Ethical issues related to
conversion or reparative therapy
By Joy S. Whitman, Harriet L. Glosoff, Michael M.
Kocet and Vilia Tarvydas
American Counseling Association members have
consulted ACA staff and leaders regarding the practice of
conversion therapy and the 2005 Code of Ethics. For this reason,
the ACA Ethics Committee is sharing its formal interpretation of
specific sections of the ACA Code of Ethics concerning the
practice of conversion therapy and the ethics of referring
clients for this practice.
Committee members individually considered a
hypothetical scenario that was based on actual questions posed
to the members and staff. The Ethics Committee then met to reach
a consensus opinion.
The scenario
During the third session of counseling, a client
reports that he is gay and states, "I want to change my way of
life and not be gay anymore. It's not just that I don't want to
act on my sexual attraction to men. I don't want to be attracted
to them at all except for as friends. I want to change my life
so I can get married to a woman and have children with her." At
the suggestion of a friend, the client has read about
reparative/conversion therapy and has researched this approach
on the Internet. He is convinced this is the route he wants to
take.
The counselor listens carefully to what the
client has to say, asks appropriate questions and engages in a
clinically appropriate discussion. The counselor informs the
client that, although she is happy to continue working with him,
she does not believe reparative/conversion therapy is effective
and no empirical support exists for the approach. She further
states that this form of therapy can actually be harmful to
clients, so she will not offer this as a treatment. The client
says he is disappointed that the counselor will not honor his
wishes. He then asks for a referral to another counselor or
therapist who will work with him to "change his sexual
orientation."
Interpretation
The ACA Ethics Committee considered many factors
and derived a consensus opinion that addresses several sections
of the ACA Code of Ethics and moral principles of practice
present in such a scenario. We started with the basic goal of
reparative/conversion therapy, which is to change an
individual's sexual orientation from homosexual to heterosexual.
Counselors who conduct this type of therapy view same-sex
attractions and behaviors as abnormal and unnatural and,
therefore, in need of "curing." The belief that same-sex
attraction and behavior is abnormal and in need of treatment is
in opposition to the position taken by national mental health
organizations, including ACA.
The ACA Governing Council passed a resolution in
1998 with respect to sexual orientation and mental health. This
resolution specifically notes that ACA opposes portrayals of
lesbian, gay and bisexual individuals as mentally ill due to
their sexual orientation. In addition, the resolution supports
dissemination of accurate information about sexual orientation,
mental health and appropriate interventions and instructs
counselors to "report research accurately and in a manner that
minimizes the possibility that results will be misleading" (ACA
Code of Ethics, 1995, Section G.3.b). In 1999, the Governing
Council adopted a statement "opposing the promotion of
reparative therapy as a cure for individuals who are
homosexual." In fact, according to the DSM-IV-TR, homosexuality
is not a mental disorder in need of being changed. With this in
mind, we have a difficult time discussing the appropriateness of
conversion therapy as a treatment plan. Regardless, there are
clients who seek out counselors in hopes of changing their
sexual behaviors, orientation or identity, so the ACA Ethics
Committee conducted a review of the literature on reparative
therapy.
We found that the majority of studies on this
topic have been expository in nature. We found no scientific
evidence published in psychological peer-reviewed journals that
conversion therapy is effective in changing an individual's
sexual orientation from same-sex attractions to opposite-sex
attractions. Further, we did not find any longitudinal studies
conducted to follow the outcomes for those individuals who have
engaged in this type of treatment. We did conclude that research
published in peer-reviewed counseling journals indicates that
conversion therapies may harm clients (refer to the full article
posted on the ACA website for references).
These findings bring several questions to the
forefront:
--Is a counseling professional
who offers conversion therapy practicing ethically?
--Since ACA has taken the
position that it does not endorse reparative therapy as a
viable treatment option, is it ethical to refer a client to
someone who does engage in conversion therapy?
--If a client insists on
obtaining a referral, what guidelines can a counselor
follow?
--If professional counselors do
engage in conversion therapy, what must they include in
their disclosure statements and informed consent documents?
Ethics Committee members agreed that it is of
primary importance to respect a client's autonomy to request a
referral for a service not offered by a counselor. In the 2005
ACA Code of Ethics, Standard A.11.b. ("Inability to Assist
Clients") states, "If counselors determine an inability to be of
professional assistance to clients, they avoid entering or
continuing counseling relationships. Counselors are
knowledgeable about culturally and clinically appropriate
referral resources and suggest these alternatives."
Additionally, Standard D.1.a. ("Different Approaches") reminds
us that "counselors are respectful of approaches to counseling
services that differ from their own."
