In 1886 noted sexologist Richard von Krafft-Ebing listed homosexuality in his definitive work, Psychopathia Sexualis. Krafft-Ebing proposed that homosexuality was caused by either "congenital inversion" or an "acquired inversion".
In 1896 Sigmund Freud published Heredity and the Aetiology of the Neuroses, which contained his first ideas on psychoanalysis. Freud believed that all humans were innately bisexual. People could develop particular sexual orientations for numerous different reasons, including environmental factors interacting with biological sexual drives. Freud expressed serious doubts about the potential for therapeutic conversion. In a famous letter to a mother who had asked Freud to treat her son, he wrote:
By asking me if I can help [your son], you mean, I suppose, if I can abolish homosexuality and make normal heterosexuality take its place. The answer is, in a general way, we cannot promise to achieve it. In a certain number of cases we succeed in developing the blighted germs of heterosexual tendencies which are present in every homosexual, in the majority of cases it is no more possible. It is a question of the quality and the age of the individual. The result of treatment cannot be predicted.
In that letter, he also stated that "homosexuality is assuredly no advantage but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness....".
In 2008 German Bundestag decided that conversion therapy is dangerous and does not help.
Medical attempts to change homosexuality included surgical treatments such as hysterectomy, ovariectomy, clitoridectomy, castration, vasectomy, pudic nerve surgery, and lobotomy. Substance-based methods included hormone treatment, pharmacologic shock treatment, and treatment with sexual stimulants and sexual depressants. Other methods included aversion therapy, the reduction of aversion to heterosexuality, electroshock treatment, group therapy, hypnosis, and psychoanalysis.
During the three decades between Freud's death in 1939 and the Stonewall riots in 1969, conversion therapy received approval from most of the psychiatric establishment in the United States. The 1952 first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-I) classified homosexuality as a mental disorder. Prominent researchers arguing for therapeutic conversion included Edmund Bergler, Irving Bieber, Albert Ellis, Abram Kardiner, Lionel Ovesey, Sandor Rado, and Charles Socarides. Rado rejected Freud's theory of innate bisexuality. Rado argued instead that heterosexuality is nature's default setting and that homosexuality is caused by parental psychopathology. Socarides developed similar theories: Socarides regarded homosexuality as an illness arising from a conflict between the id and the ego usually arising from an early age in "a female-dominated environment wherein the father was absent, weak, detached or sadistic".
The conversion therapists rejected Freud's pessimism about therapy's ability to change sexual orientation. In 1962 Bieber et al published Homosexuality: A Psychoanalytic Study of Male Homosexuals, which concluded that "although this change may be more easily accomplished by some than by others, in our judgment a heterosexual shift is a possibility for all homosexuals who are strongly motivated to change. Homosexuality was assumed to be a psychopathology: Ellis found that "fixed homosexuals in our society are almost invariably neurotic or psychotic:... therefore, no so-called normal group of homosexuals is to be found anywhere."
Evelyn Hooker was a contrary voice when she published her 1957 paper "The Adjustment of the Male Overt Homosexual," which found that "homosexuals were not inherently abnormal and that there was no difference between homosexual and heterosexual men in terms of pathology. This paper subsequently became influential.
In 1966, psychologist Martin E.P. Seligman reported that using aversion therapy to change sexual orientation "worked surprisingly well," with up to 50% of men subjected to such therapy not acting on their homosexual urges. These results produced what Seligman described as "a great burst of enthusiasm about changing homosexuality [that] swept over the therapeutic community" after the results were reported in 1966. However, Seligman notes that the findings were later demonstrated to be flawed: most of the treated men who did stop having sex with men were actually bisexual. Among men who were primarily gay, aversion therapy was far less successful.
In 1969, the Stonewall riots increased the visibility of homosexuality in the United States. In 1970, Arthur Janov published The Primal Scream, which claimed that homosexuality was a neurosis that could be cured by a therapy involving screaming. Janov's therapy became widely influential. In 1973, after intense lobbying by gay groups, new scientific information from researchers like Evelyn Hooker and Alfred Kinsey, and dissension from the psychiatric ranks, the American Psychiatric Association declassified homosexuality as a mental disorder with a vote of 58% of the membership supporting the measure.
