The Christian Broadcasting Network reports this morning on the APA task force findings.
UPDATE: The video now does not reflect the news report linked above.
Category: mental health
Wall Street Journal covers APA task force report and sexual identity therapy
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 for 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.
I will have other posts on the media reaction and additional analysis…
APA sexual orientation task force report: Analysis
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.
Press release: APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation Report
The APA released the report from the Task Force on Appropriate Therapeutic Responses to Sexual Orientation today. This post is the APA press release, I also have an analysis of the report and another post coming with press reports.
APA PRESS RELEASE
August 5, 2009
Contact: Kim Mills
(202) 336-6048 until Aug. 5
(416) 585-3800 – Aug. 5-9
——————————————————————————–
INSUFFICIENT EVIDENCE THAT SEXUAL ORIENTATION CHANGE EFFORTS WORK, SAYS APA
Practitioners Should Avoid Telling Clients They Can Change from Gay to Straight
——————————————————————————–
TORONTO—The American Psychological Association adopted a resolution Wednesday stating that mental health professionals should avoid telling clients that they can change their sexual orientation through therapy or other treatments.
The “Resolution on Appropriate Affirmative Responses to Sexual Orientation Distress and Change Efforts” also advises that parents, guardians, young people and their families avoid sexual orientation treatments that portray homosexuality as a mental illness or developmental disorder and instead seek psychotherapy, social support and educational services “that provide accurate information on sexual orientation and sexuality, increase family and school support and reduce rejection of sexual minority youth.”
The approval, by APA’s governing Council of Representatives, came at APA’s annual convention, during which a task force presented a report that in part examined the efficacy of so-called “reparative therapy,” or sexual orientation change efforts (SOCE).
“Contrary to claims of sexual orientation change advocates and practitioners, there is insufficient evidence to support the use of psychological interventions to change sexual orientation,” said Judith M. Glassgold, PsyD, chair of the task force. “Scientifically rigorous older studies in this area found that sexual orientation was unlikely to change due to efforts designed for this purpose. Contrary to the claims of SOCE practitioners and advocates, recent research studies do not provide evidence of sexual orientation change as the research methods are inadequate to determine the effectiveness of these interventions.” Glassgold added: “At most, certain studies suggested that some individuals learned how to ignore or not act on their homosexual attractions. Yet, these studies did not indicate for whom this was possible, how long it lasted or its long-term mental health effects. Also, this result was much less likely to be true for people who started out only attracted to people of the same sex.”
Based on this review, the task force recommended that mental health professionals avoid misrepresenting the efficacy of sexual orientation change efforts when providing assistance to people distressed about their own or others’ sexual orientation.
APA appointed the six-member Task Force on Appropriate Therapeutic Responses to Sexual Orientation in 2007 to review and update APA’s 1997 resolution, “Appropriate Therapeutic Responses to Sexual Orientation,” and to generate a report. APA was concerned about ongoing efforts to promote the notion that sexual orientation can be changed through psychotherapy or approaches that mischaracterize homosexuality as a mental disorder.
The task force examined the peer-reviewed journal articles in English from 1960 to 2007, which included 83 studies. Most of the studies were conducted before 1978, and only a few had been conducted in the last 10 years. The group also reviewed the recent literature on the psychology of sexual orientation.
“Unfortunately, much of the research in the area of sexual orientation change contains serious design flaws,” Glassgold said. “Few studies could be considered methodologically sound and none systematically evaluated potential harms.”
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.
“Without such information, psychologists cannot predict the impact of these treatments and need to be very cautious, given that some qualitative research suggests the potential for harm,” Glassgold said. “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.”
As part of its report, the task force identified that some clients seeking to change their sexual orientation may be in distress because of a conflict between their sexual orientation and religious beliefs. The task force recommended that licensed mental health care providers treating such clients help them “explore possible life paths that address the reality of their sexual orientation, reduce the stigma associated with homosexuality, respect the client’s religious beliefs, and consider possibilities for a religiously and spiritually meaningful and rewarding life.”
“In other words,” Glassgold said, “we recommend that psychologists be completely honest about the likelihood of sexual orientation change, and that they help clients explore their assumptions and goals with respect to both religion and sexuality.”
A copy of the task force report may be obtained from APA’s Public Affairs Office or at http://www.apa.org/pi/lgbc/publications/therapeutic-response.pdf.
Members of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation:
Judith M. Glassgold, PsyD, Rutgers University – Chair
Lee Beckstead, PhD
Jack Drescher, MD
Beverly Greene, PhD, St. John’s University
Robin Lin Miller, PhD, Michigan State University
Roger L. Worthington, PhD, University of Missouri
The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States and is the world’s largest association of psychologists. APA’s membership includes more than 150,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance psychology as a science, as a profession and as a means of promoting health, education and human welfare.
