The New York Times Magazine will have a lengthy print article on sexual identity concerns, especially among evangelical gays this sunday. The well-written article by Mimi Swartz is now up online at this link.
I have been away for several days and won’t be able to comment much under Sunday or Monday, but I think she did a nice job of bringing together several lines of thinking which led to the sexual identity management/therapy approach to handling sexual identity concerns. Her descriptions of the sexual identity therapy framework start about here and are woven throughout the later part of the article.
The one aspect of the piece I don’t like is the title – Living the Good Lie. We do not encourage this and in fact advocate for acceptance, even if that acceptance is not with approval. More on that when I can reflect a bit more…
Category: sexual identity therapy
Sexual identity: Thoughts on the status of the reorientation wars
(First posted on August 12, 2009)
So now that the dust has started to settle from the APA convention in Toronto, let’s review the status of the Reorientation Wars.
Does therapy change orientation?
In anticipation of the APA’s report, NARTH fired an opening salvo with their paper (What Research Shows…). Perhaps sensing, incorrectly as it turns out, that the APA would advocate a ban on reorientation therapy, NARTH tossed every positive reference to change they could find into the paper. They noted problems in defining sexual orientation but did little to distinguish the various definitions and their meaning in the many studies they cited. They concluded, of course, that therapy can change orientation.
The APA on the other hand, differentiated sexual orientation and sexual orientation identity. Sexual orientation for them is the biological responsiveness to one gender or both. According to their literature review, the evidence that therapy can change orientation is not sufficient to permit therapists to inform clients that therapy can change their orientation. However, sexual orientation identity (i.e., self-labeling) may shift and be responsive to a variety of factors, including religious mediation.
It seems to me that what NARTH is calling sexual orientation includes the APA’s sexual orientation identity. While this statement risks taking us into the “all or nothing” dead end discussion about change, I do not mean that one must change completely for change to be important and psychologically relevant. I suggest instead that what many studies measure is how people see themselves, even if their sexual responsiveness (orientation) has only shifted by a degree (e.g., an average of less than a point on the Kinsey scale in the Jones and Yarhouse study). Jones and Yarhouse suggest as much in their recent paper when they write:
There is also the question of sexual identity change versus sexual orientation change (see Worthington & Reynolds, 2009). Recent theoretical (e.g., Yarhouse, 2001) and empirical (e.g., Beckstead & Morrow, 2004; Yarhouse & Tan, 2004; Yarhouse, Tan & Pawlowski, 2005; Wolkomir, 2006) work on sexual identity among religious sexual minorities suggests that attributions and meaning are critical in the decision to integrate same-sex attractions into a gay identity or the decision to dis-identify with a gay identity and the persons and institutions that support a gay identity. In light of the role of attributions and meaning in sexual identity labeling, is it possible that some of what is reported in this study as change of orientation is more accurately understood as change in sexual identity?
I believe the answer to their question is that it is not only possible but probable that change in sexual identity is what is being reported. The distinction between orientation and identity (or attraction and identity as we often describe it here) is key, in my view, in order for us to understand the experience of those who say they have changed while at the same time experiencing same-sex attraction. I also believe that men and women are different and their change may be different. Women seem to describe less exclusivity than men. Fluidity may be more likely with complete shifts described. I think we need to accommodate atypical experiences such as men and women who completely shift for a time and then shift back. Whatever the pattern, I hope we can agree that sexual attraction patterns may be one thing while meaning making aspects may lead two people with the same attraction pattern to identity in disparate ways.
Is sexual reorientation harmful or beneficial?
NARTH says reorientation might harm some people but that for the most part it is not harmful. The APA says existing studies are not good enough to allow conclusions. Point for the APA here. All we can say is that some people report harm and some people report benefit. The APA notes that the benefits can occur in programs which promote congruence with religious faith. This is clear and the Jones and Yarhouse study demonstrate that health status improves modestly for those who remained in the study. However, I would say we do not yet know much about what the potent or beneficial elements of those programs are. The APA report identified some of those elements.
