by Dermot O’Callaghan
A Serious Concern
This article expresses concern that the Ethical Principles of the UK Council for Psychotherapy appear to be based on an inadequate scientific foundation, and to contravene the human rights of persons who wish to receive professional help to reduce unwanted same-sex attractions.
The authoritative book Destructive Trends in Mental Health: The well intentioned path to harm (eds Nicholas Cummings and Rogers Wright1) expresses well these concerns in an American context:
… gay groups within the American Psychological Association have repeatedly tried to persuade the association to adopt ethical standards that prohibit therapists from offering psychotherapeutic services designed to ameliorate “gayness,” on the basis that such efforts are unsuccessful and harmful to the consumer. Psychologists who do not agree with this premise are termed homophobic. Such efforts are especially troubling because they abrogate the patient’s right to choose the therapist and determine therapeutic goals. They also deny the reality of data demonstrating that psychotherapy can be effective in changing sexual preferences in patients who have a desire to do so. (p XXX)
On p 17 (by Cummings and O’Donohue) there is a section entitled, Is Treating Homosexuality Unethical? It says,
“Although the APA is reluctant or unable to evaluate questionable practices and has thus avoided addressing the issue of best practices, this did not prevent its Council of Representatives in 2002 from stampeding into a motion to declare the treatment of homosexuality unethical. This was done with the intent of perpetuating homosexuality, even when the homosexual patient willingly and even eagerly seeks treatment. The argument was that because homosexuality is not an illness, its treatment is unnecessary and unethical. Curiously, and rightly so, there was no counterargument against psychological interventions conducted by gay therapists to help patients be gay, such as those over many decades by leading psychologist and personal friend Donald Clark (the author of the best-selling Living Gay) and many others. Vigorously pushed by the gay lobby, it was eventually seen by a sufficient number of Council members as runaway political correctness and was defeated by the narrowest of margins. In a series of courageous letters to the various components of APA, former president Robert Perloff2 referred to the willingness of many psychologists to trample patients’ rights to treatment in the interest of political correctness. He pointed out that making such treatment unethical would deprive a patient of a treatment of choice because the threat of sanctions would eliminate any psychologist who engaged in such treatment. Although the resolution was narrowly defeated, this has not stopped its proponents from deriding colleagues who provide such treatment to patients seeking it.” (p 17,18)
Two Hypothetical Examples
In considering the UKCP Ethical Principles two hypothetical cases will serve as examples:
A young man has a lady friend whom he would like to marry. He is concerned, however, that he experiences same-sex attractions which he fears might derail the relationship a few years down the line. For as long as these feelings continue, he is unwilling to take the risk of marrying, not least for the sake of the woman he loves, and would like help in reducing his same-sex attractions.
A woman in her thirties is married with two children. She falls in love with another woman and is torn between leaving her family or staying. She would like help to reduce her same-sex attraction to enable her to keep her family intact.
Each of these people seeks the advice of an appropriately qualified UKCP-registered therapist and is told that science has shown that “agreeing to the client’s request for therapy for the reduction of same sex attraction is not in a client’s best interests” (2.1 – 1.1(a)) The man takes this news badly, goes into a deep depression and tries to kill himself. The woman, on the other hand, accepts the therapist’s explanation and decides to leave her husband and children, causing them great and long-lasting distress.
Such client dilemmas are not uncommon and the UKCP has a clear duty of care to avoid harm in its ethical guidance to psychotherapists. A high burden of proof would be needed to show that public safety is enhanced rather than diminished by following the UKCP ethical guidance to decline reasonable client requests in circumstances such as these.
