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Can Sexual Orientation Be Changed?

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 Journal of Gay & Lesbian Mental Health, 19:84–93, 2015
Copyright © Taylor & Francis Group, LLC
ISSN: 1935-9705 print / 1935-9713 online
DOI: 10.1080/19359705.2014.944460

Can Sexual Orientation Be Changed?

JACK DRESCHER, MD
Department of Psychiatry, New York Medical College, and William A. White Institute,
New York, New York, USA

This paper was presented at a 2013 conference at the United Na-

tions Church Center in New York City. The conference, “Selling the
Promise of Change: International Health and Policy Consequences
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of Sexual Orientation Change Efforts (SOCE),” was sponsored by

the NGO Committee on Human Rights and the NGO Committee on
HIV/AIDS. The paper begins with a review of the history of mental
health attitudes toward homosexuality from the 19th century to the
present. This is followed by a discussion of how SOCE shifted from
a clinical debate to a culture war issue. The paper then reviews
some research issues raised by the Spitzer (2003) study, some of the
problematic clinical and ethical issues raised by efforts to change
sexual orientation, and concludes with a summary of the position
statements of the American Psychiatric Association and American
Psychological Association.

KEYWORDS American Psychiatric Association, American Psy-

chological Association, conversion therapy, ethics, homosexual-
ity, reparative therapy, sexual orientation change efforts (SOCE),
Spitzer study

HISTORY OF MENTAL HEALTH ATTITUDES TOWARD

HOMOSEXUALITY

The Hungarian writer Karl Maria Kertbeny coined the terms “homosexual”
and “homosexuality” in an 1869 political treatise that argued against crim-
inalizing relations between individuals of the same sex (Bullough, 1979).
He argued that as a normal variation of human sexuality, homosexual be-
haviors are not immoral and should not be punished. In 1886, psychiatrist
Richard von Krafft-Ebing adopted Kertbeny’s term “homosexual,” and his

Address correspondence to Jack Drescher, MD, 440 W. 24th St., Suite 1A, New York, NY
10011. E-mail: jackdreschermd@gmail.com

84
 Can Sexual Orientation Be Changed? 85

Psychopathia Sexualis popularized its usage in medical and scientific com-

munities. However, unlike Kertbeny, Krafft-Ebing considered homosexuality
a “degenerative” neurological disorder.
By the middle of the 20th century, two major competing theoretical
views of homosexuality were offered by (1) psychoanalysis, a field dom-
inated by psychiatric physicians, and (2) sexology’s academic researchers.
Freud, in the early years of psychoanalysis, refuted Krafft-Ebing’s characteri-
zation of homosexuality as an illness, noting that it was found in individuals
with no other mental problems and in people “distinguished by especially
high intellectual development and ethical culture” (Freud, 1905, p. 138). In-
stead, he claimed adult homosexuality was due to a “developmental arrest,” a
form of “immaturity,” in which normal sexual instincts of childhood persisted
into adulthood (Drescher, 2001, 2002a).
Psychoanalysts after Freud, however, based their views on the work
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of Sandor Rado (1940). Unlike Freud, Rado believed there was no such
thing as normal childhood homosexuality and that heterosexuality was the
biological norm. He defined adult homosexuality as a phobic avoidance
of heterosexuality caused by inadequate, early parenting. His views were
highly influential in the pathological models of psychoanalysts of the mid-
20th century (Bieber et al., 1962; Socarides, 1968).
Psychoanalysts and psychiatrists theorized about homosexuality from a
self-selected group of patients seeking treatment for it and from prison pop-
ulations. In contrast, sexology researchers of the mid-20th century tried to
make sense of human sexual behavior in general populations. In contrast
to analytic case reports, sexologists went into the field and recruited large
numbers of nonpatient subjects for study. The research of Kinsey and his
associates (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Ppomeroy, Martin, &
Gebhard, 1953) and of Evelyn Hooker (1957) lent support to a view that ho-
mosexuality, like heterosexuality, is a normal variation of human sexual ex-
pression. American psychiatry at that time, under the sway of psychoanalytic
theory, mostly ignored sexology research and its normalizing conclusions.
In 1970, sexology research was brought forcefully to the attention of the
American Psychiatric Association (APA). Organized gay activists, convinced
that psychiatry’s pathologizing attitudes about homosexuality were a major
contributor to social stigma, disrupted first the 1970 and then again the 1971
annual APA meetings. As a result, APA embarked upon a process of study-
ing the scientific question of whether homosexuality should be considered
a psychiatric disorder. APA’s Board of Trustees charged its Nomenclature
Committee as the scientific body best suited to address this issue.
After a review lasting more than a year, the Nomenclature Committee
chaired by Robert Spitzer recommended to the Board of Trustees that APA
remove “homosexuality per se” from the diagnostic manual. After review
and approval by other APA committees and deliberative bodies, in Decem-
ber 1973 APA’s Board of Trustees voted to remove homosexuality from the
 86 J. Drescher