# # #
J. Michael Bailey on twin research and sexual reorientation
Several new twin studies have been published over the past several months. A new one, just published on the Archives of Sexual Behavior website, deals with sexual orientation and neuroticism and psychoticism (more about that study in a future post). One of the co-authors of this new paper is J. Michael Bailey. Dr. Bailey is among the world’s top sexuality researchers and author of numerous publications involving twins and sexual orientation. Here he comments on the limitations of twin studies and sexual orientation change. This conversation was triggered in part by the recent NARTH report which stated that “homosexuality is not innate” without research supporting the statement.
In an email, I asked Michael to discuss how both the right and left misunderstand twin studies and their relationship to questions of innateness. His answers are indented and presented in full with some comments from me.
Both the left and the right conflate “genetic” with “inborn.” The debate over sexual orientation (and other traits) is more about inborn than genetic. As an example of the difference, it is common for identical twins to be discordant for homosexuality (i.e., given a gay identical twin, his twin is usually straight). It is a terrible mistake, though, to assume that this reflects the kind of social environment that can be manipulated. As you know, childhood gender nonconformity is very highly predictive of adult homosexual outcome. I’ve spoken to several mothers of identical twins discordant for
extreme childhood gender nonconformity (where one male twin wants to be a girl and the other is a typical boy). In each and every case, the mothers insist they did nothing–nothing–to differentiate the twins until well after the behavioral/emotional differences emerged. I
believe them.
On this point, some observers might not be quite as believing as Dr. Bailey. However, I lean in his direction on this, especially with extreme gender nonconformity. On this blog, we had an extensive conversation with a mother of twins, one quite non-conforming and the other not. In this context, it might be good to review those posts. (part 1, part 2). At the same time, I am aware of some parents who do indeed raise kids to prefer gender nonconformity. Extremes in childrearing may in some cases influence the trait of gender nonconformity in kids, but one does not need such parenting to get the same result.
The left often assumes some genetic influence means that social environment plays no role at the individual level. If some genetic factors operate for some, then they must operate for all. However, this cannot be assumed from twin studies. Neither can it be assumed that the differences between twins all relate to environmental factors which are alterable. On this point, Bailey says:
The main issue is nature-nurture. Heritability (which can be estimated from twin studies) generally is consistent with nature. But environmentality (the complement of heritability) DOES NOT MEAN nurture as it is typically assumed (i.e., social and reversible causation). MZ twins [monozygotic or identical] can differ (and I expect usually do) for biological reasons. At this point neither hypothesis (biological or social causation of MZ twin differences) has strong evidence to for it.
Note the last statement. We simply don’t know as yet. This is another reason why I think why I believe the NARTH paper is misleading. The paper uses weak therapy research to make a statement about innateness and immutability of sexual orientation. First we do not know whether twin differences occur for social or biological reasons. And then we do not know if any of the factors in any given case are alterable. Francis Collins made this same point when reacting to how Dean Byrd at NARTH quoted his book The Language of God:
The evidence we have at present strongly supports the proposition that there are hereditary factors in male homosexuality — the observation that an identical twin of a male homosexual has approximately a 20% likelihood of also being gay points to this conclusion, since that is 10 times the population incidence. But the fact that the answer is not 100% also suggests that other factors besides DNA must be involved. That certainly doesn’t imply, however, that those other undefined factors are inherently alterable.
The recent NARTH paper implies that studies demonstrating some shifts in sexual behavior disconfirm the view that homosexuality is innate. As Bailey notes above, we do not know. However, Bailey indicates a situation which provides a problem for environmental hypotheses.
Studies of the rare conditions of penile ablation and cloacal exstrophy (in which hormonally normal males are reassigned and reared as females from a very early age) show that such males grow up to be attracted to females, as per their biological, but not their social sex. To repeat something I’ve said many many times (and have never had a good answer), if you can’t make a male attracted to other males by cutting off his penis and rearing him as a female, how likely is any social hypothesis?
Bailey adds a bit of a challenge to his comments:
The folks who insist that (male) sexual orientation can be changed should put their money where their mouths are and fund you and me (and the researcher of their choice) to do a study with objective (i.e., penile and neural) pre-post measures.
We have discussed a study like this since 2006. I am aware of people who would participate but funding is an issue. Bailey and I both have sought such funding but no one has provided encouragement.
Anyone interested?
I will have more on the NARTH paper in future posts. Thanks to Michael for his comments and expertise.