Questioning the UKCP Guidance
One must question whether research has in fact shown that therapy for the reduction of SSA is invariably “not in a client’s best interests.” The Guidance attempts to justify its position by making a non-specific reference to Drescher. Which of his works is referred to? Perhaps Ethical concerns raised when patients seek to change same-sex attractions, Journal of Gay & Lesbian Psychotherapy, 5(3/4), 181-210. A second reference is to Shidlo and Schroeder (2002). This study recruited some of its participants under the slogan, “Help us document the damage of homophobic therapists”. It would appear that neither of the sources referenced is based on a representative sample of clients, which would be necessary in order to substantiate the universal claim that therapy for reduction of same sex attraction is “not in a client’s best interests”. Yet this absolutist claim is made solely on the basis of these two references.
In section 2.1 – 1.1(b) it is stated that “There is overwhelming evidence that undergoing such therapy is at considerable emotional and psychological cost.” Where is this “overwhelming evidence”? Dr Stanton Jones in a commentary on this debate3 says that his recent research (with Dr Mark Yarhouse)4 into the question of harm “[did] not prove that no one is harmed by the attempt to change, but rather that the attempt to change does not appear to be harmful on average or inherently harmful.” Jones points out that their findings “challenge the commonly expressed views of the mental health establishment that change of sexual orientation is impossible or very uncommon, and that the attempt to change is highly likely to produce harm for those who make such an effort.”3 Dr Rogers Wright argues forcefully that their research “demands a substantial and credible re-examination of the current politically driven, politically correct dogma that homosexual orientation is immutable and that therapeutic address thereof threatens patient wellbeing.”5
I am not aware of any study that has followed clients prospectively, administered generally accepted psychological tests to measure distress, and proved that, on average, harm is caused by Sexual Orientation Change Efforts (SOCE).
One notices further that 1.3 – (e) says that for a psychotherapist to offer treatment that might ‘reduce’ same sex attraction would be “exploitative” as “to do so would be offering a treatment for which there is no illness.” Application of that logic to the two cases I have outlined above would be highly problematic. In neither case would the person be described as “ill”. But the Guidance implies that if a therapist offered treatment to help persons such as these to achieve their life goals, the therapist would thereby be ‘exploiting’ the client. The error here is to imagine that ‘treatments’ can be offered only in the case of ‘illness’. But one can have ‘treatment’ for everything from being nervous in public speaking to seeking a modest reduction in one’s weight, without being declared ill. The people in the above examples are being denied a human right to treatment intended to help them shape their lives as they wish.
Section 1.3 – (g) denies client ‘autonomy’ as sufficient justification for a therapist attempting to reduce same sex attractions, by wrongly suggesting that clients such as those in my examples are experiencing “externalised and internalised oppression.” But to categorise the desire to reduce same sex attractions in order to protect one’s family as a sign that one is experiencing “oppression” – either external or internal – is to stigmatise ordinary people who simply have ordinary life goals.
Section 3.1 (ii) concludes that “Based on the above considerations” offering ‘Sexual Orientation Change Efforts’ is “incompatible with UKCP’s Ethical Principles and Code of Professional Conduct.” In the light of the explanations given in the code of conduct, it seems to me rather that the blanket refusal of SOCE in any and all circumstances is a form of oppression and a denial of human rights.
Summary of questions
In the light of the foregoing discussion, the questions to which answers are urgently needed include:
Is it not correct to say that requests for client autonomy such as in the two examples given above are entirely reasonable and based on legitimate life goals?
What evidence is there to sustain the proposition that “agreeing to the client’s request for therapy for the reduction of same sex attraction is not in a client’s best interests” – that is to say, that there are no cases in which such a client request should be honoured and that in every case the therapist’s maxim ‘first do no harm’ would be violated by honouring the client’s request?
Is it really true that the two documents referenced in the Guidance have “shown that offering, or agreeing to the client’s request for, therapy for the reduction of same sex attraction is not in the client’s best interests”?
Is there any high quality scientific research which shows “overwhelming evidence that undergoing such therapy is at considerable emotional and psychological cost”? Such evidence would need to be better than that of Jones & Yarhouse who found to the contrary. That is to say, one or more studies would need to have followed clients prospectively, administered generally accepted psychological tests to measure distress, and proved that, on average, harm is caused by SOCE.
