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PSYCHOLOGY'S SEXUAL DIS-ORIENTATION.

Within the American mental health profession, there is now a strong movement to prevent conversion therapy, a type of psychotherapy in which a homosexual patient's sexual orientation is changed to heterosexual. Resolutions to this effect have already been adopted by the Washington State Psychological Association and a committee of the National Association of Social Workers and are now under consideration by the American Psychological Association and the American Psychiatric Association.

Many liberals who vigorously oppose any outside interference in the private decision between a woman and her doctor about aborting a fetus have no qualms about interfering in the decision between that same woman and her doctor concerning a change in her sexual orientation. This is only one of many ironies in the extraordinary history of the American mental health profession's struggle with homosexuality, a history that can itself be characterized as a "conversion." This history opens a window on our societal ambivalence toward not only homosexuality but also the broader questions of mental illness and individual rights.

Early in this century, American psychiatry was dominated by psychoanalysis. According to early psychoanalytic theory, the normal outcome of psychosexual development is an adult whose sexual activity is predominantly heterosexual vaginal intercourse. Homosexuality was therefore seen as a failure of development brought about by some childhood trauma. Ironically, this psychoanalytic position was seen by many advocates of homosexual rights as progressive because it was an advance over traditional beliefs that homosexuality is a form of moral degeneracy or even a punishable crime.

DIAGNOSING HOMOSEXUALITY

In 1952 the American Psychiatric Association formalized its system of diagnosis and published the Diagnostic and Statistical Manual of Mental Disorders (DSM). Today, a DSM listing has practical consequences; whether treatment for a problem is paid for by health insurance companies or a psychological problem qualifies as a disability under various laws often depends on whether it is listed in DSM.

Not surprisingly, given the psychoanalytic theory shared by most clinicians, the DSM listed homosexuality as a psychiatric disorder. Interestingly, it was classified as a sociopathic personality disturbance, meaning that the diagnosis could be made purely on the basis of the homosexuality alone, despite the absence of subjectively experienced distress. In the 1968 revision of the DSM, homosexuality was still included as a disorder but classified more descriptively under "sexual deviations" along with disorders such as fetishism and pedophilia. What followed is unprecedented in the annals of medicine.

The publication of DSMII coincided with the founding of a militant gay liberation movement whose goals included the normalization of homosexuality as a legitimate "lifestyle." Gay activists mounted a furious attack on the American Psychiatric Association for designating homosexuality a disease. Their most effective form of protest consisted of demonstrations at several professional conventions, most critically the 1970 disruptions in San Francisco. Over the next three years, the association was forced to reconsider not only the inclusion of homosexuality in DSMIII but also the entire conceptual basis for defining a mental disorder.

The gay liberation movement considered the psychiatric designation of homosexuality a major basis for antihomosexual attitudes in American society. It justified a wide variety of antihomosexual legislation, ranging from laws barring homosexuals from immigrating to the United States or serving in the military to regulations in New York requiring homosexual taxicab drivers to undergo semiannual psychiatric examinations. In a broader sense, the designation reinforced the prevalent attitude that homosexuality is an "illness." According to the activists, this stigmatization not only justified bigotry but also caused gay men and lesbians to turn against themselves in self-hatred. The DSMII diagnosis was seen as a societal attempt to control human sexuality under the guise of a medical diagnosis.

After intense lobbying and debate, in December 1973, the Board of Trustees passed the proposal to remove homosexuality from DSMII. Because of the sharp disagreements within psychiatry, however, the board, as a compromise, replaced homosexuality with "sexual orientation disturbance" for "individuals whose sexual interests are directed primarily toward people of the same sex and who are either disturbed by, in conflict with, or wish to change their sexual orientation." This compromise allowed homosexuality to be dropped as a disorder, giving the gay lobby what it wanted, and, at the same time, it allowed psychiatrists to treat homosexuality under the new diagnosis.

The board's decision unleashed a storm of counterprotest from many psychiatrists. Opponents saw the board's decision as a capitulation to gay activism rather than a reasoned judgment based on medical evidence. They forced the leadership to submit its decision to a referendum of the organization's membership. After an intense campaign, of the approximately ten thousand votes cast, the proposal passed with 58 percent. In retrospect, it seems shocking that the question of whether a condition is a psychiatric disorder should be decided by a vote, but a closer look at the debate indicates that a vote is not as strange as it seems.

