment 510 Motions to Vacate 871 IRSThird Party 950 Constitutionality oI
240 Torts to Land 443 Housing/ Sentence 26 USC 7609 State Statutes
245 Tort Product Liability Accommodations 530 General
290 All Other Real Property 445 Amer. w/Disabilities - 535 Death Penalty IMMIGRATION
Employment Other: 462 Naturalization Application
446 Amer. w/Disabilities - 540 Mandamus & Other 465 Other Immigration
Other 550 Civil Rights Actions
448 Education 555 Prison Condition
560 Civil Detainee -
Conditions oI
ConIinement
V. ORIGIN (Place an 'X` in One Box Onlv)
1 Original
Proceeding
2 Removed Irom
State Court
3 Remanded Irom
Appellate Court
4 Reinstated or
Reopened
5 TransIerred Irom
Another District
(specifv)
6 Multidistrict
Litigation
VI. CAUSE OF ACTION
Cite the U.S. Civil Statute under which you are Iiling (Do not cite jurisdictional statutes unless diversity):

BrieI description oI cause:
VII. REQUESTED IN
COMPLAINT:
CHECK IF THIS IS A CLASS ACTION
UNDER RULE 23, F.R.Cv.P.
DEMAND $ CHECK YES only iI demanded in complaint:
JURY DEMAND: Yes No
VIII. RELATED CASE(S)
IF ANY
(See instructions).
JUDGE DOCKET NUMBER
DATE SIGNATURE OF ATTORNEY OF RECORD
FOR OFFICE USE ONLY
RECEIPT # AMOUNT APPLYING IFP JUDGE MAG. JUDGE
JOHN DOE, by and through JACK DOE and JANE DOE, JACK DOE,
individually and on behalf of his son, JOHN DOE, JANE DOE individually
and on behalf of her son, JOHN DOE
Dimitrios Stratis, Ruta, Soulios & Stratis LLP, 10-04 River Rd., Fair Lawn,
NJ 07410. (201) 794-6200 Mathew D. Staver, Liberty Counsel, PO Box
540774, Orlando, FL 32751(800) 671-1776

CHRISTOPHER J. CHRISTIE, et.al.
Mercer County
John Jay Hoffman, Attorney General
First and Fourteenth Amendments to the United States Constitution, 42 U.S.C. 1983
Deprivation of Constitutional Rights
August 22, 2013 Dimitrios Stratis
JS 44 Reverse (Rev. 12/12)
INSTRUCTIONS FOR ATTORNEYS COMPLETING CIVIL COVER SHEET FORM JS 44
Authority For Civil Cover Sheet
The JS 44 civil cover sheet and the inIormation contained herein neither replaces nor supplements the Iilings and service oI pleading or other papers as
required by law, except as provided by local rules oI court. This Iorm, approved by the Judicial ConIerence oI the United States in September 1974, is
required Ior the use oI the Clerk oI Court Ior the purpose oI initiating the civil docket sheet. Consequently, a civil cover sheet is submitted to the Clerk oI
Court Ior each civil complaint Iiled. The attorney Iiling a case should complete the Iorm as Iollows:
I.(a) Plaintiffs-Defendants. Enter names (last, Iirst, middle initial) oI plaintiII and deIendant. II the plaintiII or deIendant is a government agency, use
only the Iull name or standard abbreviations. II the plaintiII or deIendant is an oIIicial within a government agency, identiIy Iirst the agency and
then the oIIicial, giving both name and title.
(b) County of Residence. For each civil case Iiled, except U.S. plaintiII cases, enter the name oI the county where the Iirst listed plaintiII resides at the
time oI Iiling. In U.S. plaintiII cases, enter the name oI the county in which the Iirst listed deIendant resides at the time oI Iiling. (NOTE: In land
condemnation cases, the county oI residence oI the "deIendant" is the location oI the tract oI land involved.)
(c) Attorneys. Enter the Iirm name, address, telephone number, and attorney oI record. II there are several attorneys, list them on an attachment, noting
in this section "(see attachment)".
II. Jurisdiction. The basis oI jurisdiction is set Iorth under Rule 8(a), F.R.Cv.P., which requires that jurisdictions be shown in pleadings. Place an "X"
in one oI the boxes. II there is more than one basis oI jurisdiction, precedence is given in the order shown below.
United States plaintiII. (1) Jurisdiction based on 28 U.S.C. 1345 and 1348. Suits by agencies and oIIicers oI the United States are included here.
United States deIendant. (2) When the plaintiII is suing the United States, its oIIicers or agencies, place an "X" in this box.
Federal question. (3) This reIers to suits under 28 U.S.C. 1331, where jurisdiction arises under the Constitution oI the United States, an amendment
to the Constitution, an act oI Congress or a treaty oI the United States. In cases where the U.S. is a party, the U.S. plaintiII or deIendant code takes
precedence, and box 1 or 2 should be marked.
Diversity oI citizenship. (4) This reIers to suits under 28 U.S.C. 1332, where parties are citizens oI diIIerent states. When Box 4 is checked, the
citizenship oI the diIIerent parties must be checked. (See Section III below; NOTE: federal question actions take precedence over diversity
cases.)
III. Residence (citizenship) of Principal Parties. This section oI the JS 44 is to be completed iI diversity oI citizenship was indicated above. Mark this
section Ior each principal party.
IV. Nature of Suit. Place an "X" in the appropriate box. II the nature oI suit cannot be determined, be sure the cause oI action, in Section VI below, is
suIIicient to enable the deputy clerk or the statistical clerk(s) in the Administrative OIIice to determine the nature oI suit. II the cause Iits more than
one nature oI suit, select the most deIinitive.
V. Origin. Place an "X" in one oI the six boxes.
Original Proceedings. (1) Cases which originate in the United States district courts.
Removed Irom State Court. (2) Proceedings initiated in state courts may be removed to the district courts under Title 28 U.S.C., Section 1441.
When the petition Ior removal is granted, check this box.
Remanded Irom Appellate Court. (3) Check this box Ior cases remanded to the district court Ior Iurther action. Use the date oI remand as the Iiling
date.
Reinstated or Reopened. (4) Check this box Ior cases reinstated or reopened in the district court. Use the reopening date as the Iiling date.
TransIerred Irom Another District. (5) For cases transIerred under Title 28 U.S.C. Section 1404(a). Do not use this Ior within district transIers or
multidistrict litigation transIers.
Multidistrict Litigation. (6) Check this box when a multidistrict case is transIerred into the district under authority oI Title 28 U.S.C. Section 1407.
When this box is checked, do not check (5) above.
VI. Cause of Action. Report the civil statute directly related to the cause oI action and give a brieI description oI the cause. Do not cite jurisdictional
statutes unless diversity. Example: U.S. Civil Statute: 47 USC 553 BrieI Description: Unauthorized reception oI cable service
VII. Requested in Complaint. Class Action. Place an "X" in this box iI you are Iiling a class action under Rule 23, F.R.Cv.P.
Demand. In this space enter the actual dollar amount being demanded or indicate other demand, such as a preliminary injunction.
Jury Demand. Check the appropriate box to indicate whether or not a jury is being demanded.
VIII. Related Cases. This section oI the JS 44 is used to reIerence related pending cases, iI any. II there are related pending cases, insert the docket
numbers and the corresponding judge names Ior such cases.
Date and Attorney Signature. Date and sign the civil cover sheet.

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IN THE UNITED STATES DISTRICT COURT FOR THE

DISTRICT OF NEW JERSEY

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