However, conversion therapy continued to be used. In 1992, the Phoenix Memorial Hospital in Phoenix, Arizona, was using these methods on children as young as 10. Aversion therapy is no longer sanctioned by the APA as a treatment for homosexuality.
In 1952, the British government subjected Alan Turing to hormonal treatment after he was arrested for having sex with a man.
In 2007, the Royal College of Psychiatrists, the main professional organization of psychiatrists in the United Kingdom and Ireland, issued a report stating that: "Evidence shows that LGB people are open to seeking help for mental health problems. However, they may be misunderstood by therapists who regard their homosexuality as the root cause of any presenting problem such as depression or anxiety. Unfortunately, therapists who behave in this way are likely to cause considerable distress. A small minority of therapists will even go so far as to attempt to change their client's sexual orientation. This can be deeply damaging. Although there is now a number of therapists and organisation in the USA and in the UK that claim that therapy can help homosexuals to become heterosexual, there is no evidence that such change is possible."
Western psychiatry and psychology were imported during a "Westernization Movement" in the late 19th century. That homosexuality was a mental disorder thus became the prevailing view in China. These views lasted throughout the 1970s, despite changed theoretical models of sexuality orientation in the West, during a period when the Chinese government held a "closed-door" policy on information about human sexuality. After 1980, information became more available, and views began to change. In 2000 and under pressure from both the APAs and the ACA, the Chinese Classification of Mental Disorders (CCMD-III) declassified homosexuality, but added a diagnosis resembling ego-dystonic sexual orientation. Attempts at conversion therapy are rare in China.
In India, psychiatry and psychology scholars have "preserved an almost complete silence on the subject of homosexuality". Aversion therapy continues to be used. One paper discusses behavior modification methods used to treat the sexual orientation of thirteen gay patients. They use the WHO classification of egodystonic sexual orientation, but the People's Union for Civil Liberties reports that doctors will often diagnosis the patient as egodystonic even if the patient really is egosyntonic.
In Norway the shift from a pathological to non-pathological view of homosexuality began in the 1970s, following the APA's declassification in 1973. In 2000, the General Assembly of the Norwegian Psychiatric Association overwhelmingly voted for the following position statement on conversion therapy: "Homosexuality is no disorder or illness, and can therefore not be subject to treatment. A ‘treatment’ with the only aim of changing sexual orientation from homosexual to heterosexual must be regarded as ethical malpractice, and has no place in the health system."
In the 1970s and 1980s, the South African Defence Force administered aversion therapy to people who were suspected of being gay.
The development of theoretical models of sexual orientation in non-U.S. countries with established mental health professions often tracks the history within the U.S. (although often at a slower pace) as a shift from pathological to non-pathological conceptions of homosexuality.
The World Health Organization's ICD-10, which along with the DSM-IV is widely used internationally, states that "sexual orientation by itself is not to be regarded as a disorder". It lists ego-dystonic sexual orientation as a disorder instead, which it defines as occurring where "the gender identity or sexual preference (heterosexual, homosexual, bisexual, or prepubertal) is not in doubt, but the individual wishes it were different because of associated psychological and behavioural disorders, and may seek treatment in order to change it." The APA dropped ego-dystonic homosexuality from the DSM-IV in 1987 and opposes the diagnosis of either homosexuality or ego-dystonic homosexuality as any type of disorder.
Rather than promoting cures for homosexuality, reparative therapists tend to characterize themselves as offering "a possibility of change" for homosexuals who are unsatisfied with their sexual orientation. This therapeutic model often emphasizes minimizing the patient's homosexual desires, rather than eliminating them outright. Most mental health professionals today consider reparative therapy discredited, but some professionals still attempt it. Joseph Nicolosi, Charles Socarides, and Benjamin Kaufman founded the National Association for Research & Treatment of Homosexuality (NARTH) in 1992, a mental health organization opposed to the mainstream mental health view of homosexuality that is the most vocal advocate of reparative therapy. The American Psychoanalytic Association (APsaA) has spoken against NARTH, stating "that organization does not adhere to our policy of nondiscrimination and ... their activities are demeaning to our members who are gay and lesbian.
