Docsplainin' -- it's what I do

Docsplainin'--it's what I do.
After all, I'm a doc, aren't I?

Thursday, March 26, 2009

Homosexuality was removed from the Diagnostic and Statistical Manual list of psychiatric disorders in 1973. On August 14, 1997, the American Psychological Association (APA) Council of Representatives passed, by a vote of 10 to one, a resolution against so-called "reparative therapy" for gays. The first "whereas" makes crystal clear our view, as a profession, of this type of "treatment":
Whereas societal ignorance and prejudice about same-gender sexual orientation put some gay, lesbian, bisexual, and questioning individuals at risk for presenting for "conversion" treatment due to family or social coercion and/or lack of information . . .
And yet.

And yet, more than ten years later, there are still folks out there who think they can and should "cure" people of being gay. Or bi. Or transgendered. Twisty Faster, over at I Blame the Patriarchy, or IBTP for short, has brought to the attention of Blamers worldwide this BBC report on a study just out about some retro Neanderthal types in Great Britain. The journal, BMC Psychiatry, is open access and you can read the entire study here. The study reportedly found that, if asked by the client to do so, 17% of the mental health professionals surveyed would attempt to help a client change her or his sexual orientation*. The authors' conclusion?
Given lack of evidence for the efficacy of such treatments, this is likely to be unwise or even harmful.
"Likely" to be unwise? "Or even" harmful? You think? This lukewarm disapproval is bitterly disappointing, to say the least. Such practices are deemed unethical if not downright abusive (I believe the American Psychiatric Association uses that word) by every major professional group in the United States, Canada, and Great Britain that I know of, and I assume in most other progressive societies. I wish that the authors had unequivocally condemned such behavior, called for more education of the holdouts, and stern discipline of those therapists offering such "treatments".

The authors note that this is a "significant minority" but again, I think they are under-reacting. That one in six British therapists may have attempted to "cure" somebody's sexual orientation is scary. As the writer of a student dissertation on a related topic pointed out, this reveals a really serious problem with these people's training and ethics. It points up serious failings in training programs and in our ethical oversight of our peers. In other words, this is a problem for the profession as a whole, and it is a big one. The estimates of the proportion of therapists who violate sexual boundaries is, by comparison, much smaller, but our profession has generated reams of ink on why they do it, how to stop it, the effects on the victims, and so forth. If this kind of abuse is so much more frequent, how come it's not getting the same attention?

And according to the BBC, another group of researchers is trying to collect "stories" of successful changes via a website. I couldn't track them down, so I can't tell you anything else about it. But lord, lord. Does it never end? How can any ethical psychologist contemplate conducting research into unethical treatments? How can the rest of us, as ethical psychologists, countenance others doing it? And who the hell is funding this garbage?

They just don't get it. Except for one pretty seriously flawed study, there's no evidence that this even works, never mind that it is the right thing to do. Unfortunately, some groups advocating reparative "therapy" have seized on that one. It was published in 2003, by Robert Spitzer, in the Archives of Sexual Behavior. Spitzer asked, "Can some gay men and lesbians change their sexual orientation?" His answer was a qualified "yes," and it sparked a storm of criticism (26 letters to the journal, which is almost unheard of) and outrage.

Spitzer interviewed 200 self-selected reparative "therapy" patients and reported that the majority reported achieving re-orientation to at least "predominant" heterosexuality that lasted more than five years. At what cost to their general mental health? He didn't ask. Besides that little omission, his study was criticized for its sampling method (subjects were self-selected) and for its reliance on self-report.

It has been long established scientifically that there can be extensive differences between potential subjects who do not participate in a study and those who self-select in. It is also long-established fact that people in similar situations are motivated to perceive change in the desired direction. These clients after all have spent money and time in therapy to change, and their views of what they got from these efforts are going to be biased accordingly. Spitzer's data would have been a lot more credible had he studied all the clients of a given treatment program or programs and had he obtained objective before-and-after assessments. In short, it's lame even as pilot studies go.

He's not a bad guy. But I think he exhibited terrible judgment in conducting this study. If we are going to study treatments that have already been declared unethical, of "problems" that have already been ruled not problems, then we need to be focusing our money and our time, effort, and talents on exploring the damage done by those treatments and how, if it's possible, to undo the damage to their victims. But nobody asked me.

