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:

1. 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).
2. 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.
3. 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.
4. 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).
5. 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.

References

American Counseling Association (2005). Code of ethics. Alexandria, VA: Author.
American Counseling Association (1995). Code of ethics. Alexandria, VA: Author.
Association for Gay, Lesbian, and Bisexual Issues in Counseling. (n.d.) . Competencies for counseling gay, lesbian, bisexual and transgendered (GLBT) clients. Retrieved February 7, 2006, from http://www.aglbic.org/resources/competencies.html.
American Psychological Association. (1998). Guidelines for psychotherapy with lesbian, gay, and bisexual clients. Retrieved February 7, 2006, from http://www.apa.org/divisions/div44/guidelines.htm.
Forstein., M. (2001). Overview of ethical and research issues in sexual orientation therapy.
Journal of Gay and Lesbian Psychotherapy, 5(3/4), 167-179.
Nicolosi, J., Byrd, A. D. & Potts, R. W. (2000). Retrospective self-reports of changes in homosexual orientation: A consumer survey of conversion therapy clients. Psychological Reports, 86, 1071-1088.
Shroeder, M., & Shidlo, A. (2001). Ethical issues in sexual orientation conversion therapies: An empirical study of consumers. Journal of Gay and Lesbian Psychotherapy, 5(3/4), 131-166.