sexual identity therapy

Coming Soon: Interview with Mark Yarhouse

On Tuesday July 21, I will publish an interview with Mark Yarhouse, professor at Wheaton College. Mark and I are authors of the sexual identity therapy framework which became an alternative for religious gay clients.

Mark and I will discuss the history of our work together going back to our opposition to a ban on reorientation therapy to our focus on sexual identity therapy. We also talk about Mark’s more recent work in gender identity.

I asked Mark about a relatively new group on the scene helping people navigate sexual identity concerns – Revoice. In that context, he described research into the effects of celibacy. Here is an excerpt of that conversation.

I hope you will revisit the blog on Tuesday to catch the full interview with Mark.

You can see all posts about these interviews by clicking this link.

Also subscribe to my Psychvideos Youtube channel where I am posting them.

Is There a War on Psychotherapy?

Last week, this came across my path:

I assume Christopher Doyle refers to the effort around the country to prohibit sexual reorientation change efforts for minors. However, I write this post to address a couple of points.

When it comes to sexual orientation and psychotherapy, the reparative therapy narrative of defective parenting doesn’t hold water or match up with research or experience. However, there are still therapists who believe that and try to impose it on their clients and their families. Much of my work has been to develop a therapy approach (sexual identity therapy) which requires therapists to present scientific research about sexual orientation to clients and allow clients to decide what to do about it.

On the other hand, the Family Research Council speaker Christopher Doyle worked and trained with Richard Cohen who has a different approach. Here is a snapshot of a couple of Richard Cohen’s techniques.

I will leave it to readers. Is this psychotherapy?

Doyle defended these and other outrageous techniques in this legal brief designed to be used in a New Jersey trial involving JONAH, a Jewish change therapy group. JONAH lost at trial.

You can see Doyle in action in this review of a documentary called Sunday Sessions in which Doyle provides sexual orientation change counseling to a young adult man. Note that Richard Cohen is involved in the group sessions at the beginning.

In the end, the young man feels somewhat better but credits the teachings of the Catholic church for his mood improvement. There is no indication that his sexual attractions changed.

I watched the documentary (I recommend it although there is no real conclusion to the story), and I need to make another thing clear. In the film (and on this page), Doyle calls his approach to therapy “Sexual Identity Affirming Therapy.” I want to say plainly that what he does is unrelated to “Sexual Identity Therapy” as developed by Mark Yarhouse and me.

In the documentary, Doyle did not provide a range of information about the development of male homosexuality but instead authoritatively expressed the reparative narrative of weak fathers and an unmasculine upbringing. The directive style demonstrated in the movie review above is not taken out of context. None of this is consistent with sexual identity therapy. People working within the principles of SIT do not attempt to change a client’s sexual orientation. SIT is antithetical to what Doyle demonstrates in the documentary and more broadly, to what Cohen does in his various public demonstrations.

The War is Over

In my opinion, within psychotherapy, the war is actually over and change therapy has lost. No training programs teach it. I know of no Christian training programs that teach it (although I would like to be corrected if I am wrong). It is misleading to pretend there is a wronged group of psychotherapists who want to practice it and can’t. The courts have not been inclined to defend it.

On the other hand, there has been a resurgence of interest in ex-gay type ministries. While I don’t yet see an accompanying revival of professional interest in change therapy, it is the nature of true believers to keep trying.