That same year, another group published a study of a more general nature, also using survey data. This one, "Predictors of psychotherapeutic benefit of lesbian, gay, and bisexual clients: The effects of sexual orientation matching and other factors," was published in 2003 in Psychotherapy: Theory, Research, Practice, Training. Note that the authors were not specifically investigating reparative therapies, but therapy for LGB clients in general. These authors found that
Negative predictors include having a therapist who is an analyst, who uses reparative therapy, or who violates sexual boundaries (p. 289).
A quick check of PsychLit tonight produced no additional published research, only a how-to book containing "personal testimonies" and one single-case study (by an analyst). In short, no one advocating this practice is producing any real data to say that it works. (Spitzer, it must be noted, is not an advocate. He just thinks we need more data, which is hard to disagree with, except I just have to ask, "Man, if it's not a disorder, why do we give a rat's ass whether you can cure it?") Plus, those advocating this practice are proceeding on the clearly-stated assumption that being gay is dysfunctional, which assumption no professional group of which I am aware accepts.

If being gay, bi-sexual, or lesbian is normal, which the helping professions all now agree that it is, then buying into the client's desire to change it is buying into their internalized homophobia. (I'm not even going into forced treatment of children and adolescents: That's a whole 'nother rant.) It is agreeing with them that a core facet of their very identity is something to be disgusted by and ashamed of. Therapists like the 17% in the Great Britain survey may claim the best of intentions, but in fact are using their power as credentialed healers to do severe damage to suffering individuals who instead need to be relieved of their shame, not their orientations.

One of my absolute favorite clients made her first call to the office to ask The Question: "My son needs a therapist. But he is gay and before I make an appointment with you, I want to know how you feel about that." Usually, that question is code for, "Our kid just came out to us and we're in total panic and want you to fix him/her now, if not sooner." It's a hard question to answer, not because I don't know how I feel--I do--but because I want that teen in therapy with me. The last thing I want for him or her is for ignorant, homophobic parents to keep calling around until they find a therapist who will agree it's just a phase, a fad, or something to be cured. So I took a deep breath, and answered, as I usually do, "That's like asking me how I feel about gravity, or the weather. It just is what it is. May I ask why you want to know?" When the parent(s) tell me that they want treatment for the gay-ness or the trans-ness I do my best to educate them and get them to schedule an intake. Sometimes it works, sometimes it doesn't.

This mom, God bless her, laughed out loud, and said "Good! Because being gay is not his problem and I didn't want a therapist who would assume that it was." And we scheduled an appointment.

We did talk about being gay in that young man's therapy, because his father wasn't quite 100% on board with it, and because his school allowed bullying to continue unabated--even blaming my client for coming out at school (he didn't, he was outed). He was already well wired-in to the gay community, so he didn't need any pointers there. What he was here for was his obsessive-compulsive anxiety disorder, and that is what we focused on.

And that is as it should be. Any therapist who attempts to make a lesbian's or gay man's orientation an issue any more than a straight patient's would be ought to be taken to the ethics woodshed. Same goes for any therapist who would make an issue out of a transgendered person's identity: It should be no more of a factor in the therapist's mind than a straight client's gender identity would be, except for the obvious--that LGBT clients are a harassed, discriminated-against, abused, and not-infrequently-murdered-for-it minority who also suffer internalized homophobia. And those problems certainly should be at the top of a therapist's list of issues to deal with.

*A student at Kennesaw State is conducting a similar study, but asking whether therapists think a long list of practices associated with reparative therapy are ethical. To me, it's not up for discussion (this is Ethics Codes for Dummies) and I'm more than a little uncomfortable with the study for that reason; nevertheless, it will be interesting to see whether his results tally with the 17% of the other study. I'll keep you posted.


Virginia S. Wood, PsyD said...

In any event, you can't call it a "cure" that these reparative therapists are achieving. In my opinion, and in the absence of any objective evidence that the victims are happier and healthier afterwards, all you can say that has occurred is that the client has been helped back into the closet. And we all know that, long before reparative therapy came along, gays were doing that on their own. Dating members of the opposite sex, getting married, having children, sharing fag jokes at work. They might keep it up four times as long as Spitzer's five-year cut-off, but it was killing them.

Anonymous said...

I'm so glad to see you taking notice of this. I was excited to read it myself. Here is a link to an interesting resource about longitudinal results of religiously mediated change therapy. Dr. Mark Yarhouse continues to work to investigate efficacy of interventions that mediate change.

You're absolutely right! KSU does have a student investigating this right now! He'll probably want to know more about what you think on the subject.

Virginia S. Wood, PsyD said...

Dear Anonymous: I am not sure you read my post. In the first place, I am not addressing religious change programs. I am discussing the ethics of professionals attempting change. In the second place, I thought it was pretty clear that I am against it.

Anonymous said...

Oh I'm reading you loud and clear. Sounds like you have a pretty good emotional argument worked up here. Can you help me find good empirical data on the efficacy of affirmative approaches? I heard from a different psychologist that affirmative approaches were harmful and caused long term emotional damage.