Reparative Therapy: The Adolescent, the Psych Nurse, and the Issues

jcap_214 29..35

Laura C. Hein, PhD, RN, NP-C, and Alicia K. Matthews, PhD

TOPIC:

Reparative therapy aims to modify the

sexual orientation of lesbian, gay, and bisexual (LGB) people into that of heterosexuals. Although denounced as harmful by most professional organizations, these treatments continueyouth may be particularly vulnerable to the negative consequences.
PURPOSE:

Laura C. Hein, PhD, RN, NP-C, is Assistant Professor, University of South Carolina Columbia, South Carolina. Alicia K. Matthews, PhD, is Associate Professor, University of Illinois, Chicago, Illinois, USA.
eparative therapy, also known as conversion therapy, is a general term for approaches aimed at changing lesbian, gay, and bisexual (LGB) people to a heterosexual sexual orientation (Yarhouse, 2002) or at diminishing same-sex behavior and/or attractions. Foundational to the practice of reparative therapy is the belief that homosexuals are defective, broken, sinful and unacceptable (Ford, 2001, p. 77) and that sexual orientation can be changed. Professional organizations are in consensus that reparative therapy may be harmful to clients (American Medical Association, 2007; American Psychiatric Association, 2000a; American Psychological Association, 1997; National Association of Social Workers, 2000; Whitman, Glosoff, Kocet, & Tarvydas, 2006). APA recommends that ethical practitioners refrain from attempts to change individuals sexual orientation, keeping in mind the medical dictum to rst, do no harm (American Psychiatric Association, 2000b). Despite this, reparative therapy continues to be practiced and encouraged by some individual professionals, lay organizations, religions, and denominations. The aims of this paper are to (a) discuss reparative therapy, (b) discuss the potential risks LGB youth face from reparative therapy, (c) describe potential sequelae psychiatric nurses might expect in youth exposed to these therapies, and (d) discuss ethical issues stemming from nurse participation in reparative therapies. Before proceeding, several terms require dening: Sexual orientation refers to an individuals pattern of physical and emotional arousal toward other persons (Frankowski & The American Academy of Pediatrics Committee on Adolescence, 2004, p. 1827). Homosexual people (gay and lesbian) are emotionally and physically attracted to members of their own sex; bisexuals are attracted to members of both sexes.

The purpose of this article is to discuss

reparative therapies, the potential harm LGB youth may experience, clinical and practice issues for psychiatric nurses, and the ethical issues surrounding nurse involvement in reparative therapy.
CONCLUSIONS:

Reparative therapy for

adolescents raises important clinical and ethical issues for psychiatric nursing. Further discussion of nurse involvement in these treatments is needed.
Search terms: Adolescence, conversion therapy,

gay, homosexual, LGBT, reparative therapy

doi: 10.1111/j.1744-6171.2009.00214.x 2010 Wiley Periodicals, Inc. Journal of Child and Adolescent Psychiatric Nursing, Volume 23, Number 1, pp. 2935
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Prevalence of LGB Youth

Population-based studies suggest that 26% of adolescents self-identify as gay, lesbian, or bisexual (Garofalo, Wolf, Kessel, Palfrey, & DuRant, 1998; Saewyc et al., 2006). A study
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Reparative Therapy: The Adolescent, the Psych Nurse, and the Issues

of 36,741 1220-year-olds in Minnesota found that 6% of adolescent males self-identied as gay or bisexual (Remafedi, Resnick, Blum, & Harris, 1992). Measurement of sexual orientation can be challenging. Sexual orientation may be measured by asking how a person self-identies (e.g., as gay or bisexual), inquiring about who they are sexually attracted to, or by inquiring about sexual behavior. A combination of these measures is sometimes used. Some individuals who engage in same-sex sexual behavior do not identify as gay, lesbian, or bisexual. Additionally, some persons who selfidentify as gay, lesbian, or bisexual may not currently or ever have been sexually active. In a qualitative study of adolescents, participants identied physiological and cognitive sexual attraction as key to sexual orientation (discounting the relevance of sexual behavior and self-identication) (Friedman et al., 2004). Considering sexual behavior as well as sexual identity increases the prevalence of nonheterosexuality to 21% from the 6% found by Remafedi et al. Sell, Wells, and Wypij (1995) surveyed 3,931, 1650-year-old people across three countries and found that 20.8% of males in the United States reported either homosexual behavior or homosexual attraction since the age of 15. The prevalence of nonheterosexual youth in the population (between 2% and 21%) is not insubstantial and as such has important implications when discussing reparative therapy. It is unknown what percentages of LGB youth have undergone reparative therapy.