Standard A.1.a. ("Primary Responsibility"),
however, states that "the primary responsibility of counselors
is to respect the dignity and to promote the welfare of
clients." Referring a client to a counselor who engages in a
treatment modality not endorsed by the profession and that may,
in fact, cause harm does not promote the welfare of clients and
is a dubious position ethically. This position is supported by
Standard A.4.a. ("Avoiding Harm"), which says, "Counselors act
to avoid harming their clients, trainees and research
participants and to minimize or to remedy unavoidable or
unanticipated harm."
Professionals also engage in treatment only after
appropriate educational and clinical training and do not
practice outside of their areas of competence (Standard C.2.a.,
"Boundaries of Competence"). This standard clearly states that
"counselors practice only within the boundaries of their
competence, based on their education, training, supervised
experience, state and national professional credentials, and
appropriate professional experience." In addition, per Standard
C.2.b. ("New Specialty Areas of Practice"), "Counselors practice
in specialty areas new to them only after appropriate education,
training and supervised experience. While developing skills in
new specialty areas, counselors take steps to ensure the
competence of their work and to protect others from possible
harm." Therefore, any professional engaging in conversion
therapy must have received appropriate training in such a
treatment modality with the requisite supervision. There is,
however, no professional training condoned by ACA or other
prominent mental health associations that would prepare
counselors to provide conversion therapy.
In addition, requests by clients seeking to
change their sexual orientation should be understood within a
cultural context. Standard E.5.c. ("Historical and Social
Prejudices in the Diagnosis of Pathology") requires that
"counselors recognize historical and social prejudices in the
misdiagnosis and pathologizing of certain individuals and groups
and the role of mental health professionals in perpetuating
these prejudices through diagnosis and treatment." Historically,
the mental health professions viewed homosexuality as a mental
disorder. But in 1973, homosexuality was removed from the
Diagnostic and Statistical Manual as a mental disorder. However,
within various religious and cultural communities, same-sex
attractions and behaviors are still viewed as pathological. Yet
the professional communities of counseling and psychology no
longer diagnose a client who has attractions to people of the
same sex as mentally disordered. To refer a client to someone
who engages in conversion therapy communicates to the client
that his/her same-sex attractions and behaviors are disordered
and, therefore, need to be changed. This contradicts the
dictates of the 2005 ACA Code of Ethics.
Clients may ask for a specific treatment from a
counseling professional because they have heard about it from
either their religious community or from popular culture. A
counselor, however, only provides treatment that is
scientifically indicated to be effective or has a theoretical
framework supported by the profession. Otherwise, counselors
inform clients that the treatment is "unproven" or "developing"
and provide an explanation of the "potential risks and ethical
considerations of using such techniques/procedures and take
steps to protect clients from possible harm" (Standard C.6.e.,
"Scientific Bases for Treatment Modalities").
Considering all the above deliberation, the ACA
Ethics Committee strongly suggests that ethical professional
counselors do not refer clients to someone who engages in
conversion therapy or, if they do so, to proceed cautiously only
when they are certain that the referral counselor fully informs
clients of the unproven nature of the treatment and the
potential risks and takes steps to minimize harm to clients
(also see Standard A.2.b., "Types of Information Needed"). This
information also must be included in written informed consent
material by those counselors who offer conversion therapy
despite ACA's position and the Ethics Committee's statement in
opposition to the treatment. To do otherwise violates the spirit
and specifics of the ACA Code of Ethics.
Informing clients about
conversion therapy
So what do ethical counselors do if clients state
they are still interested in pursuing a referral for a counselor
who offers conversion therapy? We advise professional counselors
to discuss the potential harm of this therapy noted in
evidence-based literature from scholarly publications in a
manner that respects the client's decision to seek it. This
again relates to Standard A.1.a. ("Primary Responsibility") and
Standard A.4.b. ("Personal Values"), which requires counselors
to be "aware of their own values, attitudes, beliefs and
behaviors and avoid imposing values that are inconsistent with
counseling goals." The responsibility of counseling
professionals at this juncture is to help clients make the most
appropriate choices for themselves without the counselor
imposing her/his values. To do so respects a client's request
and leaves open the possibility that the client can return to
the professional counselor if the conversion therapy is
ineffective and harms the client.
Again, Ethics Committee members agree that
ethical practitioners refer clients seeking conversion therapy
only under the conditions previously discussed. Further, it is
imperative that counselors provide clients seeking conversion
therapy with information about this form of treatment, including
what types of information clients should expect from referral
counselors. The following must be included in informed consent
material and communicated to clients seeking referral:
Conversion therapy assumes that a person who has
same-sex attractions and behaviors is mentally disordered and
that this belief contradicts positions held by the American
Counseling Association and other mental health and biomedical
professional organizations. Additionally, the ACA passed a
resolution in 1999 stating that it does not endorse reparative
therapy as a "cure" for homosexuality. Any professional who
engages in conversion therapy is not offering the professional
standard of care and would need to include that he or she is
offering it not as a professional counselor but is providing
counseling within the scope of practice of some other profession
(i.e., Christian counselor).