Nicolosi is today's leading representative of the view that same-sex desires are a form of arrested psychosexual development, resulting from "an incomplete bond and resultant identification with the same-sex parent, which is then symbolically repaired in psychotherapy". His corresponding psychoanalysis-based intervention plans involve conditioning a man to a traditional masculine gender role. He should "(1) participate in sports activities, (2) avoid activities considered of interest to homosexuals, such [as] art museums, opera, symphonies, (3) avoid women unless it is for romantic contact, (4) increase time spent with heterosexual men in order to learn to mimic heterosexual male ways of walking, talking, and interacting with other heterosexual men, (5) Attend church and join a men’s church group, (6) attend reparative therapy group to discuss progress, or slips back into homosexuality, (7) become more assertive with women through flirting and dating, (8) begin heterosexual dating, (9) engage in heterosexual intercourse, (10) enter into heterosexual marriage, and (11) father children".
This anti-gay psychoanalytic approach toward homosexuality has been repudiated by the psychoanalytic mainstream and the theories that underlie it countered by analysts offering gay-affirmative approaches. Exodus International considers reparative therapy to be a useful tool, but not a necessary one.
Practitioners who view homosexuality as learned behavior may adopt behavioral modification techniques. These may include masturbatory reconditioning, visualization, and social skills training. The most radical involve electroconvulsive therapy, a form of aversion therapy. Documented cases include electric shocks being administered to patients' genitalia, "sometimes paired with disturbing images, including a bowl of feces and pictures of Kaposi's Sarcoma lesions". In another case plethysmography, which uses electric sensors attached to a person's genitals to measure sexual arousal, was used in conjunction with shock therapy to electrically shock the patient's penis when he became sexually aroused by same-sex images.
The medical and scientific consensus is that conversion therapy is potentially harmful, but that there is no scientifically adequate research demonstrating either its effectiveness or harmfulness. No mainstream medical organization endorses conversion therapy. Many organizations have expressed concerns over its practice. The American Psychological Association has affirmed several principles with regard to treatments to alter sexual orientation. A survey of the American Psychological Association rated reparative therapy as "certainly discredited", though the authors warn that the results should be interpreted carefully as an initial step, not a final word. The American Psychiatric Association noted in 1997 that "the ethics, efficacy, benefits, and potential for harm of therapies that seek to reduce or eliminate same-gender sexual orientation are under extensive debate in the professional literature and the popular media."
The ethics guidelines of the mental health establishment discourage, and sometimes prohibit, the practice of conversion therapy. The APA states that as a general principle, a therapist should not determine the goal of treatment. It also recommends that ethical practitioners refrain from attempts at conversion therapy until more research is available."
Mainstream health organizations critical of conversion therapy include the American Medical Association, American Psychiatric Association, the American Psychological Association, the American Counseling Association, the National Association of Social Workers, the American Academy of Pediatrics, the American Association of School Administrators, the American Federation of Teachers, the National Association of School Psychologists, the American Academy of Physician Assistants, and the National Education Association. According to Kenji Yoshino, conversion therapy based on psychoanalytic techniques has become a largely marginalized practice as a result of these views, and "the most high-profile contemporary purveyors of conversion therapy tend to be religious organizations."
In 2007, the American Psychological Association convened a task force to evaluate its policies regarding reparative therapy; ex-gay organizations expressed concerns about the lack of representation of pro-reparative-therapy perspectives on the task force, while alleging that anti-reparative-therapy perspectives were amply represented.
In 1998, the American Psychiatric Association issued a statement opposing any treatment which is based upon the assumption that homosexuality is a mental disorder or that a person should change their orientation, but did not have a formal position on other treatments that attempt to change a person's sexual orientation. In 2000, they augmented that statement by saying that as a general principle, a therapist should not determine the goal of treatment, but recommends that ethical practitioners refrain from attempts to change ones' sexual orientation until more research is available.