Determinants of Sexual Orientation

Often, we determine the acceptability of people of different sexual orientations based on whether we believe they have chosen or can control their sexual orientation (Tygart, 2000). There is evidence for the genetic basis of both male and female sexual orientation from studies of twins with heritability of homosexuality between 30% and 62% (Kendler, Thornton, Gilman, & Kessler, 2000; Kirk, Bailey, Dunne, & Martin, 2000; Mustanski, 2003). However, heritability, genetics, and determination of environmental contributions to sexual orientation are of questionable relevance to a discussion of reparative therapy. Ones belief in the immutability of sexual orientation is not relevant to whether reparative therapy may be harmful to youth (Young, 2006).

sustenance; and/or full rejection (Saltzburg, 2004; Willoughby, Malik, & Lindahl, 2006). For example, Balsam, Rothblum, and Beauchaine (2005), in a comparative study, found that LGB people experience higher rates of emotional, physical, and sexual abuse than their heterosexual counterparts. Rejection by family is a frequent consequence of disclosure or parental discovery of a childs LGB orientation (Radkowsky & Siegel, 1997). DAugelli, Hershberger, and Pilkington (1998) found increased prevalence of verbal and physical abuse and heightened suicidal ideation among those who disclosed their sexual orientation to their families. In a subsequent study, DAugelli, Grossman, and Starks (2005) found that youth whose parents were aware of their sexual orientation reported a history of more verbal abuse than youth with parents who were unaware of their sexual orientation. However, these same disclosed (out) youth subsequently reported experiencing less verbal abuse than in the past (before their parents denitively knew about their sexual orientation/gender identity). One further consequence of disclosure of sexual orientation/gender identity is that LGB adolescents may be forced by their parents or guardians to undergo outpatient or inpatient reparative therapy treatment (Gay Lesbian and Straight Education Network, 1999; Hicks, 2000; Mournian, 2000; Ricks, 1993). The legal ability of parents to institutionalize their children in a psychiatric facility, if a physician agrees that the child is suitable for treatment, has been upheld by the Supreme Court (Parham v. J. R. [1979]; 442 U.W. 584). The involvement of a physician or any licensed mental healthcare provider is often unnecessary for residential or nonresidential religious-based treatment, sometimes provided under the purview of a boarding school (Penn, 2007). Parents may employ escort services (International Survivors Action Committee, 2003; Strugglingteens.com, 2007; Woodbury Reports, 2007) to assist in the forcible transport of their children to these facilitiesin handcuffs if they desire (WMCTV, 2006). These services typically utilize the element of surprisearriving at night and forcibly remove the youth from their bed (Penn; Weiner, 2003). Lacking legal standing to procure discharge from these institutions and facilities, escape is the remaining alternative, often rendering these youth homeless (Mournian; Ricks).

Parental Reactions to a Childs Nonheterosexuality

Sexual orientation and gender identity can play a substantial role in the life of an adolescentimpacting their social and family relations and their safety. Upon coming out (disclosing ones sexual orientation/gender identity to others), a youth may be confronted with several responses from their families that may include acceptance, tolerance, violence, or threat of violence; a requirement for them to seek treatment to change their sexual orientation for continued shelter and
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Reparative Therapy
People with various levels of training conduct reparative therapy: psychiatrists, psychologists, counselors, clinical social workers, family counselors, pastoral counselors, religious leaders, and laymen with no formal training (Yarhouse, 2002; Yarhouse, Burkett, & Kreeft, 2002). Organizations specializing in or conducting these treatments include Exodus-afliated ministries (residential and outpatient programs for youth and adults), Homosexual
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Anonymous chapters, religious denomination-sponsored ministries (CourageCatholic; EvergreenLatter Day Saints; JONAHJewish), and various private residential treatment facilities and boarding schools (Penn, 2007; Yarhouse et al.).

Reparative Therapies

Reparative treatments span the breadth of psychological practice.