In the context of the two cases outlined above, how would it be “exploitative” for a therapist to offer treatment that might ‘reduce’ same sex attraction and enable them to achieve their life goals?
Are there no circumstances in which UKCP permits therapists to offer treatments “for which there is no illness” (such as modest weight loss and normal nervousness in public speaking)?
Is it scientifically proven that the desire to reduce same sex attractions in order to protect one’s family is a sign of “oppression” – either external or internal?
Is it the case that the denial of a client’s request to receive help to achieve the type of life goals that outlined in this paper is based on scientific evidence that is of such a high standard as to warrant denial of this basic human right in the interest of public safety?
UKCP’s Ethical Principles and Codes of Professional Conduct: Guidance on the Practice of Psychological Therapies that Pathologise and/or Seek to Eliminate or Reduce Same Sex Attraction
The purposes of this document are to guide training and supervision in the subjects of ethics and sexuality, and to ensure consistent application of the UKCP’s Ethical Principles and Code of Professional Conduct in relevant cases, in order to support best practice and reduce harm to clients brought about by bias or selective inattention to research findings regarding same sex attraction.
UKCP’s Ethical Principles and Code of Professional Conduct (the UKCP Ethics Code) defines generic UKCP ethical principles which UKCP members commit to and maintain. The UKCP Ethics Code must be taken into account (in conjunction with any other ethical documents which may apply) by the Professional Conduct Officer, Professional Conduct Committee, Preliminary Investigating Committee, Fitness to Practise Tribunal and Appeal Tribunal when considering allegations of conduct which may impair a UKCP member’s fitness to practise under the Central Complaints Process and Central Final Appeal Procedure.
1.3 The UKCP Ethics Code will apply when considering complaints related to the practice of any psychological therapy that seeks to eliminate or reduce same sex attraction, irrespective of the name given to the modality of therapy. This document identifies the appropriate provisions of the UKCP Ethics Code, and gives guidance on the appropriate interpretation of these provisions.
This guidance has been prepared by the Ethics Committee after close consultation with, and input from, the Diversity, Equalities and Social Responsibility Committee and Forum, has been agreed by those committees and the Board of UKCP.
When considering allegations under the UKCP’s Central Complaints Process, codes of practice, conduct or ethics or standards of competence or equivalent documents, issued by UKCP and a relevant organisational member can apply (clause 4.1 of the Central Complaints Process). This guidance represents UKCP’s position on these issues. It therefore must be taken into account by the Professional Conduct Officer, the Professional Conduct Committee and UKCP (and Organisational Members’) panels or committees who are considering complaints of this nature.
1.6 This guidance must be taken into account by UKCP colleges and organisational members when considering complaints relating to therapies that pathologise and/or seek to eliminate or reduce same sex attraction.
1.7 This guidance applies to psychotherapists, psychotherapeutic counsellors, teachers on psychotherapy training courses and supervisors.
2. Guidance ON Relevant Sections of the UKCP Ethics Code
2.1 Section 1 of UKCP Ethics Code: Best Interests of Client
1.1 The psychotherapist takes responsibility for respecting their client’s best interests when providing therapy.
Research has shown that offering, or agreeing to the client’s request for, therapy for the reduction of same sex attraction is not in a client’s best interests. (Drescher, Shidlow and Schroeder, 2002).
An ethical response to a request by a client for psychotherapy to reduce same sex attraction would be to establish a clear contract with the client regarding the nature of psychotherapy as a process rather than an outcome, and to share with the client basic information on the findings of research on therapy that aims to change or reduce same sex attraction, which is that research does not suggest this therapy is effective, although sometimes limited effect has been reported. There is overwhelming evidence that undergoing such therapy is at considerable emotional and psychological cost.
A competent first response to a request by a client for psychotherapy to reduce same sex attraction would be to establish where the pressures are coming from for the client to seek making such a change
If the therapist feels that they do not have sufficient competence to work on these issues they should inform the client, and where possible make a referral to an appropriate practitioner.