The American Counseling Association has stated that they do not offer or condone any training to educate and prepare a counselor to practice conversion therapy. They strongly suggest counselors do not refer clients to a conversion therapist or to proceed cautiously once they know the counselor fully informs clients of the unproven nature of the treatment and the potential risks and takes steps to minimize harm to clients. However, "it is of primary importance to respect a client's autonomy to request a referral for a service not offered by a counselor." A counselor performing conversion therapy "must define the techniques/procedures as 'unproven' or 'developing' and explain the potential risks and ethical considerations of using such techniques/procedures and take steps to protect clients from possible harm." The counselor must also provide complete information about the treatment, offer referrals to gay-affirmative counselors, discuss the right of clients, understand the client's request within a cultural context, and only practice within their level of expertise.
The American Psychological Association "is concerned about [conversion] therapies and their potential harm to patients.... Any person who enters into therapy to deal with issues of sexual orientation has a right to expect that such therapy would take place in a professionally neutral environment absent of any social bias." The APA stated, with regard to conversion therapy,
...that psychologists do not knowingly participate in or condone unfair discriminatory practices... do not engage in unfair discrimination based on sexual orientation... respect the rights of individuals to privacy, confidentiality, self-determination and autonomy... , try to eliminate the effect on their work of biases based on [cultural, individual and role differences due to sexual orientation]... where differences of sexual orientation significantly affect psychologist's work concerning particular individuals or groups, psychologists obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals... do not make false or deceptive statements concerning the scientific or clinical basis for their services... obtain appropriate informed consent to therapy or related procedures which generally implies that the client or patient (1) has the capacity to consent, (2) has been informed of significant information concerning the procedure, (3) has freely and without undue influence expressed consent, and (4) consent has been appropriately documented... [and that] the American Psychological Association urges all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientation." (internal quotes, brackets, and ellipses omitted).
The American Psychiatric Association has stated that "anecdotal reports of 'cures' are counterbalanced by anecdotal claims of psychological harm." It further states that there are no scientifically rigorous outcome studies to determine the actual harm of conversion treatments. However, they have also stated that the "potential risks of 'reparative therapy' are great, including depression, anxiety, and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by a patient." In Nicolosi's survey, 7.1% of patients reported that they were worse after therapy than before. He concluded that "clients who have decided they wish to affirm a gay identity could feel shamed and emotionally hurt if therapists attempted to impose conversion therapy on them."
Mainstream medical bodies state that conversion therapy can be harmful because it may exploit guilt and anxiety, thereby damaging self-esteem and leading to depression and even suicide. Participants are at increased risk for guilt, depression, anxiety, confusion, self-blame, suicidal gestures, unprotected anal intercourse with untested partners, and heavy substance abuse.
Beyond harms caused to individual people, there is a broad concern in the mental health community that the advancement of conversion therapy itself causes social harm by disseminating inaccurate views about sexual orientation and the ability of gay and bisexual people to lead happy, healthy lives. The APA warns that the conversion therapy movement helps "create an environment in which prejudice and discrimination can flourish." Stephen Halpert says "To attempt to 'cure' is to reinforce bigotry."
The APA encourages and supports research to determine risks versus benefits.
There is extensive debate in the professional literature over the ethics, efficacy, benefits, and potential for harm of conversion therapies. Those against conversion therapy focus on the potential for harm and the negative effects it has on gay rights. Those for conversion therapy focus on freedom of choice for the client and potential for success.
In the United States, conversion therapy is currently allowed, under the American Psychological Association's code of conduct which states: "Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination." However, the code of conduct also states that "Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making."
Opponents of conversion therapy argue that clients who request it do so out of social pressure and internalized homophobia, pointing to evidence that rates of depression, anxiety, alcohol and drug abuse and suicidal feelings are roughly doubled in those who undergo conversion therapy.
The American Psychological Association states that harassment and abuse, as well as pressure from family, peers, and religious groups ignorant about and prejudiced against homosexuality, may cause high levels of emotional stress for LGB people. These pressures may lead people to feel forced into attempting to change their sexual orientation. Other researchers have found that social pressure plays a key role in a person's desire to change his or her sexuality.
Conversion therapists generally respond to the mainstream medical view with three main points. First, they argue that the mainstream medical view (from the 1973 declassification of homosexuality as a mental disorder to the current opposition to conversion therapy) is the result of political beliefs and lobbying. Second, they argue that there is evidence that conversion therapy is effective. Third, they argue that people should be able to determine their own therapeutic goals.