Conversion therapy as a practice is a religious, not
psychologically-based, practice. The premise of the treatment is
to change a client's sexual orientation. The treatment may
include techniques based in Christian faith-based methods such
as the use of "testimonials, mentoring, prayer, Bible readings,
and Christian weekend workshops" (Shroeder & Shidlo, 2001, p.
150). It may also use cognitive-behavioral techniques such as
aversion therapy (i.e.; stopping clients from masturbating to
same-sex images; encouraging imagery of getting AIDS paired to
same-sex arousal), reinforcement techniques that emphasize
traditional gender role behavior (i.e., for men to "engage in
team sports, to go the gym, and to attend Promise Keepers" and
for women "to learn how to cook, sew, and apply make-up";
Shroeder & Shidlo, 2001, p. 149), and use of sexual surrogates.
However, there is no training offered or condoned by the
American Counseling Association to educate and prepare a
professional counselor wishing to engage in this type of
treatment.
Research does not support conversion therapy as an effective
treatment modality. There have been "no objective screening
criteria, no consensus about outcome measurement, and no blinded
or side-by-side studies" (Forstein, 2001, p. 173) and there is
"no article in a peer reviewed scientific journal" stating that
conversion therapy alters someone's sexual orientation (p. 177).
The results of some research indicate that some clients seeking
this treatment do change their behavior approximately 30% of the
time, but the same clients report changing only their behaviors
but not their sexual orientation. This is an important
distinction to share with clients, helping them understand the
difference between behaviors and sexual identity. Further, no
long-term studies have been conducted to discern whether
research participants who reported a change in their behaviors
maintained these changes over time.
There is potential for harm when clients participate in
conversion therapy. Results of studies indicate that there are
clients who enter this type of treatment and then report that
they function more poorly than when they entered (Nicolosi,
Byrd, & Potts, 2000; Schroeder & Shidlo, 2001).
There are treatments endorsed
by the Association for Gay, Lesbian, and Bisexual Issues in
Counseling (see
http://www.aglbic.org/resources/competencies.html),
a division of the American Counseling Association and the
American Psychological Association (see
http://www.apa.org/pi/lgbc/guidelines.html)
that have been successful in helping clients with their sexual
orientation. These treatments are gay affirmative and help a
client reconcile his/her same-sex attractions with religious
beliefs.
In summary, if clients still decide that they
wish to seek conversion therapy as a form of treatment,
counselors should also help clients understand what types of
information they should seek from any practitioner who does
engage in conversion therapy. The Committee members agree that
counselors who offer conversion therapy are providing "treatment
that has no empirical or scientific foundation" (ACA, 2005,
C.6.e.) and, therefore, must "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" (ACA, C.6.e.). Additionally, any client seeking
treatment is entitled to complete information about the
treatment. This is consistent with A.2.b (Types of Information
Needed) that state "counselors explicitly explain to clients the
nature of all services provided. They inform clients about
issues such as, but not limited to, the following: the purposes,
goals, techniques, procedures, limitations, potential risks, and
benefits of services; the counselor's qualifications,
credentials, and relevant experience; continuation of services
upon the incapacitation or death of a counselor; and other
pertinent information." Counselors who do not include this
information would be considered by the Committee to be in
violation of the ACA Code of Ethics.
There also was agreement among the Committee
members that any counselors stating that they can offer
conversion therapy must also offer referrals to gay, lesbian,
and bisexual-affirmative counselors and should discuss
thoroughly the right of clients to seek these professionals'
counsel. In doing so, counselors must explore with clients the
underlying reasons for their interest in changing their sexual
orientation and discuss the social, political, and religious
influences that underpin homophobia that may be harming the
client.
Counselor Education
Finally, in
addition to educating potential clients about conversion
therapy, the members of the Ethics Committee agreed that
counselor education training programs must also adhere to
section F.6.f (Innovative Theories and Techniques), which states
that "when counselor educators teach counseling
techniques/procedures that are innovative, without an empirical
foundation, or without a well-grounded theoretical foundation,
they define the counseling techniques/procedures as 'unproven'
or 'developing' and explain to students the potential risks and
ethical considerations of using such techniques/procedures." A
similar approach to informed consent for clients seeking
conversion therapy must be upheld when discussing this treatment
with counseling students.