Diagnostic and Statistical Manual of Mental Disorders, second edition (DSM-

II) (Bayer, 1981; Drescher & Merlino, 2007). Before that removal was for-
mally implemented, psychoanalysts petitioned APA to hold a referendum of
the entire membership to overturn the Board’s decision. In 1974, the Board’s
decision to remove was upheld by a 58% majority of voting APA mem-
bers.1 Following the referendum, APA also issued a groundbreaking position
statement supporting civil rights protection for gay people in employment,
housing, public accommodation and licensing and the repeal of all laws that
criminalized homosexuality between consenting adults.2

SEXUAL CONVERSION THERAPIES: FROM CLINICAL DEBATES

TO CULTURE WARS
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After the 1973 APA decision, cultural attitudes about homosexuality changed
in the United States and other countries as those who accepted scientific
authority on such matters gradually came to accept the normalizing view. If
homosexuality was not an illness, and if one did not literally accept biblical
prohibitions against it, and if gay people were able and prepared to function
as productive citizens, then what is wrong with being gay? Similar shifts
gradually took place in the international mental health community as well.
In 1990, the World Health Organization removed homosexuality per se from
the International Classification of Diseases (ICD-10).
The international psychoanalytic community, however, took longer to
adopt this perspective. Following the 1973 decision, their influence gradually
declined in the mental health professions. As normalization took place in the
rest of the culture, analysts, in their journals and at their meetings, continued
to write and speak about homosexuality in pathological terms. They also
continued to deny openly gay men and lesbians the option of training in
their institutes for years afterward. However, in response to a threatened
lawsuit (Isay, 1996), in 1991 the American Psychoanalytic Association (AP-
saA) adopted a sexual orientation nondiscrimination policy regarding the
selection of candidates and revised it in 1992 to include selection of faculty
and training analysts as well (Hoffman et al., 2000; Drescher, 2008).
Following their marginalization from the APsaA, conversion therapists
formed their own organization: The National Association for Research and
Therapy of Homosexuality (NARTH; Drescher, 1998). NARTH Members re-
gard homosexuality as a mental disorder and argue that those who so de-
sire should receive “treatment” to change their sexual attractions. While the
causes of homosexuality (and heterosexuality) are unknown, that is not the
case for NARTH members who claim knowledge of its “etiology.” Their
theories about homosexuality’s causes and its “treatment” derive from both
religious (faith healing) and secular (Radoite psychoanalytic) approaches.
Most significantly, NARTH provides religious and social conservatives a
 Can Sexual Orientation Be Changed? 87

dissenting, scientific-sounding voice to counter mainstream mental health

views of homosexuality (Drescher, 2009).
NARTH members argue from an illness/behavior model (Drescher,
2002b) that regards any open expressions of homosexuality as behavioral
symptoms pathognomonic of psychiatric illness, a moral failing, or some
combination of both. This position maintains that illness and immorality
cannot provide a foundation for creating a normal identity or serve as a
basis for defining membership in a sexual minority. From the perspective of
an illness/behavior model, those who engage in homosexual behavior do
not merit the kinds of modern legal protections afforded to racial, ethnic
or religious minorities and efforts to obtain such protections are defined as
“special rights.”
In recent years, social conservatives have adopted the illness/behavior
model for political purposes. By conflating “biology” with “immutability,”
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they essentially argue that if homosexual behavior can be changed in just

one person, then homosexuality cannot possibly be an inborn trait like race.
Their position is that if homosexuality is not inborn, then gay people should
not be considered a minority entitled to legislative protections.
In addition to NARTH, which provides spokespersons with professional
degrees to make these arguments, social conservatives have also enlisted so
called ex-gays to reinforce their message. One example is the use of ex-gays
in advertisements opposing hate crimes legislation intended to protect indi-
viduals on the basis of their sexual orientation. A black and white picture
shows two men and two women, looking very seriously into the camera as
the text reads, “Hate Crime laws say we were MORE VALUABLE as homo-
sexuals than we are now as former homosexuals.”3 The messages here are
twofold: (1) Homosexuality is not innate because we were once gay and
now we are not, and (2) hate crime laws should be opposed because gay
“rights” are “special rights.”
In many ways, ex-gay political strategies designed to obstruct the gay
civil rights movement resemble those used by proponents of “Intelligent
Design” (Drescher, 2009). This is not altogether unsurprising, as many of
the individuals who support the ex-gay movement also do not believe in
evolution of the species (referred to as “Darwinism” by its critics). Their
strategies include:

• Present an issue to the public as if it were a debate in the mental health

professions;
• Finance and promote ideological “experts” and “think tanks” (NARTH);
• Personal testimonies (ex-gays);
• Discredit science, motives and methods of mainstream mental health or-
ganizations;
• Attack individuals whose work undermines their agenda (Kinsey, LGB
professionals, or straight supporters); and
 88 J. Drescher

• Confuse the public with pseudo-science and selective scientific citations

(conflate homosexuality with pedophilia and gender dysphoria).