DECIDING WHAT IS HEALTHY AND WHAT IS A DISORDER

Although the gay liberation movement's arguments were based mostly on the social implications of the diagnosis, the board tried to limit its consideration to scientific and medical arguments. The "scientific" considerations were based on two kinds of evidence. One was a body of research strongly pointing to a major biological basis for homosexuality. This included ethological studies finding homosexuality throughout the animal kingdom, cross-cultural investigations indicating homosexuality is a human universal (and in some cultures, socially accepted), and neuroendocrinological studies showing the effects of hormones on brain development. The implication was that homosexuality is not simply the result of childhood trauma. It is neither freely chosen nor "unnatural."

The more important evidence came from psychological studies of gay men and lesbians in the general population. A major criticism of pathological theories of homosexuality was that they were derived from observations of homosexual patients who were seeking professional help. Not surprisingly, they found that homosexuality was closely associated with a variety of psychopathologies. However, when nonpatient homosexual populations were studied, it was found that many homosexual adults were leading well-adjusted, fulfilling lives. In general, homosexuality was not associated with any increased incidence of psychopathology.

Neither of these bodies of evidence is decisive. To be sure, findings supporting a biological contribution to homosexuality undermine the early psychoanalytic explanations. But the evidence is not all in, and even today it is too early to prejudge the issue. More important, even if homosexuality is shown to be genetically based, biological determination does not preclude a condition from being a disorder or from being treated. Some forms of depression and anxiety are known to have biological causes but are nevertheless considered psychiatric disorders and are often effectively treated, both biologically and psychologically.

The second argument, that homosexuality is not associated with other conditions recognized as psychopathologies, also falls short. It begs the question as to whether homosexuality in and of itself is a psychopathology. From the fact that a person can be perfectly healthy except for a broken bone, we would not argue that fractures are not medical problems. One could just as well argue that because many people with phobic anxieties manage to cope well, live full lives, and show no symptoms other than their narrowly focused anxiety, phobias are not psychopathologies. Furthermore, several of the disorders retained in DSMII also do not necessarily involve subjective distress (e.g., fetishism).

The scientific evidence is not decisive because it is irrelevant. Whether something is a psychopathology can be judged only relative to standards of mental health, and these, in turn, depend on our societal conceptions of healthy functioning, the good life, and the purposes of human existence. What is considered healthy functioning in one society may be viewed as an illness in another. Clearly, there is an evaluative dimension in deciding what is healthy and what is a disorder, and this dimension involves our deepest values as a society. Science can provide information, but it cannot decide questions of values. It can tell us what we are, not how we ought to be. Psychopathology is thus necessarily a matter of social construction, subject to historical, cultural, as well as political forces.

The DSM implicitly recognizes the social constructive nature of the disorders it describes. Frequently, diagnostic criteria include personality features, such as a tendency to worry, that are quite common, and the DSM requires that to meet the criteria the feature must be "excessive" or "clinically significant." The DSM instructs the clinician to take into account contextual factors like the person's culture, family, social role, and occupation. What is considered "excessive" subservience in one culture might be valued as virtuous humility in another. Diagnosis is always relative to a set of values.

SEXUAL DISORDER

Thus, the decision whether homosexuality is a psychopathology is really a social-cultural question rather than a scientific one, and settling the matter by debate and a vote is not as bizarre as it initially appears. Scientific studies may inform the discussion, but the final decision must be a societal value judgment. Accordingly, the continuing controversy in the mental health profession over this issue merely reflects the cultural divergences in our wider society over homosexuality, and polities within the profession have been critical in every stage of this debate.