Why the Mental Health Professions Want to Ban Conversion Therapy

While there are several reasons why mental health advocates want to ban sexual orientation change efforts, I want to focus on the recent push to legislate bans on the practice by licensed professionals.
Historically, therapists who treat gays with an aim to change them have viewed homosexuality as a developmental disorder. Some may also think same-sex sexual behavior is immoral, but principally the use of therapeutic techniques is driven by a belief that there is something psychologically wrong with someone who is attracted to the same sex. If the right techniques can be applied, eventually the GLB person will experience a shift in psychological perspective and find the opposite sex attractive. In short, homosexuality is an illness to be cured.
As most readers know, this view of same-sex orientation isn’t held by any medical or mental health professional organization today. Only a tiny group of practitioners hold to this view and they are among those who are fighting legislative efforts to ban sexual orientation change efforts. When legislators craft bills to stop treatment of same-sex orientation, they are hoping to stop efforts to cure something that isn’t a disorder.
To me, this is a sensible stance. No disorder, no need for treatment.
On the other hand, many religious traditions disagree with same-sex sexual behavior. They discourage such behavior as inconsistent with their moral teachings. Churches and religious groups have the right to teach this and advise their members in keeping with their principles. When people ask for their advice or opinion, churches can teach their views. In fact, anyone can teach and speak any view about homosexuality.
However, when a person joins a learned profession and gets a state license to practice that profession, there are certain restrictions that come along with that choice. Mental health professionals are not clergy. We have a role to enhance the mental health of our clients and curing non-existent diseases doesn’t seem to me to be a part of that mandate. If clergy need to speak against certain behaviors, that is their right and the state’s regulation of mental health professionals cannot stop them.
I do have sympathy for those clients who believe that their same-sex attractions result from some historical trauma. In fact, there is a very small subset of people for whom those factors might be relevant to an understanding of their overall personality, including their sexual interests. I also believe that those people can continue to receive therapy, under these laws, if the treatment is not framed as a direct effort to change orientation.
Ultimately, I believe this is an issue of regulation of mental health professionals and not one of religious liberty. Since there is no universe in which sexual orientation change efforts are effective, why would mental health professionals make space for them? The rare exceptions can be accommodated via other frameworks (e.g., identity exploration, trauma recovery). Religious views will continue to be shared and any challenge to them will not succeed. We can coexist.

For more information on helping non-affirming same-sex attracted people live in keeping with traditional sexual ethics without engaging in sexual orientation change efforts, see the following articles and websites:

Sexual Identity Therapy Framework
Institute for the Study of Sexual Identity
A New Therapy on Faith and Sexual Identity (WSJ)
Living the Good Lie (NYT)

Robert Spitzer, Father of Modern Psychiatric Diagnosis, Dies at 83

Robert Spitzer at his home in 2004, screencap from I Do Exist.

According to the New York Times, psychiatrist and author of the third edition of the American Psychiatric Association’s diagnostic manual Robert Spitzer died on Christmas Day. Spitzer is credited with changing the way mental health professionals view diagnosis of mental disorders. By basing the assessment of mental disorder on personal distress and diminished functioning, Spitzer promoted a more rigorous approach to diagnosis.
More famously, Spitzer’s modifications also paved the way for reconsidering homosexuality as a mental disorder. After meeting gay psychiatrists who did not experience distress over homosexuality, Spitzer, in the early 1970s, led the effort to remove homosexuality from psychiatry’s list of mental disorders.
I first talked to Bob Spitzer when he invited me to take part in a debate over sexual orientation change efforts at the American Psychiatric Association meeting in 2000. The debate was canceled when, near the beginning of the conference, the two psychiatrists arguing against sexual orientation change backed out. Bob later told me that the psychiatrists who declined to participate wanted out because they heard that I was a member of the National Association for the Research and Therapy of Homosexuality (NARTH). While I had been a NARTH member for one year in 1997, I had allowed my membership to lapse by 2000. An irony is that I later became one of NARTH’s biggest critics. Bob knew I tracked NARTH’s actions and about once a year asked about any news on their activities.
Although I was unable to attend, the following year Bob invited me to speak as a part of a symposium where he presented results of his research on ex-gays. Eventually, that study was published in 2003 in the Archives of Sexual Behavior and was one of the most controversial studies in modern psychiatry. At the time, due to his conversations with people who described themselves as ex-gay, Spitzer believed that some gays had been able to modify their sexuality toward the straight side of the continuum. Later, in 2012, Spitzer retracted that interpretation of his research, denounced his earlier beliefs, and apologized to gays.
In 2004, I met Bob Spitzer in person and spent a few hours at his home near New York City while filming for the video I Do Exist, a video with the testimonies of five people who told me they changed from gay to straight. Because one of the main participants retracted his statements and two others had significant changes, I later retracted the video in January 2007. My views were also altered by the emergence of new data on sexual orientation and the failure of change therapy supporters to produce evidence in their favor.
After he published his study, Bob’s collaboration with social conservatives was something he later regretted. On one occasion in November 2008, I sent him a link to Focus on the Family’s website where they had misrepresented his study. He wrote back and said, “That is awful. Whoever wrote it must have known it to be incorrect. Can you do something about it?” Focus later modified the statements slightly but still did not fully represent Bob’s views.
In 2007, Spitzer told me in a phone call that he endorsed the sexual identity therapy framework that I developed with Mark Yarhouse. The endorsement was later published on the SIT framework site:

I have reviewed the sexual identity framework written by Warren Throckmorton and Mark Yarhouse. This framework provides a very necessary outline to help therapists address the important concerns of clients who are in conflict over their homosexual attractions. The work of Drs. Throckmorton and Yarhouse transcend polarized debates about whether gays can change their sexual orientation. Rather, this framework helps therapists work with clients to craft solutions tailored to their individual situations and personal beliefs and values. I support this framework and hope it is widely implemented.
Robert L. Spitzer, M.D., Professor of Psychiatry, Columbia University, New York State Psychiatric Institute, New York City, NY. Co-editor of the Diagnostic and Statistical Manual of Mental and Emotional Disorders, 3rd Edition and 3rd Edition (Revised).

On a personal level, I liked Bob immediately. He was friendly and very approachable. While he seemed to like the controversy, in my hearing he communicated no malice toward any side of the gay change debate. He seemed to be a genuine truth seeker and wanted to follow the evidence no matter what. I will miss him.
Bob Spitzer, R.I.P.

Desire, Faith & Therapy: Sexual Orientation and Orthodox Jews; Rabbinical Council Rejects JONAH

Desire Conf Columbia On Sunday, I participated in a conference titled Desire, Faith and Therapy at the Kraft Jewish Student Center at Columbia University on appropriate therapeutic responses to sexual orientation. The conference was designed for therapists, rabbis and other interested members of the Orthodox Jewish community.
From the brochure:

“Desire, Faith and Psychotherapy” presents a Psychoanalytic perspective on sexual orientation and gender identity in the Orthodox Jewish community. We will explore the intersection of psychological, religious and communal issues that present with LGBT people from Orthodox & Hasidic communities. The program features experts in the field and professionals with experience working with this population. They will review the latest research and develop a conceptual framework in which therapists and Orthodox rabbis can work together to offer the best care.

I didn’t let the organizers know in time to make the brochure but I spoke as a part of a panel with Jack Drescher and Rabbi Mark Dratch. Drescher covered research and history of sexual orientation change efforts, Rabbi Dratch covered the position of the Rabbinical Council of America and I described the sexual identity therapy framework.
Rabbinical Council of America Repudiates Reparative Therapy and JONAH
The framework seemed to fit the audience well in that affirming and non-affirming members of the Orthodox community were present and interested in working together for best practices. I was pleased to hear Rabbi Dratch describe the Rabbinical Council’s repudiation of JONAH, and reparative therapy in general. Dratch told the crowd that the Rabbinical Council asked JONAH numerous times to remove the 2004 letter recommending JONAH. In fact, even after the Council issued their repudiation of JONAH, the 2004 endorsement remains up on JONAH’s website. JONAH advertises falsely in more ways than one.
The lawsuit against JONAH will be a test of the consumer protection laws in New Jersey. JONAH continues to claim efficacy from the strange practices used to try to change sexual orientation. With a couple of exceptions, the crowd at the conference seemed to join the sentiment expressed by the Rabbinical Council concerning JONAH.
My powerpoint can be viewed here.

Reparative Therapy Makeover Continues: JONAH Responds to SPLC Suit

A group called Freedom of Conscience Defense Fund has taken on the defense of Jews Offering New Alternatives to Healing (JONAH) against a suit filed by the Southern Poverty Law Center. The SPLC complaint alleges that JONAH violated New Jersey’s consumer fraud law by promising sexual reorientation to clients without success. The complaint is here.

It is very discouraging to see the JONAH complaint framed as a freedom of conscience case. As the complaint outlines, the techniques alleged by the plaintiffs have been discredited within the mainstream mental health community and as such should be confronted. Please see this post on the “oranges therapy” and this one on the use of nudity by JONAH counselors.

Furthermore, it is misleading for JONAH to describe what it does in the following manner:

For over twelve years, JONAH has helped hundreds of people live the lives that they want, consistent with their personal values. JONAH’s mission is to give all people the opportunity to explore their internal conflicts around sexuality and other values in a caring, non-judgmental environment.