Homosexuality and pathology
NARTH says homosexuals have more pathology than any other group of similar size. The APA says homosexuality is normal. By this they mean that homosexuality is not a developmental disorder or indicator of a mental disorder. The two recent reports go off in different directions but some observations can be made.
The NARTH report spends lots of time reporting on greater levels of mental health and health problems among homosexuals as compared to heterosexuals. The APA report does not do this. However, I believe the point regarding different levels of symptoms would be stipulated by the APA. However, the APA raises the minority stress model as responsible for many difficulties faced by non-heterosexual people. The NARTH report discounts the role of stigma.
I doubt the APA would dispute the health status data for another reason: greater group pathology does not mean inherent disorder. The APA’s position is not that gays have equal health outcomes but rather that the unequal health outcomes do not imply inherent pathology – that SSA is not inherently the result of pathological development. This is of course in great contrast to the reparative therapists. Joseph Nicolosi says that the only way you get SSA is to traumatize a child.
The reparative impulse to find trauma behind every gay person is misguided I believe, conceptually and for sure empirically. Women have greater levels of mental health problems than men but we would not consider women inherently disordered. NARTH has chosen some good studies to cite in the section of their paper which relates to health status (as well as some really bad and irrelevant ones). However, I don’t think it really gets them where they want to go.
And where do they want to go? This is clear from their press release complaining about the APA task force report. They state:
Further, if some clients are dissatisfied with the therapeutic outcome [of reorientation therapy], as in therapy for other issues, the possibility for dissatisfaction appears to be outweighed by the potential gains. The possibility of dissatisfaction also seems insignificant when compared to the substantial medical, emotional, and physical risks associated with homosexual behavior.
NARTH would suggest that these medical and emotional risks, along with the incongruity of homosexual behavior with the personal and religious values of many people will continue to be the motivation for some individuals to seek assistance for their unwanted homosexual attraction.
According to NARTH, gays ought to seek reorientation therapy because being gay is a risky life, full of health and mental health disadvantages. Their hypothesis is implied but hard to miss: reduce the SSA and reduce the health risks. The assumption appears to be that ex-gays will have better health outcomes than gays. One problem with this line of thinking is that there is no empirical evidence for it and some evidence against it.*
One researcher quoted in the NARTH paper regarding health risks was New Zealand’s David Fergusson. Dr. Fergusson has done significant work in this field. I asked him to look at the section of the NARTH paper in which his work was quoted. Here is a statement he provided about it:
While the NARTH statement provides a comprehensive and accurate analysis of the linkages between sexual orientation and mental health, the paper falls far short of demonstrating that homosexuality should be classified as a psychiatric disorder that may be resolved by appropriate therapy. To demonstrate this thesis requires an in depth understanding of the biological and social pathways that explain the linkages between homosexual orientation and mental health. At present we lack that understanding. Furthermore it is potentially misleading to treat what may be a correlate of mental disorder as though it were a disorder in its own right.
Fergusson also told me that one would need to develop studies to demonstrate that any changes in orientation associate with improvements in health status. The Jones and Yarhouse study provide some very general assessment but many potential confounds are uncontrolled. For instance, it is not possible to say that the modest shifts on the Kinsey scale were responsible for the shifts in health status. These folks were quite religious and religion is associated with enhanced health status. I suspect religious gays have a better health status than non-religious gays, on average. The point is we do not have evidence that sexual orientation status per se is what leads to the differences in health status.
While I am on the subject of health status, I need to mention that there are other factors which NARTH ignored. One, gender non-conformity is strongly correlated with adult homosexuality and is also associated with poorer mental health. Two, homosexuals report higher levels of sexual victimization which is also associated with higher levels of mental health problems. And, three, no one can discount the possibility that biological factors which associate with the development of homosexuality may also influence the development of emotional problems (i.e., in the same way women are more likely to report depression than men).