With the decision voted upon, homosexuality was dropped in the seventh printing of DSMII, and "sexual orientation disturbance" was substituted. In DSMIII, further refinements were introduced. First, "sexual orientation disturbance" was replaced with "ego-dystonic homosexuality" as a term to diagnose clients persistently distressed by their homosexuality and wishing to have heterosexual relationships. This change clarified that only homosexuals were intended and emphasized the impairment in heterosexual functioning. Second, the stated causes of this disorder consisted of the negative attitudes of society toward homosexuality and/or desire for heterosexual life of family and children. Thus, contrary to psychoanalytic theory, the causes were presented as entirely social rather than internal conflicts or family dynamics.

Eventually, even this revised compromise was opposed. Critics charged that the new terminology singled out only homosexuality as an orientation that might lead to distress. Second, it suggested that homosexuality itself can still be considered a disorder rather than a normal variant of human sexuality. Third, it failed to recognize that in the United States, almost all people who are homosexual normally pass through a phase in which their homosexuality is ego-dystonic. Consequently, yet another compromise was devised. In DSMIII-Revised, even ego-dystonic homosexuality was omitted. Clients with a "persistent and marked distress about sexual orientation" would now be diagnosed with "sexual disorder not otherwise specified." The term homosexuality no longer appeared.

This arrangement continues in the current DSMIV published in 1994; however, refinements were introduced in the diagnoses of the remaining sexual disorders. Now, a sexual disorder, such as pedophilia, cannot be diagnosed unless the client shows clinically significant distress or impairment in important areas of functioning. Thus, pedophilia, in and of itself, is no longer a disorder, a change supported by the North American Man-Boy Love Association, an organization committed to the legitimization of pedophilia.

Three years after the publication of DSMIII-Revised, Congress passed the Americans with Disabilities Act. Ironically, in formulating this law, an alliance emerged between gay rights supporters and congressional conservatives. The former did not want to see homosexuality included as a disability because they considered it healthy, and the latter also opposed its inclusion because they did not want homosexual citizens to be granted accommodations and protections under the law. Consequently, the act explicitly disqualifies homosexuality as a disability.

Thus, in the early nineties, despite the elimination of homosexuality itself as a disorder, clients seeking conversion therapy could still be diagnosed and obtain treatment. But forces were at work to block even this one remaining avenue. For example, the Gay and Lesbian Caucus of the American Psychiatric Association advocated declaring the practice of conversion therapy to be professionally unethical. In response, the National Association for Research and Therapy of Homosexuals (NARTH) was founded in 1992 to protect the right to conversion therapy. NARTH planned to hold a 1995 conference, and, as is standard professional practice, it attempted to publish an announcement of its conference in the monthly newspaper of the American Psychological Association, the Monitor. The association refused to publish the announcement, however, because of NARTH's position that homosexuality is a treatable mental disorder.

This incident clearly indicates the ideological nature of the debate over the psychiatric status of homosexuality. Our understanding of sexuality, both homosexual and heterosexual, is very limited. We do not know, for example, how either comes about or what explains the great variety in the ways they are manifested. One can theorize about these matters and propose hypotheses. But it hardly makes sense, given our ignorance, for a professional group to take a firm stand if the issue were purely scientific. Only if the decision is seen as a value judgment is it reasonable for the APA to say, as a matter of policy, that homosexuality is not a mental disorder and to try to silence another professional group holding a different opinion.

CONVERSION THERAPY

Thus, the current proposal discouraging conversion therapy is simply the culmination of a long series of steps in the mental health profession's conversion. Within the American Psychological Association, pressure to pass the proposal comes from the Society for the Psychological Study of Lesbian and Gay Issues as well as the Committee on Lesbian and Gay Concerns. These groups have long championed the causes of homosexual individuals within the mental health profession. The immediate impetus for the current proposals arises from two related sources. First is the emergence of a powerful fundamentalist Christian movement to recruit and convert homosexual Christians to heterosexuality or to celibacy. Groups such as Homosexuals Anonymous, Metanoia Ministries, and EXIT have vigorously preached the message that homosexuality is sinful and have formed counseling programs and support groups for homosexual Christians. This sort of ideology is anathema to homosexual rights groups. A second reason for the current concern about conversion therapy is the increase in the number of reports of adolescents being coerced into involuntary conversion therapy by parents or religious leaders.