The psychotherapist undertakes not to abuse or exploit the relationship they have with their clients, current or past, for any purpose, including the psychotherapist’s sexual, emotional or financial gain.
It is exploitative for a psychotherapist to offer treatment that might ‘cure’ or ‘reduce’ same sex attraction as to do so would be offering a treatment for which there is no illness.
It is exploitative to offer treatment to reduce same sex attraction when various studies bring into question whethersuch treatments change a person’s sexuality.
The psychotherapist undertakes to respect their client’s autonomy.
The psychotherapist undertakes not to harm or collude in the harming of their client or a client of others.
It is not a sufficient defence for a therapist to argue that in attempting (or expecting as an outcome of therapy) reduction of same sex attraction they were acting in the client’s best interests, or according to the client’s wishes and autonomy, as offering such therapy would be contributing to and reinforcing their externalised and internalised oppression and likely to cause harm to the client, or extend their existing distress.
2.2 Section 2 of UKCP Ethics Code: Diversity and Equality
The psychotherapist undertakes to actively consider issues of diversity and equalities as these affect all aspects of their work. The psychotherapist accepts no one is immune from the experience of prejudice and acknowledges the need for a continuing process of self-enquiry and professional development.
This includes internal competencies of self-awareness, understanding and tolerance of difference and awareness of one’s own limits of experience, and openness regarding the limits of research in establishing definitive causes or fixed types of sexual orientation.
This includes sensitivity to possible differences in form and intensity of oppression, that may range from fears of ridicule, to loss of community, to genuine threat to life, and which may be influenced by a person’s age, family role, profession, geography or cultural and religious ties and attachments
j.This also includes appreciation of various culturally located, non-pathologising resources and bonds in the client’s existing social framework and support of the client’s choices in how they benefit from these.
This may include informing the client of the range of LGBT services available to people from their social grouping.
l.Psychotherapists who are members of faith groups (or are of no faith) must commit to the same ethical requirement of respect and sensitivity towards all people and to their understanding and knowledge of beliefs, practices and cultures different from theirs.
2.2 The psychotherapist undertakes not to allow prejudice about a client’s sex, age, colour, race, disability, sexuality, social, economic or immigration status, lifestyle, religious or cultural beliefs to adversely affect the way they relate to the client.
2.3 The psychotherapist undertakes not to engage in any behaviour that is abusive or detrimental to any client or colleague based on the above factors.
m.To approach psychotherapeutic practice from the basis that same sex attraction is a psychopathology is to hold prejudice in relation to a client’s sexuality and thus could be detrimental to the client.
To seek to identify pathological causes for a client’s same sex attraction, and/or to seek to identify the client’s same sex attraction as the root cause of their unhappiness or distress would be to contribute to and reinforce a client’s externalised and internalised oppression.
2.3 Section 5 of UKCP Ethics Code: Professional Knowledge, Skills and Experience
5.3 The psychotherapist commits to recognise the boundaries and limitations of their expertise and techniques and to take the necessary steps to maintain their ability to practice competently.
5.5 The psychotherapist commits to adhering to the UKCP policies on standards of education, training and practice.
5.6 The psychotherapist commits to an on-going process of professional and personal enquiry and challenge, commonly referred to as “Continuing Professional Development”. The psychotherapist commits adhering to the Continuing Professional Development policies held by UKCP and the relevant section of the UKCP that the psychotherapist is a member of.
Many psychotherapists completed their initial training while same sex attraction was still categorised as a mental health condition. However, this would not be a defence to an ethical breach, as a psychotherapist commits to a process of ongoing professional and personal enquiry, and to maintain their ability to practise competently.
5.4 If it becomes clear that a case is beyond a psychotherapist’s scope of practice, the psychotherapist commits to inform the client and where appropriate offer an alternative psychotherapist or other professional where requested.