Analysis of patient reparative therapy experiences ranging from 1951 to 1999 revealed that those treatment approaches used in the 1950s (prior to current standards for ethics in mental health) are still being used (Shidlo & Schroeder, 2002). These treatments include (a) various talking-based therapies: individual and group (Beckstead & Morrow, 2004; Ford, 2001; Socarides, 1995; Williamson, 2008; Yarhouse et al., 2002); (b) electric shocks to the torso, hands, or genitals (faradic therapy) while exposing the client to homoerotic material (Beckstead & Morrow; Cox, 2000a; Ford); (c) exorcism (Besen, 2003; Ford; Human Rights Campaign, 2000; Killian, 1996); (d) covert sensitizationimagining an erotic situation and pairing this with something revolting or terror inducing (Foucher, 2007; Human Rights Campaign; Summers, 2000; Williams, 2005) and/or administration of emetics while homoerotic material is presented (Penn, 2007); (e) restraints and isolation (Summers); and (f) gender modication therapy (training in how to behave more hetero-gender-congruent: male coaching in sports activities; and female training in coifng or cosmetics application) (Beckstead & Morrow; Cox; Human Rights Campaign). Interestingly, many of these same treatments (administered to a lesbian in Russia) were deemed mental and physical torture by the Ninth Circuit Court of Appeals and sufciently horric to grant U.S. asylum (Pitcherskaia v. Immigrations and Naturalization Service, 118 F.3d 641 [1997]). Talking-based reparative therapies continue today through various professional and lay venues (Malony, 2005; Williamson, 2008; Yarhouse et al., 2002). There are reports of reparative therapy treatments on adolescents as recently as 2005 (Penn, 2007; Williams, 2005; Williamson; WMCTV, 2006), restraint and covert sensitization as recently as 1997 (Summers, 2000), and faradic therapy in 1995 and 1998 (Cox, 2000a, 2000b). Whereas reports are typically made by former patients to the media or disclosed in blogs, sometimes years after treatment, it is not surprising that these reports may appear isolated.
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Some reparative therapy is being administered in private treatment facilities and boarding schools under diagnoses or presenting complaints of homosexuality (Homosexuality was removed as a diagnosis from the Diagnostic and Statistical Manual in 1973.), gender identity disorder, negativity, and being sullen and distant or deant (Haldeman, 2001; Penn, 2007). Abuse, neglect, and abuse-related deaths of youth have occurred with sufcient frequency (across diagnoses and sexual orientations) in private treatment facilities to have drawn the attention of Congress. An October 2007 report by the U.S. Government Accountability Ofce found that during 2005 alone, 33 states reported 1,619 staff members involved in incidents of abuse in residential programs (U.S. Government Accountability Ofce, 2007, p. 2). Testimony before the House Education and Labor Committee (October 10, 2007 testimony) revealed that many of these facilities are uncertied, unlicensed, and unregulated (U.S. Government Accountability Ofce). Although reports exist (Penn; Williams, 2005), it is unknown to what extent reparative therapy is being conducted in private treatment facilities or boarding schools.

Reparative Therapy Efcacy

To date, there is no conclusive evidence that reparative therapy is benecial to patients. The success rates claimed by reparative therapists vary by sex and are reported to range from 11% (complete change in females) to 37% (complete change in males) (Spitzer, 2003). Nicolosi, Byrd, and Potts (2000) report that 34% of their sample experienced much change in sexual orientation. However, in some reparative therapy efcacy studies, such as the Spitzer study, it is unclear if the participants were homosexual or bisexual prior to starting therapy. Reparative therapists dene successful treatment in several different ways. Successful treatment outcomes range from celibacy to bisexual behavior and sometimes to heterosexual behavior (Spitzer; Yarhouse, 2002). Yarhouse, a strong proponent of reparative therapy, writes Ex-gays may be understood to be those who experience same-sex attraction but choose not to integrate same-sex impulses into an LGB identity (p. 237). Continued same-sex sexual attraction is often not factored into a determination of successful conversion by reparative therapists. Instead, success is often viewed as refraining from homosexual behavior (celibacy) while continuing to ght off the temptation of homosexual thoughts and feelings. Therefore, control of behavior rather than changed feelings, desires, or attractions often constitutes success in treatment. Despite the low success rates and lack of research documenting treatment efcacy, there are a number of reasons why youth might choose to undergo reparative therapy. Shidlo and Schroeder (2002) identied several reasons why adults seek reparative therapy: maintaining family
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Reparative Therapy: The Adolescent, the Psych Nurse, and the Issues

relationships, force and coercion, incongruence with religious beliefs, religious guilt or fear of rejection by their church or fear of damnation, to seek help for depression, anxiety, or guilt about being homosexual (p. 55), and recommendation by their therapist. These motivations to seek therapy may be related to societal discrimination against LGB persons, internalized homophobia (the internalization of negative societal views of homosexuals), simply a desire to change their same-sex thoughts, feelings, or behaviors, or a combination of several aspects.