When the anticonversion proposal was introduced to the Council of Representatives of the American Psychological Association, it immediately ran into a host of problems. Foremost was the advice of the association's own legal counsel. He noted that a resolution against conversion therapy could be challenged on the basis of antitrust laws as an unreasonable restraint on free trade. Conversion therapists could not practice their profession, and willing clients could not purchase the service. To defend against such a challenge, the association would have to show that the resolution is supported by sound scientific and professional data, and he raised the question as to whether this is the case. As he stated, "If the courts view APA's motivation as more political or ideological, rather than patient protective, the reasons for enacting the resolution would be less defendable."

Furthermore, the resolution was opposed by a number of bodies within the American Psychological Association. For example, the Committee on Ethnic Minority Affairs supported clients' right to choose to understand and alter aspects of their sexuality they find problematic. In its evaluation of the proposal, the Committee on Women in Psychology questioned the resolution's assertion that conversion therapy is ineffective or harmful and called for more research. Similarly, the council representative from the Division for Humanistic Psychology opposed the resolution on the ground that it prejudged a number of issues before the data warranted any strong conclusions and therefore interfered with freedom of expression.

Because of the problems encountered by the resolution, a subcommittee has been appointed to review the resolution, revise it, and propose a substitute. Although the substitute will undoubtedly soften some of the language of the original, it will certainly continue the trend toward normalization of homosexuality and opposition to any theory or treatment that disagrees with that stand. Given the political climate prevailing in the association, it is likely that some form of the resolution will eventually be adopted. As a result, homosexuality, once regarded as a disorder requiring psychotherapy, will be seen as a normal condition for which treatment is discouraged even if requested.

ASSESSING CONVERSION THERAPY

The arguments in favor of this current antichoice position fall roughly into two classes, clinical and ethical. The first clinical argument is that conversion therapy does not work. This claim is controversial and complicated. First, the category "homosexual" covers a very wide variety of phenomena. For example, it is now thought that gay men and lesbians differ greatly in their psychodynamics, psychosexual development, and sexuality. Even within these two groups, there is wide variety. At one end of the continuum are individuals who from childhood are exclusively homosexual in their erotic fantasy, desires, identity, and behavior. At the other end of the continuum are individuals who are heterosexual to a corresponding degree. In between is a large number of people, some of whom are "bisexual," and many of whom identify themselves as either homosexual or heterosexual. Further complicating matters is that for many, sexual orientation is fluid, changing over the life span. Thus, human sexuality is more complex than the simple dichotomy of homosexuality and heterosexuality.

Similarly, there is variety in what is considered conversion. At one extreme is a complete change in erotic fantasy, desire, identity, and behavior from homosexual to heterosexual. But other forms of change are also possible. For example, a gay male may wish to increase his sexual desire for women sufficiently to acquire a heterosexual repertoire. Or he may wish to control his behavior so that homosexual urges do not lead to homosexual behavior. He may thus continue to experience homosexual desires and imagery, but he may succeed in diminishing their frequency, intensity, and urgency, or may learn to react to them very differently.

Finally, "conversion therapy" covers a variety of methods ranging from fundamentalist Christian programs to psychoanalysis. One form of successful conversion therapy uses the techniques of behavior therapy, a type of psychotherapy now in its fourth decade and currently considered one of the most effective treatments for depression and anxiety. Behavior therapy sees all behavior in neutral terms and does not categorize homosexuality as either pathological or sinful. Whether a behavior is to be modified depends on the agreement of therapist and client. To the extent that behavior is a function of environmental factors and experience, behavior can be modified by altering those conditions.

A behavior-therapy conversion program consists of two components. On the one hand, the client is taught a repertoire of heterosexual behavior. This is accomplished by reducing any anxieties involving heterosexual activities, learning heterosexual social skills, and increasing heterosexual arousal through conditioning. On the other hand, homosexual behavior and urges are decreased. This is achieved by "aversion conditioning" in which homoerotic stimuli, such as photos, are associated with unpleasant stimuli, such as mental images of repulsive homosexual contacts under stressful conditions or with electric shock. The client also learns self-control methods, including relaxation and imagery techniques, to control remaining homosexual urges.