As I have noted elsewhere, reparative therapists are beginning to use the language of the sexual identity therapy framework to describe what they do. However, reparative therapy is inconsistent with the SIT Framework.

Sexual Identity Therapy is Not Reparative Therapy

I have had to make this case several times over the years but the defensive posture of reparative therapists of late makes it necessary to do it again. As more people are coming against reparative drive theory, reparative therapists are softening and in some cases altering their rhetoric regarding what they believe and what they do. Note my posts here and here.

In a NBC News article last Wednesday, NARTH’s Executive Secretary David Pruden defends reparative therapy with a line of reasoning that doesn’t sound half bad. He says

“Once people felt less shamed – and I think that’s really positive – there was less a feeling that they couldn’t talk about it,” Pruden said. But those who do want to minimize those feelings, Pruden said, “deserve to have their needs met as well.”

“To say to them, we’re not willing to walk alongside you in your journey feels to me as cruel as the other extremes we used to be at, when people were hurt for saying, ‘I’m gay, and I’m OK with that,’” Pruden said. “In a sense it’s a pro-choice movement – people should have the right to deal with this.”

Walking along side someone in a journey and acknowledging a client’s right to deal with conflict surrounding sexuality seems reasonable and fair. However, that stance is not what is under attack in legislatures and court rooms around the country. If all reparative therapists did was support clients in exploration of their beliefs and values about their sexual orientation, then they would not be experiencing the scrutiny they are now.

What Pruden describes in this brief interview (and to be fair, he may have said more about change therapy that the reporter did not include) is similar to what Mark Yarhouse and I promote in the sexual identity therapy framework. We walk along side people who are struggling with conflicts involving their sexuality and moral beliefs. We do not offer change interventions and in fact stress that we do not see orientation change as the aim of the SITF. I indicate to clients that the evidence does not support efforts to change orientation. I respect the rights of people to make behavioral choices in line with what they believe to be right and work with people to move in a moral direction they believe in. However, reparative therapists do so much more than that.

Check out what Joseph Nicolosi believes about homosexuality as stated in the NBC article. He gives the usual reparative narrative about weak fathers and overbearing mothers being the culprit and then to those who don’t want to take his therapy he says:

“We say, fine, you want to be gay, but are you curious in understanding why you’re gay?” Nicolosi said.

Reparative therapists think they know why people are gay and their interventions of building masculinity with journeys into manhood, complete with holding therapy, sports training, etc., are what attracts the ire of opponents. The reparative therapists have a hammer and to them every gay person is a nail. The reparative therapists on the Dr. Oz show last week seemed oblivious to the message being delivered by the reparative drive theory. Reparative therapy begins with the assumption that gays are disordered and in need of some kind of treatment to cure the underlying psychological damage which may (they don’t all promise that the proper therapy leads to complete change) then lead to a lessening of attraction to the same sex. They compare being homosexual to being an addict, depressed or some other malady.

Walking along side someone does not require what reparative therapists do. Working with someone to work out an adjustment involving religious morality and sexual behavior does not require a belief that same-sex attraction is a disorder or the result of deficient families.

Let’s keep things straight, reparative therapy is one thing and sexual identity therapy is another.

NARTH likes half of the NYT Magazine's coverage of sexual identity issues

NARTH is recommending the Glatze article but not the article by Mimi Swartz which addresses the APA position on sexual orientation change.
At least they tell readers

While the story is his own and does not necessarily represent a typical NARTH client his observations and thoughts are very interesting. They represent a perspective usually missing in the popular press on the subject of homosexuality.

Missing from the NARTH post is the perspective of the longer article of the two. Gotta go to the popular press for that.