However, youth who refuse to comply with parentinitiated reparative therapy may nd themselves forcibly transported to these facilities or homeless.

Sequelae of Reparative Therapy Psychiatric Nurses May Observe

A number of harmful consequences of reparative therapy have been reported by former reparative therapy patients and in the literature (Cox, 2000a; Haldeman, 2001, 2004). To date, no outcome studies of reparative therapy have been conducted with youth. Data on the negative sequelae of reparative therapy comes from various sources: research studies with adults (Beckstead & Morrow, 2004; Shidlo & Schroeder, 2002; Tozer & Hayes, 2004), online and print media by former reparative therapy patients (adult and adolescent) and former reparative therapy leaders (Bussee, 2007; Cox; Ford, 2001; Penn, 2007; Summers, 2000; Williamson, 2008; WMCTV, 2006), and case reports by mental health professionals who have treated former reparative therapy patients (Ford; Haldeman, 2001, 2004).

Arguments for Reparative Therapy

Proponents of reparative therapy cite a patients right to self-determination (or a parents right to govern their child) as the basis for their efforts, stating that it is unethical to deny treatment to those who would seek it (Yarhouse & Throckmorton, 2002). However, to refuse to provide a potentially harmful treatment to someone requesting it would hardly be deemed as prohibiting self-determination. Proponents have also argued that providing reparative therapy respects the diversity of moral and religious beliefs of patients regarding homosexual behavior (Yarhouse & Throckmorton). However, this argument neglects consideration of the heterosexist environment in which this desire for therapy nds genesis. Internalized homophobia has been found to predict propensity to seek reparative therapy (Tozer & Hayes, 2004). Social opprobrium against nonheterosexuals persists in contemporary American society. For instance, up until 2003 and the landmark ruling of Lawrence v. Texas (539 U.S. 558, 2003) homosexual intimacy was a criminal act in 14 states. 1 Youth are in a precarious legal position relative to reparative therapy. Troxel v. Granville, 530 U.S. 57 (2000) conrmed a parents fundamental right to make decisions concerning the care, custody, and control of their children. Parental rights over the control of their childs liberty, autonomy, and self-determination are established principles of common-law (Parham v. J. R. (1979); 442 U.W. 584). Traditionally at common law, and still today, unemancipated minors lack some of the most fundamental rights of self determinationincluding even the right of liberty in its narrow sense, i.e., the right to come and go at will. They are subject, even as to their physical freedom, to the control of their parents or guardians (Veronia School District v. Acton, 515 U.S. 646, 654 [1995] Justice Scalia majority opinion).

Although some of these reports are not scientic studies, the experiences and symptoms reported by former patients elicit concern and the need for further investigation.

Alabama, Florida, Idaho, Kansas, Louisiana, Michigan, Mississippi, Missouri, North Carolina, Oklahoma, South Carolina, Texas, Utah, and Virginia.