Thus, in assessing the effectiveness of conversion therapy, it is important to specify the patient population, the method, and the definition and measurement of effectiveness. Much of the controversy over the effectiveness of conversion therapy surrounds disagreements over these issues. Conversion therapy may be less effective for those exclusively homosexual under a very strict criterion of effectiveness. However, for many homosexual clients in the middle of the continuum and for less extreme kinds of change, success is clearly possible. To be sure, the efficacies of the various types of conversion therapy have not yet been subjected to rigorous scientific tests. Nevertheless, contrary to the beliefs of some critics, the lack of conclusive evidence for effectiveness is not the same as conclusive evidence for a lack of effectiveness.

Clients should, of course, be informed of their likelihood of success, but even under circumstances for which the rate of success is low, informed clients may still reasonably choose to try. Similarly, a low success rate is not a good argument against research to discover more effective methods. As in all science, we cannot know in advance what future research may reveal.

A second antichoice argument is that homosexuality is part of a person's core identity. Trying to change this can only do violence to the person's self-identity and damage him psychologically. Again this is a controversial and complicated matter. Certainly, clients should not be coerced, and they should be informed of possible risks. Obviously, conversion therapy methods that proved to be harmful should be banned. Nevertheless, there is currently no good evidence that all methods of conversion therapy harm clients. Indeed, one reason that the APA resolution could be legally challenged is that there is insufficient evidence to prove that conversion therapy is harmful.

Even on the theoretical level, there is reason to believe that conversion therapy can decrease rather than increase identity conflict. Consider two hypothetical cases:

* A 47-year-old woman, married with two children, shows no psychopathology. She lives a fulfilling life within her career and family. After the birth of her second child, she had become active in feminist causes. As she became more involved politically, she found for the first time in her life that she was experiencing an increasingly intense erotic attraction toward another woman. She reports that she loves her husband and that she does not want to destroy her marriage and family, but she believes that acting on her lesbian urges will end the marriage. She asks help in learning to control her urges.

* A 20-year-old Orthodox Jewish male reports homosexual erotic fantasies and desires since childhood. He has not acted on them because he considers them sinful. He is very well integrated into his Orthodox Jewish community and greatly desires to live a life consistent with its values. He appears well adjusted otherwise. He asks for a change in orientation sufficient to live a heterosexual life.

In both these cases, there are already serious conflicts among core aspects of these persons' identities. It does not seem unreasonable for them to choose to modify their sexual orientation. Conversion therapy adds no conflict not already present and might, in fact, decrease it to facilitate better integration of personality.

According to a third antichoice argument, although clients may report that the homosexuality is unwanted, the real problem is their inability to accept themselves. They have internalized the antihomosexual attitudes of our culture, and the treatment should be aimed at self-acceptance rather than changing homosexuality. Extreme versions of this argument claim that in our antihomosexual society, negative attitudes are so easily internalized that a request by a homosexual client for a change in sexual orientation must always be seen as "coerced," a result of societal attitudes, rather than genuine.

This third argument raises important issues. In all requests for change in psychotherapy, both therapist and client must together come to understand the motivation for the request. In many instances, the motivation may be found to be neurotic. A request for heterosexuality can just as well function, consciously or unconsciously, as a defense against homosexuality as readily as homosexuality can serve as defense against heterosexuality. As in all cases, a therapist must exercise good clinical judgment in exploring when a request for change represents a problem in self-acceptance. Yet, there are instances, as in the two cases described above, when the desire for heterosexuality is a conscious choice, not a neurotic defense, and a change in sexual orientation is a reasonable and clinically defensible resolution to a conflict.

To claim that a request for conversion therapy is always coerced, that clients do not really want change, is to attribute a false consciousness to clients; we know better than they what they want. Not only is this a patronizing and disrespectful attitude, but it mirrors psychiatric attitudes of fifty years ago. Well-adjusted homosexual adults were told that although they believed they were happy, psychiatry, with its superior insights, knew that they were sick. We have now come full circle. In the words of one NARTH official, "The oppressed have now become the oppressors."