New York Times on therapy for sexual identity concerns

The New York Times Magazine will have a lengthy print article on sexual identity concerns, especially among evangelical gays this sunday. The well-written article by Mimi Swartz is now up online at this link.
I have been away for several days and won’t be able to comment much under Sunday or Monday, but I think she did a nice job of bringing together several lines of thinking which led to the sexual identity management/therapy approach to handling sexual identity concerns. Her descriptions of the sexual identity therapy framework start about here and are woven throughout the later part of the article.
The one aspect of the piece I don’t like is the title – Living the Good Lie. We do not encourage this and in fact advocate for acceptance, even if that acceptance is not with approval. More on that when I can reflect a bit more…

Sexual identity: Thoughts on the status of the reorientation wars

(First posted on August 12, 2009)
So now that the dust has started to settle from the APA convention in Toronto, let’s review the status of the Reorientation Wars.
Does therapy change orientation?
In anticipation of the APA’s report, NARTH fired an opening salvo with their paper (What Research Shows…). Perhaps sensing, incorrectly as it turns out, that the APA would advocate a ban on reorientation therapy, NARTH tossed every positive reference to change they could find into the paper. They noted problems in defining sexual orientation but did little to distinguish the various definitions and their meaning in the many studies they cited. They concluded, of course, that therapy can change orientation.
The APA on the other hand, differentiated sexual orientation and sexual orientation identity. Sexual orientation for them is the biological responsiveness to one gender or both. According to their literature review, the evidence that therapy can change orientation is not sufficient to permit therapists to inform clients that therapy can change their orientation. However, sexual orientation identity (i.e., self-labeling) may shift and be responsive to a variety of factors, including religious mediation.
It seems to me that what NARTH is calling sexual orientation includes the APA’s sexual orientation identity. While this statement risks taking us into the “all or nothing” dead end discussion about change, I do not mean that one must change completely for change to be important and psychologically relevant. I suggest instead that what many studies measure is how people see themselves, even if their sexual responsiveness (orientation) has only shifted by a degree (e.g., an average of less than a point on the Kinsey scale in the Jones and Yarhouse study). Jones and Yarhouse suggest as much in their recent paper when they write:

There is also the question of sexual identity change versus sexual orientation change (see Worthington & Reynolds, 2009). Recent theoretical (e.g., Yarhouse, 2001) and empirical (e.g., Beckstead & Morrow, 2004; Yarhouse & Tan, 2004; Yarhouse, Tan & Pawlowski, 2005; Wolkomir, 2006) work on sexual identity among religious sexual minorities suggests that attributions and meaning are critical in the decision to integrate same-sex attractions into a gay identity or the decision to dis-identify with a gay identity and the persons and institutions that support a gay identity. In light of the role of attributions and meaning in sexual identity labeling, is it possible that some of what is reported in this study as change of orientation is more accurately understood as change in sexual identity?

I believe the answer to their question is that it is not only possible but probable that change in sexual identity is what is being reported. The distinction between orientation and identity (or attraction and identity as we often describe it here) is key, in my view, in order for us to understand the experience of those who say they have changed while at the same time experiencing same-sex attraction. I also believe that men and women are different and their change may be different. Women seem to describe less exclusivity than men. Fluidity may be more likely with complete shifts described. I think we need to accommodate atypical experiences such as men and women who completely shift for a time and then shift back. Whatever the pattern, I hope we can agree that sexual attraction patterns may be one thing while meaning making aspects may lead two people with the same attraction pattern to identity in disparate ways.
Is sexual reorientation harmful or beneficial?
NARTH says reorientation might harm some people but that for the most part it is not harmful. The APA says existing studies are not good enough to allow conclusions. Point for the APA here. All we can say is that some people report harm and some people report benefit. The APA notes that the benefits can occur in programs which promote congruence with religious faith. This is clear and the Jones and Yarhouse study demonstrate that health status improves modestly for those who remained in the study. However, I would say we do not yet know much about what the potent or beneficial elements of those programs are. The APA report identified some of those elements.
Homosexuality and pathology
NARTH says homosexuals have more pathology than any other group of similar size. The APA says homosexuality is normal. By this they mean that homosexuality is not a developmental disorder or indicator of a mental disorder. The two recent reports go off in different directions but some observations can be made.
The NARTH report spends lots of time reporting on greater levels of mental health and health problems among homosexuals as compared to heterosexuals. The APA report does not do this. However, I believe the point regarding different levels of symptoms would be stipulated by the APA. However, the APA raises the minority stress model as responsible for many difficulties faced by non-heterosexual people. The NARTH report discounts the role of stigma.
I doubt the APA would dispute the health status data for another reason: greater group pathology does not mean inherent disorder. The APA’s position is not that gays have equal health outcomes but rather that the unequal health outcomes do not imply inherent pathology – that SSA is not inherently the result of pathological development. This is of course in great contrast to the reparative therapists. Joseph Nicolosi says that the only way you get SSA is to traumatize a child.
The reparative impulse to find trauma behind every gay person is misguided I believe, conceptually and for sure empirically. Women have greater levels of mental health problems than men but we would not consider women inherently disordered. NARTH has chosen some good studies to cite in the section of their paper which relates to health status (as well as some really bad and irrelevant ones). However, I don’t think it really gets them where they want to go.
And where do they want to go? This is clear from their press release complaining about the APA task force report. They state:

Further, if some clients are dissatisfied with the therapeutic outcome [of reorientation therapy], as in therapy for other issues, the possibility for dissatisfaction appears to be outweighed by the potential gains. The possibility of dissatisfaction also seems insignificant when compared to the substantial medical, emotional, and physical risks associated with homosexual behavior.
NARTH would suggest that these medical and emotional risks, along with the incongruity of homosexual behavior with the personal and religious values of many people will continue to be the motivation for some individuals to seek assistance for their unwanted homosexual attraction.

According to NARTH, gays ought to seek reorientation therapy because being gay is a risky life, full of health and mental health disadvantages. Their hypothesis is implied but hard to miss: reduce the SSA and reduce the health risks. The assumption appears to be that ex-gays will have better health outcomes than gays. One problem with this line of thinking is that there is no empirical evidence for it and some evidence against it.*
One researcher quoted in the NARTH paper regarding health risks was New Zealand’s David Fergusson. Dr. Fergusson has done significant work in this field. I asked him to look at the section of the NARTH paper in which his work was quoted. Here is a statement he provided about it:

While the NARTH statement provides a comprehensive and accurate analysis of the linkages between sexual orientation and mental health, the paper falls far short of demonstrating that homosexuality should be classified as a psychiatric disorder that may be resolved by appropriate therapy. To demonstrate this thesis requires an in depth understanding of the biological and social pathways that explain the linkages between homosexual orientation and mental health. At present we lack that understanding. Furthermore it is potentially misleading to treat what may be a correlate of mental disorder as though it were a disorder in its own right.

Fergusson also told me that one would need to develop studies to demonstrate that any changes in orientation associate with improvements in health status. The Jones and Yarhouse study provide some very general assessment but many potential confounds are uncontrolled. For instance, it is not possible to say that the modest shifts on the Kinsey scale were responsible for the shifts in health status. These folks were quite religious and religion is associated with enhanced health status. I suspect religious gays have a better health status than non-religious gays, on average. The point is we do not have evidence that sexual orientation status per se is what leads to the differences in health status.
While I am on the subject of health status, I need to mention that there are other factors which NARTH ignored. One, gender non-conformity is strongly correlated with adult homosexuality and is also associated with poorer mental health. Two, homosexuals report higher levels of sexual victimization which is also associated with higher levels of mental health problems. And, three, no one can discount the possibility that biological factors which associate with the development of homosexuality may also influence the development of emotional problems (i.e., in the same way women are more likely to report depression than men).
So where are we? I hope we have a larger middle and smaller numbers of people at the opinion extremes. People on both sides can agree that erotic responsiveness is extremely durable for men and perhaps less so for women, but behavior and self-identity reflection is alterable. People on both sides agree that conclusions about benefit and harm are not possible in any general sense. Also, I hope we can agree that full informed consent should be conducted prior to engaging in counseling. Regarding health status, both sides can agree that homosexuals have higher levels of problems but there is little agreement about what the differences mean.
Those on the far sides of the continuum will continue to argue that change is possible or change is impossible, and/or that reorientation is always harmful or never harmful and/or that health status difference mean something vital or irrelevant about inherent pathology.
The wars will continue but perhaps fewer people will be engaged in them; now is the time rather to reason together.
*Nottebaum, L. J., Schaeffer, K. W., Rood, J., & Leffler, D. (2000). Sexual orientation—A comparison study. Manuscript submitted for publication. (Available from Kim Schaeffer, Department of Psychology, Point Loma Nazarene University, 3900 Lomaland Drive, San Diego, CA 92106) – In this study, the authors found that mental health was better among the gay sample than the Exodus sample.
(Note: Social psychologist David Myers referred to this post in an op-ed on the APA task force printed in the Wall Street Journal.)