The goal of this strategy is not to persuade the mental health mainstream
of the correctness of their views (which would involve doing actual research)
but rather to try and persuade the public and policy makers on the issues of
gay rights (Lund & Renna, 2003; Drescher, 2009).

RESEARCH ISSUES

In 2003, Robert L. Spitzer, MD, published a widely reported study of 200

individuals having claimed to change their sexual orientation (Spitzer, 2003;
Drescher & Zucker, 2006). The study’s 200 subjects included 143 men and
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57 women interviewed by telephone for 45 minutes to determine if they had

changed their sexual orientation. According to Spitzer, a majority reported
some change from a “predominantly or exclusively” homosexual orientation
to a “predominantly or exclusively” heterosexual orientation.
There were many methodological criticism of the study (Drescher &
Zucker, 2006), including

• no follow up or face to face interviews of subjects;

• the use of retrospective rather than prospective accounts;
• a lack of physiological measures of sexual arousal such as plethysmogra-
phy;
• difficulty recruiting 200 subjects—it took 16 months; and
• sample bias in the subject recruitment—approximately 20% of subjects
were professional ex-gays who led their own ex-gay ministries.

Despite the study’s methodological limitations, it was published without

conventional peer review. Instead, reviewer commentaries (mostly negative)
accompanied the study’s publication. Spitzer’s revamping of the American
psychiatric diagnostic system in 1980’s DSM-III had given him an esteemed
standing among the international scientific community that no conversion
therapist has ever achieved (Drescher, 2003). Publishing the study in this
manner made it appear as if the Archives of Sexual Behavior was trading on
Spitzer’s reputation, rather than on the quality of his study. In a similar vein,
for more than a decade, antigay social forces and ex-gay advocates sought
to use Spitzer’s reputation to legitimize their approach.
In 2012, Spitzer repudiated his own study. Speaking of the study’s “fatal
flaw” in a letter published in Archives of Sexual Behavior, he wrote, “there
was no way to judge the credibility of subject reports of change in sexual
orientation. I offered several (unconvincing) reasons why it was reason-
able to assume that the subject’s reports of change were credible and not
 Can Sexual Orientation Be Changed? 89

self-deception or outright lying. But the simple fact is that there was no way
to determine if the subject’s accounts of change were valid.”
He went on to say, “I believe I owe the gay community an apology for
my study making unproven claims of the efficacy of reparative therapy. I
also apologize to any gay person who wasted time and energy undergoing
some form of reparative therapy because they believed that I had proven
that reparative therapy works with some ‘highly motivated’ individuals.”

CLINICAL AND ETHICAL ISSUES

Little research has been done on either the benefits or harm of sexual orien-
tation change efforts (SOCE) (American Psychiatric Association, 2000; Amer-
ican Psychological Association, 2009). In published reports by SOCE advo-
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cates, the majority who try to change do not and it is not uncommon to
overstate claims of benefits while concerns about possible harm are mini-
mized or dismissed (Jones & Yarhouse, 2011).
In the past, SOCE were regarded by professional organizations as private
agreements between individual patients and therapists. It was believed, either
explicitly or implicitly, that efforts to eradicate homosexuality were a reason-
able undertaking from which no harm could come (Drescher, 2002b). In
recent years, however, complaints about poor outcomes have led to greater
scrutiny. There is now an emerging clinical focus on individuals who, after
attempting and failing SOCE, later adopted a gay or lesbian identity.4 An ac-
cumulation of anecdotal accounts paints a disturbing picture: therapists may
be doing psychological damage to patients (and families of patients) who
fail to convert and who eventually decide to come out as gay.
Ethical violations in these treatments include subjective informed con-
sent (i.e., telling patients that homosexuality is a mental disorder because the
practitioner believes that it is), breaches of confidentiality (i.e., informing re-
ligious school authorities that gay students are engaging in sexual behavior),
improper pressure placed on patients (i.e., threatening to end a treatment if
the patients do not submit to the therapist’s authority), and the relinquish-
ment of fiduciary responsibility to patients who eventually decide to come
out as gay (i.e., unwillingness to refer a patient to a gay affirmative therapist
when the SOCE fails) (Shidlo & Schroeder, 2002).
In addition, SOCE practitioners rarely adopt stringent selection criteria.
Regardless of the probability of success, anyone who wants to try and change
can usually find someone who will work with them. Also patient motivation,
rather than the skill of a therapist or efficacy of the “treatment,” is usually
credited as the primary factor leading to change. This is a set up for “patient
blaming” as most people who try to change do not. After “treatment” fails,
patients may feel worse and blame themselves, question their faith or their
motivation. This may lead to worsening of depression, the onset of anxiety,
 90 J. Drescher