The first of the ethical antichoice arguments is simple. Since homosexuality is not a disorder, it should not be treated simply to satisfy cultural prejudice. To see the weaknesses of this argument, consider the analogous case against cosmetic surgery, which exposes the patient to the risks of surgery to change a condition that is not a disorder. Often, such surgery is chosen because of prejudice (e.g., Asian women who undergo cosmetic surgery to look more "Western"). Similarly, for most abortions, pregnancy is not a disorder. Often, the reasons for the abortion are cultural--societal expectations about the "appropriate" financial and time resources needed to raise a child. Yet we do not discourage these procedures, and in some cases society funds them.

A second ethical antichoice rationale argues that although treatment without a pathology might be ethical in specific instances, the message implied by such treatment is morally problematic. By "treating" homosexuality, the profession sends the message that homosexuality is a disorder. Moreover, the theories on which treatment is based are psychopathological models of homosexuality. To many homosexual individuals, especially teenagers confused, shamed, and overwhelmed by their emerging homosexuality, the message that homosexuality can be "cured" intensifies their anguish, leading possibly to suicide.

This argument shares some of the weaknesses of the previous one. Psychological treatment does not imply a disorder. For example, psychologists treat people who want to increase their ability to relax, improve communication, manage time better, as well as a host of other American ideals of the nineties. Does abortion send a message that pregnancy is a disorder? Furthermore, some conversion therapies, most notably behavior therapy, are not based on a pathological model of homosexuality.

According to a third ethical antichoice argument, although conversion therapy does not logically imply that homosexuality is a disease, it will nevertheless be misconstrued as sending that message, given the antihomosexual attitudes of some segments of our society, including many practitioners of conversion therapy. Cosmetic surgery, sports medicine, and stress reduction do not reinforce any comparable preexisting prejudices in our society. But the very existence of conversion therapy justifies prejudice and increases psychological distress for homosexual people. We must consider the societal impact of our practices, even if they are reasonable and moral in individual instances.

CONCLUSION

How do we balance the opposing societal interests? On the one hand, society has an interest in discouraging practices that may promote dangerous prejudices. On the other hand, society has an interest in maintaining access to treatment as well as the free expression of ideas and opinions.

On the level of individual rights, however, the conflict is not so even. Individuals have privacy fights to decide with their therapists about psychotherapy goals, free from the ideological agendas of others. The antichoice argument is that the exercise of this right results in anti-homosexual attitudes. Certainly, homosexual individuals have the right not to be assaulted, harassed, or discriminated against, or even forced into therapy, and we can and do have laws to ensure this. As long as we have freedom of thought and speech, however, individuals do not have a right to be free from negative attitudes directed against them, especially since not all antihomosexual opinions derive from ignorance or prejudice. The individual fights of those seeking conversion therapy seem to take precedence.

Of course, society may choose to override individual rights for the greater good. In thinking about whether society's interests in eliminating antihomosexual attitudes override individual freedoms, we may once again look to the analogous issue of abortion. Many have argued that allowing abortions on demand, especially for frivolous reasons like the gender of the fetus, devalues life. After all, if you can kill the fetus before it emerges from the womb, why can't you abuse it afterward? Our society (at least our courts) has decided that the negative impact of abortion on societal attitudes is not sufficient to override the individual's right to abortion.

Similarly, societal interests in decreasing conversion therapy are not sufficiently overwhelming to override the individual's right to choose a psychotherapeutic treatment. It is highly doubtful that discouraging conversion therapy would have a measurable impact on prejudice. The existence of voluntary conversion therapy as practiced by professionally accredited psychotherapists plays a very minor role in the creation of dangerous antihomosexual prejudice, as compared with religion, gender norms, and ignorance.

With or without conversion therapy, antihomosexual attitudes will continue. But for those seeking conversion therapy, its unavailability will make a major difference. Their suffering and the loss of individual rights to psychotherapeutic privacy and control over one's own psyche seem too steep a price to pay for a minor increment in society's tolerance. Society must be made aware of how a commendable attempt to eliminate dangerous prejudice has grown into a threat to individual liberty and freedom of thought.

G.E. Zuriff is professor of psychology at Wheaton College and a clinical psychologist in the Medical Department of the Massachusetts Institute of Technology.
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Author:Zuriff, G.E.
Publication:World and I
Date:Apr 1, 1997
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