5.7 The psychotherapist accepts responsibility to ensure that they are competent and have sufficient supervisory arrangements and other necessary support to enable them to meet their psychotherapeutic obligations to any client. This includes the responsibility of ensuring the very careful consideration of how best to refer a client to another psychotherapist or professional should it become clear that this would be in the client’s best interest.
The ethical response of a psychotherapist who is not sufficiently experienced or trained to work with issues of minority sexuality would be to act in the client’s best interest by recognising the limits of practice and where possible refer the client to another psychotherapist.
The ethical response of a psychotherapist whose personal, theoretical or religious beliefs precludes them from working in a non-judgmental way with a lesbian, gay, bisexual or transgender client or one who is experiencing same sex attraction, would be to act in the client’s best interest by recognising the limits of practice and where possible refer the client to another psychotherapist.
r. An appropriate referral in such a case would be to a psychotherapist who is qualified in working with matters of sexuality based on training that has covered the diversity of human sexuality, the range of theoretical models and practice methods, based on a breadth of research, and not on the basis of a training that prescribes one outcome for clients based on one theory of human sexuality or a theory which pathologises same sex attraction.
3.4 Section 11 of UKCP Ethics Code: Advertising
11.3 The psychotherapist undertakes not to make or support unjustifiable statements relating to particular therapies or therapists or include testimonials from clients in any advertising material.
Advertising treatment to reduce same sex attraction would be an unjustifiable statement, in the same way that it is unjustifiable to advertise any psychotherapeutic treatment as providing a specific result.
Based on the above considerations of ethical practice it may be generally concluded that the following are incompatible with UKCP’s Ethical Principles and Code of Professional Conduct:
Practising, or offering to practise psychotherapy which supports within its tenets that homosexuality, bisexuality, resistance to labelling one’s sexual orientation, fluidity of sexuality, or same sex attraction are psychopathologies or symptoms of a psychopathology.
Offering ‘Sexual Orientation Change Efforts’ (also called SOCE, ‘reparative’, ‘conversion’ or ‘reorientation’ therapy) or similar therapies by other names.
Practising any other form of psychotherapy that seeks to eliminate or reduce same sex attraction in their clients (whether by stated intention, or in practice.)
Knowingly referring a client to a psychotherapist or other professional whose practice aims to eliminate or reduce same sex attraction on the basis of prejudice against minority sexuality as immoral, unnatural or pathological.
Teaching material on training courses and/or when supervising psychotherapists which promotes or seeks to justify therapy that pathologises same sex attraction.
3. 2. A psychotherapist who practises, teaches, supervises or makes referrals to practitioners of any of the forms of therapy referred to above acts in breach of UKCP’s Ethics Code pursuant to, but not limited to, the following sections of the code:
1. Best Interests of Client
2. Diversity and Equality
5. Professional knowledge, skills and experience
3.3 It is recognised by UKCP that a client’s attraction to a person or persons of the same or opposite sex may increase or decrease while they are receiving psychotherapy. In itself this does not suggest (still less prove) unethical conduct by the psychotherapist.
3.4 It is recognised that all modalities of psychotherapy are based on texts which were written in specific historical and cultural contexts and which may express or imply prejudice against people with same sex attraction. In itself this does not suggest (still less prove) ethically incompatible psychotherapy. Practitioners are required to consider all such texts from a position of reflective critique. Trainers and Supervisors are required to use opportunities presented by these texts to engage Trainees and Supervisees in processes of professional and personal enquiry, increasing awareness of Diversity and Equality issues.
1 Rogers Wright is a past president of two of the divisions of the APA
Nicholas Cummings is a past president of the APA
William O’Donohue is Professor of Organized Behavioral Healthcare Delivery at the University of Nevada
2 Robert Perloff is a past president of the APA
3 http://www.wheaton.edu/CACE/Hot-Topics A less technical version of this paper is at http://www.firstthings.com/article/2012/01/same-sex-science
4 First published in Jones & Yarhouse, Ex-Gays? IVP 2007
5 Testimonial by Rogers Wright in opening pages of Ex-Gays?