So where are we? I hope we have a larger middle and smaller numbers of people at the opinion extremes. People on both sides can agree that erotic responsiveness is extremely durable for men and perhaps less so for women, but behavior and self-identity reflection is alterable. People on both sides agree that conclusions about benefit and harm are not possible in any general sense. Also, I hope we can agree that full informed consent should be conducted prior to engaging in counseling. Regarding health status, both sides can agree that homosexuals have higher levels of problems but there is little agreement about what the differences mean.
Those on the far sides of the continuum will continue to argue that change is possible or change is impossible, and/or that reorientation is always harmful or never harmful and/or that health status difference mean something vital or irrelevant about inherent pathology.
The wars will continue but perhaps fewer people will be engaged in them; now is the time rather to reason together.
*Nottebaum, L. J., Schaeffer, K. W., Rood, J., & Leffler, D. (2000). Sexual orientation—A comparison study. Manuscript submitted for publication. (Available from Kim Schaeffer, Department of Psychology, Point Loma Nazarene University, 3900 Lomaland Drive, San Diego, CA 92106) – In this study, the authors found that mental health was better among the gay sample than the Exodus sample.
(Note: Social psychologist David Myers referred to this post in an op-ed on the APA task force printed in the Wall Street Journal.)
Sexual identity: Wall Street Journal reports on APA report and sexual identity therapy
(First posted on August 6, 2009)
The Wall Street Journal’s Stephanie Simon has captured well the application of the APA task force sexual orientation report in an article out this morning. Of course I would say that…
The men who seek help from evangelical counselor Warren Throckmorton often are deeply distressed. They have prayed, read Scripture, even married, but they haven’t been able to shake sexual attractions to other men — impulses they believe to be immoral.
Dr. Throckmorton is a psychology professor at a Christian college in Pennsylvania and past president of the American Mental Health Counselors Association. He specializes in working with clients conflicted about their sexual identity.
The first thing he tells them is this: Your attractions aren’t a sign of mental illness or a punishment for insufficient faith. He tells them that he cannot turn them straight.
But he also tells them they don’t have to be gay.
For many years, Dr. Throckmorton felt he was breaking a professional taboo by telling his clients they could construct satisfying lives by, in effect, shunting their sexuality to the side, even if that meant living celibately. That ran against the trend in counseling toward “gay affirming” therapy — encouraging clients to embrace their sexuality.
But in a striking departure, the American Psychological Association said Wednesday that it is ethical — and can be beneficial — for counselors to help some clients reject gay or lesbian attractions.
The APA is the largest association of psychologists world-wide, with 150,000 members. The association plans to promote the new approach to sexuality with YouTube videos, speeches to schools and churches, and presentations to Christian counselors.
According to new APA guidelines, the therapist must make clear that homosexuality doesn’t signal a mental or emotional disorder. The counselor must advise clients that gay men and women can lead happy and healthy lives, and emphasize that there is no evidence therapy can change sexual orientation.
But if the client still believes that affirming his same-sex attractions would be sinful or destructive to his faith, psychologists can help him construct an identity that rejects the power of those attractions, the APA says. That might require living celibately, learning to deflect sexual impulses or framing a life of struggle as an opportunity to grow closer to God.
While the report doesn’t use my exact words (e.g., I don’t say ‘you don’t have to be gay’), she does catch important aspects of the APA report and the stance I use within the sexual identity therapy framework. Furthermore, I don’t show the video at the same time in the same order of things to clients and then they make a decision about their direction. I do however, do extensive informed consent and answer lots of questions which involves videos and slides to answer. Thanks to Michael Bailey for those vids.
This report captures the essence of the novel findings in the APA report in contrast to the AP report which continues to present a polarized picture. For sure, as long as the dialogue around change is important to people, we keep talking past each other. However, when you look at what both sides actually claim, they are not that far apart. According to the AP report, Jones and Yarhouse are going to report over half of 61 subjects either changed or are celibate. Whatever the percentage, it is clear that change cannot be promised to clients as a predictable function of therapy or ministry. We should be able to agree about that and then place emphasis on belief and value congruence. From there, see what happens.
