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Is “reparative” therapy in the best interest of the patient?

F. J. Gianola, PA

F. J. Gianola is the department editor for PA Quandaries and is on the faculty of the MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine, Seattle. He has indicated no relationships to disclose relating to the content of this article.

CASE

Mr. D. is a 45-year-old man who comes to the office with a complaint of acute knee pain. This is his first visit. Mr. D. mentions to the physician that the injury occurred when he and his boyfriend were playing soccer. The physician asks Mr. D. if he is gay, and the patient affirms that he is a homosexual. After additional conversation, the physician leaves the room to speak to the PA in his practice. The physician (who is the PA’s supervising physician) shares his concerns with the PA about the patient’s homosexuality, which he says is an “unhealthy” lifestyle. The physician gives the PA literature about “reparative” therapy provided by a local therapist. This therapy, also called “conversion” therapy, attempts to change a homosexual orientation to a “natural” and “safer” heterosexual orientation. After the PA reads the literature, the physician asks the PA to present it to Mr. D., discuss it, and assist him in contacting the therapist for consultation. This therapeutic approach is new to the PA, and he is uncertain if it is the proper approach.

THE ETHICAL QUANDARY

Is reparative therapy in the best interest of the patient?

DISCUSSION

MEDICAL INDICATIONS Reparative therapy is a talking therapy that purports to change the sexual orientation of the patient being treated from homosexual to heterosexual. “Cure” rates are variable, depending on the studies reviewed. Haldeman discusses in detail the origins of psychological conversion programs.¹ They are rooted in a psychoanalytic tradition that holds that homosexuality represents “an arrest in normal psychosexual development….”¹ An example is Bieber’s work of intensive, long-term therapy to “rid the pathologic state that was not compatible with a happy life.”² Haldeman also presents numerous studies identifying “cure” rates from 10% to 30%, making the following observation: “Evidence for efficacy of sexual conversion programs is less than compelling. All research in this area has evolved from unproven hypothetical formulations about the pathological nature of homosexuality … treatments both analytic and behavioral … [are] designed to cure something that has never been demonstrated to be an illness.”¹

Advocates of conversion programs maintain the pathologic perspective, by a new paradigm of identity synthesis, by orthodoxy’s spiritual pathology, or by a descriptive diagnosis of ego-dystonic homosexuality. Examples include Howsepian,³ Yarhouse,⁴ and Carlton.⁵ Schroeder and Shidlo present several foundational issues, including negative side effects of conversion therapy.⁶ These include depression, poor self-esteem, and difficulties with intimate relationships.

PATIENT PREFERENCE Mr. D. is not sure he wants to engage in conversion therapy. He is content with his sexuality. He has decision-making capacity. He understands this is a long-term therapeutic commitment. His religious upbringing is the one thing that makes him feel unsettled about his homosexual relationship. He no longer attends the same denomination of church that he did as a child and teenager.

QUALITY OF LIFE Mr. D. considers himself to be in a loving, monogamous relationship with his partner of 15 years, with whom he has two adopted children. However, the physician believes Mr. D. has a poor quality of life because of his sexual orientation.

CONTEXTUAL FEATURES Many professional medical and therapeutic organizations reject reparative therapy, including the American Medical Association (AMA), American Academy of Pediatrics, American Psychiatric Association (APA), American Psychoanalytic Association, American Psychological Association, National Association of Social Workers, and American Counseling Association. The core concern of these organizations is that being homosexual does not constitute a psychopathology. In 1968, the American Psychiatric Association removed homosexuality from the list of mental disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The diagnosis of ego-dystonic homosexuality remained in the manual until the 1987 revised third edition (DSM-III-R), when it too was removed.

The position of three of the organizations represents the opinion of the majority of the groups opposed to this manner of therapy.

The AMA’s position is as follows:

Whereas, the American Psychiatric Association removed homosexuality from its list of mental disorders in the Diagnostic and Statistical Manual in 1973, and the American Psychological Association followed with a similar action two years later; … RESOLVED, That the American Medical Association oppose any psychiatric treatment, such as “reparative” or “conversion” therapy which is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his/her homosexual orientation.⁷

The APA’s position paper on therapies to change sexual orientations includes the following:

The validity, efficacy and ethics of clinical attempts to change an individual’s sexual orientation have been challenged. … There are no scientifically rigorous outcome studies to determine either the actual efficacy or harm of reparative treatments…. Until there is such research available, APA recommends that ethical practitioners refrain from attempts to change individuals’ sexual orientation, keeping in mind the dictum to first, do no harm.⁸

The Washington State Psychological Association policy in part states:

Psychologists do not provide or sanction cures for that which has been judged not to be an illness. Individuals seeking to change their sexual orientation do so as a result of internalized stigma and homophobia; given consistent scientific demonstration that there is nothing about homosexuality per se that undermines psychological adjustment. It is therefore our objective as psychologists to educate and change the intolerant social context, not the individual who is victimized by it. Conversion treatments, by their very existence, exacerbate the homophobia which psychology seeks to combat.¹

SUPPORTERS OF REPARATIVE THERAPY In 1992, Socarides, a psychoanalyst who disagreed with removing homosexuality from the DSM,⁹ and Nicolosi, who first described reparative therapy,¹⁰ founded the National Association of Research and Therapy of Homosexuality (NARTH). NARTH has led the research into and treatment using reparative therapy. This is the only professional member organization that actively advocates reparative and conversion therapies.

NARTH is an association founded to study homosexuality. We make the assumption that obligatory homosexuality is a treatable disorder.…

The NARTH officers may opt to deny or remove membership when an individual’s written statements or public speeches show a clear antipathy to this position. We … will do so when, in our judgment, a potential member is likely to be disruptive because he or she is blatantly opposed to our goals.

Our criterion of discrimination is philosophical; we do not … discriminate on the basis of sexual orientation. In fact, many of our members are ex-gays or homosexual people in a state of transition toward heterosexuality.¹¹

NARTH maintains the principle of autonomy and claims that if the patient is informed and coercion is not involved, the therapy is ethical and defensible. Rosik articulates this position in his paper, “Motivational, Ethical, and Epistemological Foundations in Treatment of Unwanted Homoerotic Attraction.”¹²

RECOMMENDATION As we examine the data and consider the principles that stand in the background of the analysis, what are your conclusions? The ethical conundrum is whether reparative therapy is in the best interest of the patient. Mr. D. is unsure if he wants to participate in it. He believes he has a very good quality of life as a homosexual man in a long-term committed relationship. The quintessential reasons for any treatment are the existence of pathology and whether the treatment fulfills the goals and benefits of medicine. Two of the core goals of treatment are to cure disease and avoid harm to the patient. In 1987, homosexuality was removed from the DSM as a mental disorder. Peer reviewed papers report negative side effects from reparative or conversion therapy, including depression, poor self-esteem, and difficulties with intimate relationships. Contextually, numerous professional organizations oppose this therapy. NARTH is the only organization supporting reparative therapy and defining homosexuality as a treatable disorder. To offer a therapeutic treatment when no illness actually exists is antithetical to the goals and values of the PA profession.

REFERENCES

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