On multiple occasions teenagers have reportedly been forcibly treated by ex-gay organizations. A 2006 report outlined evidence that conversion therapy groups are increasingly focusing on children. Several legal researchers have responded to these events by arguing that parents who force their children into aggressive conversion therapy programs are committing child abuse under various state statutes.
There have been few, if any, medical malpractice lawsuits filed on the basis of conversion therapy. Laura A. Gans suggested in an article published in The Boston University Public Interest Law Journal that this is because there is an "historic reluctance of consumers of mental health services to sue their care givers" and because of "the difficulty associated with establishing the elements of... causation and harm... given the intangible nature of psychological matters." Gans also suggested that a tort cause of action for intentional infliction of emotional distress might be sustainable against therapists who use conversion therapy on patients who specifically say that his or her anxiety does not arise from his or her sexuality.
In one of the few published U.S. cases dealing with conversion therapy, the Ninth Circuit addressed the topic in the context of an asylum application. A Russian citizen "had been apprehended by the Russian militia, registered at a clinic as a 'suspected lesbian,' and forced to undergo treatment for lesbianism, such as 'sedative drugs' and hypnosis.... The Ninth Circuit held that the conversion treatments to which Pitcherskaia had been subjected constituted mental and physical torture. The court rejected the argument that the treatments to which Pitcherskaia had been subjected did not constitute persecution because they had been intended to help her, not harm her.... The court stated that 'human rights laws cannot be sidestepped by simply couching actions that torture mentally or physically in benevolent terms such as "curing" or "treating" the victims.'" "
American medical organization have have expressed concerns over potential harms of attempts to change sexual orientation through therapy. The director of the APA's LGBT Concerns Office stated: "I don't think that anyone disagrees with the idea that people can change because we know that straight people become gays and lesbians.... the issue is whether therapy changes sexual orientation, which is what many of these people claim. The American Psychiatric Association has stated "To date, there are no scientifically rigorous outcome studies to determine either the actual efficacy or harm of "reparative" treatments," and supports research to further determines risks versus its benefits. Similarly, United States Surgeon General David Satcher issued a report stating that "there is no valid scientific evidence that sexual orientation can be changed".
Nicolosi states that when a man changes orientation, he "doesn't immediately walk down a street and get a sexual charge from looking at a woman. But he will begin to notice women. He will begin to feel a desire to get married and have a family." Nicolosi states a successful client may still have same-sex attractions, but adds "that sexual desire is greatly diminished." Other proponents of conversion therapy argue that it is possible for a person's sexual orientation to be changed. Some research supports that contention, although such research differs regarding the likelihood of such change. However, Exodus International warns its members not to go to counselors who "glibly" claim that all attractions to the same gender can be eliminated; Exodus indicates that such statements may reflect the counselor's inexperience regarding conversion therapy. Evergreen International similarly warns its members that "therapy will likely not be a cure in the sense of erasing all homosexual feelings.
In 2000, the APA stated: "In the last four decades, 'reparative' therapists have not produced any rigorous scientific research to substantiate their claims of cure." It has called for more scientific research to determine the risks and benefits involved, and until such research is available, recommended that "ethical practitioners refrain from attempts to change individuals' sexual orientation." However, there is anecdotal evidence of effectiveness. Studies from the 1950s–1980s generally reported rates of positive outcomes at about 30%, with more recent survey research generally consistent with the extant data. In a survey of 882 people who were undergoing therapy, attending ex-gay groups or ex-gay conferences, 22. 9% reported they had not undergone any changes, 42.7% reported some changes, and 34.3% reported much change in sexual orientation. As a group, they reported large reductions in homosexual thoughts and fantasies and improvements in their psychological, interpersonal, and spiritual well-being.
In 2001, Dr. Robert Spitzer, who was involved in the APA's declassification of homosexuality as a mental disorder, presented a paper on conversion therapy at the APA annual convention. He reported that 66% of the men and 44% of the women he sampled had achieved "good heterosexual functioning" through interventions. This paper was widely reported by proponents of conversion therapy as evidence of success of the therapy.