Sexual identity: APA sexual orientation task force report – Analysis
(First posted August 5, 2009)
Earlier today, the American Psychological Association governing board received the report of the Task Force on Appropriate Therapeutic Response to Sexual Orientation. The report and press release were embargoed until now. With this post, I want to comment on the paper and recommendations made by the Task Force.
Generally, I believe the paper to be a high quality report of the evidence regarding sexual orientation and therapy. The authors of the paper (see this post for the new release which contains authorship information) provide a very helpful discussion of the professional literature on sexual orientation change efforts (SOCE), potential benefits and harm and the role of religion and values in sexual orientation identity exploration. Before I get to a more detailed look at highlights, I want to note an important statement from the APA press release made by Task Force Chair, Judith Glassgold:
Practitioners can assist clients through therapies that do not attempt to change sexual orientation, but rather involve acceptance, support and identity exploration and development without imposing a specific identity outcome.
Dr. Glassgold here describes sexual identity therapy. In fact, as I will point out, the SIT framework is referred to positively throughout the paper. Whereas some evangelicals may be troubled by the negative view of sexual reorientation in this report, there is much here that clarifies important aspects of work in this field. The paper is long (130 pages) and so one post cannot capture all that is important. I want to start with what for me are the high spots, beginning with the abstract:
The 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 to change their sexual orientation. Thus, the appropriate application of affirmative therapeutic interventions for those who seek SOCE involves therapist acceptance, support, and understanding of clients and the facilitation of clients’ active coping, social support, and identity exploration and development, without imposing a specific sexual orientation identity outcome. (p. v)
While the paper takes a dim view of change efforts, the authors indicate that attempts to change have been viewed as helpful by some and harmful by others. This is a fair reading of the research. Given these assessments of the research, the stance the APA recommends is to provide supportive psychotherapy without imposing an identity outcome on the client. To get to this view, the authors review change literature, literature on outcomes and research regarding religion and sexual orientation. I want to briefly recap each section.
Efficacy of change efforts
The Task Force reviewed 83 studies that met basic standards for inclusion. They were not impressed with the methodological rigor of the body of research. Their conclusion:
Thus, the results of scientifically valid research indicate that it is unlikely that individuals will be able to reduce same-sex attractions or increase other-sex sexual attractions through SOCE. (p. 3)
Safety of change efforts
The Task Force provided a cautious and nuanced response to the question of harm or benefit from SOCE. I believe they are on target here. Some people report harm and some report benefit but there are no studies which allow conclusions about likelihood of either outcome for any given person. About safety, the press release notes:
As to the issue of possible harm, the task force was unable to reach any conclusion regarding the efficacy or safety of any of the recent studies of SOCE: “There are no methodologically sound studies of recent SOCE that would enable the task force to make a definitive statement about whether or not recent SOCE is safe or harmful and for whom,” according to the report.
Religion and change efforts
One of the highlights of the report is the discussion of religion and sexual orientation. The authors are to be commended for their balanced and thoughtful approach. I especially like the discussion surrounding the concepts of “organismic congruence” and “telic congruence.” On page 18, the paper summarizes these concepts well:
The conflict between psychology and traditional faiths may have its roots in different philosophical viewpoints. Some religions give priority to telic congruence (i.e., living consistently within one’s valuative goals) (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 & Yarhouse, 2006). Affirmative and multicultural models of LGB psychology give priority to organismic congruence (i.e., living with a sense of wholeness in one’s experiential self (W. Hathaway, personal 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 conflicts between their ideal self and beliefs and their 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 group’s perceived rejection of homosexuals or the other group’s 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 may be difficult to bridge.
On this blog, we have frequently grappled with these differences. Many such discussions have sides talking past each other because different views of congruence are assumed to be determinative. In this CNN clip about the Task Force, Psychiatrist McCommon and I came to about the same conclusion regarding congruence.
There are different assumptions about what best constitutes the answer to the question: ‘who am I?’ This paper nicely addresses these assumptions and acknowledges that people who are deeply committed to a non-gay-affirming religious position may stay same-sex attracted but not identify as gay. As the paper notes, this is an acceptable alternative.