and possible feelings of suicide. Disturbingly, these anecdotal results are

never reported in the SOCE literature.
Some individuals are encouraged to marry during a course of SOCE
lasting several years and may have spouses and children when they realize
that change has not happened. Sometimes these families break apart. In
cases where religious beliefs discourage divorce, mixed orientation couples
stay together living in tragic circumstances.
Finally, years of trying fruitlessly to change one’s sexual orientation can
delay the decision to come out as gay. When the individual does come
out, the experience of SOCE, which can be likened to a concentrated dose
of antihomosexual stereotyping, may create intimacy and sexual problems.
Haldeman (2001) refers to this as a “spoiled” gay identity.
All of these factors raise another ethical issue: Even if the questionable
claims of SOCE’s effectiveness are valid, should the conversion of some
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“homosexuals” to heterosexuality condone the iatrogenic harm done to other

patients who later come out as gay (Drescher, 2002b)? In other words, should
it not matter how many gay people are hurt in the process of creating a few
heterosexuals?
The two APAs have weighed in on these issues. In 2000, the American
Psychiatric Association issued a position statement about SOCE with three
recommendations:

1. APA affirms its 1973 position that homosexuality per se is not a diagnos-
able mental disorder. Recent publicized efforts to repathologize homosex-
uality by claiming that it can be cured are often guided not by rigorous
scientific or psychiatric research, but sometimes by religious and political
forces opposed to full civil rights for gay men and lesbians. APA rec-
ommends that the APA respond quickly and appropriately as a scientific
organization when claims that homosexuality is a curable illness are made
by political or religious groups.
2. As a general principle, a therapist should not determine the goal of treat-
ment either coercively or through subtle influence. Psychotherapeutic
modalities to convert or “repair” homosexuality are based on develop-
mental theories whose scientific validity is questionable. Furthermore,
anecdotal reports of “cures” are counterbalanced by anecdotal claims of
psychological harm. In the last four decades, “reparative” therapists have
not produced any rigorous scientific research to substantiate their claims of
cure. Until there is such research available, APA recommends that ethical
practitioners refrain from attempts to change individuals’ sexual orienta-
tion, keeping in mind the medical dictum to First, do no harm.
3. The “reparative” therapy literature uses theories that make it difficult to
formulate scientific selection criteria for their treatment modality. This
literature not only ignores the impact of social stigma in motivating ef-
forts to cure homosexuality, it is a literature that actively stigmatizes
 Can Sexual Orientation Be Changed? 91

homosexuality as well. Reparative therapy literature also tends to over-

state the treatment’s accomplishments while neglecting any potential risks
to patients. APA encourages and supports research in the NIMH and the
academic research community to further determine reparative therapy’s
risks versus its benefits.

In 2009, the American Psychological Association also issued a complex

peer reviewed report on SOCE. Among its findings, the report:

• affirms that same-sex sexual and romantic attractions, feelings, and behav-
iors are normal and positive variations of human sexuality regardless of
sexual orientation identity;
• reaffirms its position that homosexuality per se is not a mental disorder;
• opposes portrayals of sexual minority youths and adults as mentally ill due
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to their sexual orientation;

• concludes that there is insufficient evidence to support the use of psycho-
logical interventions to change sexual orientation;
• encourages mental health professionals to avoid misrepresenting the ef-
ficacy of sexual orientation change efforts by promoting or promising
change in sexual orientation; and
• concludes that the benefits reported by participants in sexual orientation
change efforts can be gained through approaches that do not attempt to
change sexual orientation.

ACKNOWLEDGMENTS

This paper is based on remarks made at a January 31, 2013, conference, “Sell-
ing the Promise of Change: International Health and Policy Consequences
of Sexual Orientation Change Efforts (SOCE).” The conference, which took
place at the United Nations Church Center in New York City, was spon-
sored by the NGO Committee on Human Rights and the NGO Committee
on HIV/AIDS.

NOTES

1. Approximately 10,000 of APA’s 20,000 members voted in the referendum.

2. Available online at http://www.psych.org/edu/other_res/lib_archives/archives/197310.pdf
3. The ad can be viewed on an “ex-gay” Facebook page at http://goo.gl/IfpWRf
4. Referring to themselves as “ex-gay survivors,” these individuals have begun organizing them-
selves; see http://www.beyondexgay.com/

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