Harmful sequelae of reparative therapy reported include (a) anxiety (Cox, 2000a; Haldeman, 2001; Shidlo & Schroeder, 2002; Summers, 2000), (b) depression (Beckstead & Morrow, 2004; Bussee, 2007; Ford, 2001; Human Rights Campaign, 2000; Shidlo & Schroeder; Summers), (c) avoidance of intimacy or sexual dysfunction (Haldeman; ODonovan, 2004; Shidlo & Schroeder), (d) post-traumatic stress disorder (Kaufman, 2001; Yarhouse et al., 2002), (e) demasculinization (Kaufman, 2001; Yarhouse et al., 2002), (f) lack of self-condence and selfefcacyan inability to trust ones own instincts (Beckstead & Morrow; Ford; Shidlo & Schroeder; Tozer & Hayes, 2004), (g) shame/guilt (Hardy, 1978; Human Rights Campaign; Nguyen, 2006; Shidlo & Schroeder; WMCTV, 2006), (h) selfdestructive behavior (Bussee; Ford; Shidlo & Schroeder), and (i) suicidality (Beckstead & Morrow; Ford; Human Rights Campaign; Nguyen; Oulton, 2000; Shidlo & Schroeder; Summers; Williamson). In addition to experiencing these therapy-induced symptoms, it is possible that youth who have undergone these treatments will be fearful of psychiatric facilities and mental health providers.
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Treatment Issues
As with all therapies, treatment decisions with patients who have undergone reparative therapy should be tailored to the needs of the individual patienttheir level of resilience, available social support, and the type and duration of reparative therapy they experienced (Haldeman, 2001). Based on clinical practice with patients who had undergone reparative therapy, Haldeman (2001, 2004) reports presenting problems of depression related to loss, intimacy avoidance, sexual dysfunction, demasculinization, and difculty reconciling religious/spiritual beliefs and sexual orientation. Indicated therapeutic interventions include grief counseling, therapy related to attitudes and feelings about intimacy, relaxation techniques and appropriate intimacy risk-taking; assistance in developing a male or female self-identity consistent with their sense of themselves; and assistance with ways to integrate their sexual orientation with their spirituality (Haldeman, 2001, 2004).

core tenets of nursing. Although the source is unconrmed, there are reports of nurse involvement in reparative therapy (Summers, 2000). Even one instance of nurse involvement in these therapies is cause for concern. Nursing has been at the forefront of advocating for the ethical care and treatment of patients. Consideration and discussion of nurse involvement in these therapies may be warranted.

Future Considerations
No youth-based studies have been conducted on the effects of reparative therapies. Consequently, denitive research-based ndings on youth who have undergone these treatments are not available. However, reports of some youth who have undergone these treatments exist, and it is reasonable to anticipate that adolescents would experience some of the same consequences of reparative therapy as adults. It is possible some of these youth will seek mental health services in the future. However, at present, no systematic training is available to psychiatric nurses to guide them in the care of patients who have undergone treatment for their sexual orientation. It is incumbent upon psychiatric and national American nursing organizations to critically consider these therapies and guide nurses on how best to provide care to youth who have undergone reparative therapy treatments. Values central to nursing practice are health and wellbeing, choice, dignity, condentiality, justice, accountability, and quality practice environments that are conducive to safe, competent, and ethical care (Canadian Nurses Association, 2002). Nurses have an ethical mandate to provide care in response to need: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (American Nurses Association, 2001, provision 1). Our fundamental responsibilities as nurses are to promote health, to prevent illness, to restore health and to alleviate suffering (International Council of Nurses, 2006a, p. 2). Nursing has a social contract with society to advocate for and prevent harm to our patients (LaRochelle, 1983)youth who may be considering or who may have undergone reparative therapy. It is incumbent upon psychiatric and national nursing organizations to reexamine their code of ethics relative to these treatmentsit is an issue of social responsibility. Author contact: Laura C. Hein PhD, RN, NP-C, University of South Carolina, College of Nursing, 1601 Greene St., Columbia, SC 29208; (803) 777-7683; Hein@sc.edu, with a copy to the Editor: poster@uta.edu
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Ethical Issues of Nurse Participation in Reparative Therapy

Nurses have an ethical and moral duty to advocate for our patients. Recognizing nursing is inseparable from the social context Donaldson and Crowley (1977) wrote: Nursing considers human health in terms of politics and history as well as in terms of inexorable laws of health (p. 4). Nurses have a social contract to be advocates for the underserved, the powerless, and the disenfranchised. Consistent with this, it is considered unethical for nurses to participate in any act or behavior harmful to mental and physical health (International Council of Nurses, 2006b) or to be associated with torture or degrading treatment (Chamberlain, 2001). It is a gross contravention of medical ethics, as well as an offence under applicable international instruments, for health personnel, particularly physicians, to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment (United Nations, 1982). Provision three of the American Nurses Association Code of Ethics states that the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (American Nurses Association, 2001). Advocacy is representing those within our care and their needs to those in power (Shore, 1998). Assisting with or providing reparative therapy services, something professional organizations believe may be harmful to patients, violates the
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Reparative Therapy: The Adolescent, the Psych Nurse, and the Issues

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