Clinical approaches
The authors consider the role of therapy and ministries groups as aspects of SOCE. What they say about support groups is interesting.
These effects are similar to those provided by mutual support groups for a range of problems, and the positive benefits reported by participants in SOCE, such as reduction of isolation, alterations in how problems are viewed, and stress reduction, are consistent with the findings of the general mutual support group literature. The research literature indicates that the benefits of SOCE mutual support groups are not unique and can be provided within an affirmative 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. (p. 3)
In a nutshell, support groups can have benefit when the singular focus is not change of orientation. Our conversations here regarding the change versus congruence model is relevant. I think the kind of changes that are most common are ideological and behavioral. And when I say behavioral, I mean both cessation of unwanted behavior and also less preoccupation with seeking harmful sexual behavior. I think some people feel they have moved on the Kinsey scale because they have better self-control regarding same-sex behavior. These are good and important telic changes but they don’t represent the kinds of changes which reflect dramatic organismic shifts. Orthodox Christianity does not require organismic changes in order to pursue spiritual development.
Moving from ministry to clinical worlds, the application seems obvious to me. And perhaps it seems obvious since I have been advocating for this stance for several years now. The client sets the value direction and the outcome is not imposed.
In our review of the research and clinical literature, we found that the appropriate application of affirmative 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 & O’Neill, 1989, 1995; Tan, 2008; Throckmorton & Yarhouse, 2006; Yarhouse & Tan, 2005a; and Yarhouse, 2008). (P.55)
It is heartening to see the SIT framework referenced here (and elsewhere in the APA paper) as one “appropriate application of affirmative therapeutic interventions.” In general, I think the APA strategies and the SIT framework are quite compatible.
Bottom line: The APA report will likely be quite influential for years to come. They call for more research on SOCE and a cautious, and I think accurate, interpretation of the research on reorientation. I believe the therapeutic strategies called for are akin to the SIT framework and clarifies nicely the appropriate stance of therapists. The report also respects the place of religion in identity development and exploration. These issues were not clear prior to this report.
In additional posts, I will deal with various aspects of the paper as well as media coverage. The press release is here and here on the APA website.
Sexual Identity Therapy Framework resources
Peter LaBarbera today reprints Laurie Higgins critique of an article by Mark Yarhouse regarding the application of our sexual identity therapy framework (SITF). I am aware he does not mean to promote the framework but his articles have increased my emails about the framework and requests for referrals to therapists who practice in that manner. I refer them to the registry of practitioners who claim to use the SITF at the Institute for the Study of Sexual Identity. However, a quick look will confirm that many areas of the country are unrepresented there. This area clearly needs to be developed.
Those affiliated with ISSI include people working in several graduate programs in counseling and we aware of other programs who inform students about the SITF. By far, the largest organization that offers information regarding the SITF is the American Association of Christian Counselors. Mark and I presented a preconference workshop at the 2007 AACC conference titled, Introduction and Clinical Application of the Sexual Identity Therapy Guidelines.” A 3 CD set of that workshop is available on the AACC website. In 2008, Mark presented the SITF at the AACC West Region conference. A audio of that workshop is also available on the AACC website.
The website supporting the SITF is www.sitframework.com. There we have posted articles consistent with the SITF and a list of presentations regarding it. On YouTube, there is a two part demonstration of how I worked with BBC reporter David Akinsanya in 2005. Akinsanya had just left Love in Action early because he felt it did not fit him and his values. This interview was conducted in 2005 as the SITF was being developed.
Wall Street Journal reporter has followed the development of the SITF with a 2007 article in the LA Times and then a 2009 piece in the Wall Street Journal. Wikipedia has an entry on the SITF. The APA’s 2009 sexual orientation task force cited the SITF favorably as a means for clients to therapeutically explore their options.
Much needs to be done to develop the model and describe how existing models are applied with it. Between us, Mark and I have trained several hundred mental health and ministry professionals in the model and look forward to providing more opportunities for supervision and training.