The APA immediately issued an official disavowal of the paper, noting that it had not been peer-reviewed and stating that "There is no published scientific evidence supporting the efficacy of reparative therapy as a treatment to change one's sexual orientation." Two years later, Spitzer published the paper in the Archives of Sexual Behavior. The publication decision sparked controversy and one sponsoring member resigned in protest. The paper has been criticized on various grounds, including using non-random sampling and poor criteria for "success". Critics argue that it relied upon samples selected by conversion therapists themselves (86 participants were handpicked by ex-gay organizations), that proper random samplings were not used, that small samplings were used, that the subjects appeared to be ex-gay advocates who may have been biased in favor of conversion therapies, that 60% of the subjects had previously reported being bisexual, and that no follow-up study had been carried out to ascertain long-term conversion.
Spitzer himself played down the results of his own paper; upon being asked about the 200 patient sample after 16 months, and the percentage of people who might succeed, Spitzer said that it took almost a year and a half to only find 200 willing individuals, and therefore, the number of gay people who could successfully become heterosexual was likely to be "pretty low". He also conceded that the study's participants were "unusually religious."
A 2002 peer-reviewed study found that 88% of participants failed to achieve a sustained change in their sexual behavior and 3% reported changing their orientation to heterosexual. The remainder reported either losing all sexual drive or attempting to remain celibate, with no change in attraction. Some of the participants who failed felt a sense of shame and had gone through conversion therapy programs for many years. Others who failed believed that therapy was worthwhile and valuable. Of the 8 respondents (out of a sample of 202) who reported a change in sexual orientation, 7 worked as ex-gay counselors or group leaders.
Likewise, there are non-peer-reviewed studies that show evidence of change, conducted either by NARTH or other professional therapists. For example, many groups point to "Ex-Gays? A Longitudinal Study of Religiously Mediated Change in Sexual Orientation", a book published by researchers Stanton Jones and Mark Yarhouse. The study showed that out of a sample size of 98 people who sought a change in their sexual orientation, 15% reported a change in orientation over a three year period. The American Psychological Association is currently looking into the results of this study.
Francis Mark Mondimore argued that the reason for the focus on gay men is more political than medical. In his view, conservative and rigidly defined gender roles are the core value system used by conversion therapists, and male sexuality, with its emphasis on masculine and patriarchal hierarchies, is seen as more important and valuable than female sexuality.
Conversion therapy has become highly politicized, and the ensuing debates "have obscured the scientific data by calling into question the motives and even the character of individuals on both sides of the issue." Some conservative Christian political and social lobbying groups such as Focus on the Family, the Family Research Council, and the American Family Association actively promote to their constituencies the accounts of change of conversion therapies.
Individuals who feel conversion therapy has been helpful have felt oppressed by LGBT activists opposed to conversion therapy. They have protested the policies of the APA, stating that their views on issues such as the immutability of homosexuality have caused real harm to real people and patients. A. Dean Byrd commented "There exists a climate of prejudice in APA against clients -- often people of traditional values -- who wish to decrease their homosexual attractions and develop their heterosexual potential. In 2008, the organizers, including a gay psychiatrist, of an APA panel on the relationship between religion and homosexuality canceled the event after gay activists objected that "conversion therapists and their supporters on the religious right use these appearances as a public relations event to try and legitimize what they do.
Conversion therapy is not opposed by all gay people: Camille Paglia, a lesbian writer, wrote in her book Tramps and Vamps, "ACT UP's hysteria made me reconsider those vilified therapists and ministers who think change of homosexual orientation is possible and whose meetings are constantly disrupted by gay agitators. Is gay identity so fragile that it cannot bear the thought that some people may not wish to be gay? The difficulties in changing sexual orientation do not spring from its genetic innateness. Sexuality is highly fluid, and reversals are theoretically possible.
Psychologist John Gonsiorek called the position espoused by the Christian right hypocritical. He wrote "some conservative Christian institutions actively foster social conditions to maximize distress for such clients about their sexual orientations, and these institutions simultaneously promote conversion therapy as the solution to this distress.
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