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JME Online First, published on May 4, 2016 as 10.1136/medethics-2016-103562
1
Department of Bioethics,
National Institutes of Health,
Bethesda, Maryland, USA
2
Department Philosophy and
Political Science, Northeastern
University, Boston,
Massachusetts, USA
Correspondence to
Dr Sean Aas, Department
of Bioethics, National Institutes
of Health,
10 Center Drive, Room 1C118,
Bethesda, MD 20892, USA;
sean.aas@gmail.com
Received 24 December 2016
Accepted 29 March 2016
To cite: Aas S, Delmas C.
J Med Ethics Published
Online First: [ please include
Day Month Year]
doi:10.1136/medethics-
2016-103562
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd under licence.
Clinical ethics
PAPER
The ethics of sexual reorientation: what should
clinicians and researchers do?
Sean Aas,1 Candice Delmas2
ABSTRACT
Technological measures meant to change sexual
orientation are, we have argued elsewhere, deeply
alarming, even and indeed especially if they are safe
and effective. Here we point out that this in part
because they produce a distinctive kind of ‘clinical
collective action problem’, a sort of dilemma for
individual clinicians and researchers: a treatment which
evidently relieves the suffering of particular patients, but
in the process contributes to a practice that
substantially worsens the conditions that produce this
suffering in the first place. We argue that the role
obligations of clinicians to relieve the suffering of their
patients put them in a poor position to solve this
problem, though they can take measures to avoid
complicity in the harms that would result from
widespread use of individually safe and effective
reorientation biotechnology. But in the end the medical
community as a whole still seems obligated to provide
these measures, if they become technologically feasible.
Medical researchers are in a better position to prevent
the harms that would result if reorientation techniques
were safe, effective and widely available. We argue that
the harms attendant on the development of safe and
effective re-orientation techniques give researchers
reason to avoid ‘applied‘ research aimed at developing
these techniques, and to be careful in the conduct of
basic orientation research which might be applied in
this way.
Many people think that, when it comes to sexual
orientation, we are all ‘born this way’, innately and
uncontrollably attracted to the sexes and genders
we are attracted to. The immutability of sexual
orientation is supposed to ground claims of equal
respect for LGBT people as well as explain what
makes ‘reparative’ therapy or sexual orientation
change efforts (SOCE) objectionable. Thus, the
American Psychiatric Association1 stresses that ‘[ p]
sychotherapeutic modalities to convert or “repair”
homosexuality are based on developmental theories
whose scientific validity is questionable’. And yet,
recent research shows that sexual orientation is
neither fully innate nor entirely immutable, even
though basic sexual attractions are unchosen.2 Of
course, it remains the case that sexual orientation
cannot be altered. But, future advances in the
neurobiology of sexual orientation may someday
make it possible for us to safely and effectively
change and choose our basic sexual preferences, be
it through neuropharmacology, deep brain stimula-
tion or germ line genetic engineering.
Aas S, Delmas C. J Med Ethics 2016;0:1–8. doi:10.1136/medethics-2016-103562
To date, there has been very little bioethical
reflection on safe and effective sexual reorientation
therapy. Earp et al3 are among the rare neuroethi-
cists to have addressed some of the ethical issues
surrounding sexual reorientation. They have argued
that such therapy could benefit, and thus be justifi-
ably provided to, those who suffer seriously from
unwanted sexual desires. Granting this, we have
argued in ‘Sexual Re-Orientation in Ideal and
Non-Ideal Theory’4 that the widespread use of
reorientation therapy, although not intrinsically
bad, could have disastrous effects on sexual minor-
ities, potentially dooming queer communities to
extinction. There is thus, we argued, good reason
to carefully regulate reorientation research in the
present, and, should safe and effective reorientation
techniques be developed, good reason to adopt pol-
icies discouraging their application to adults and
forbidding them for minors.
In this paper, we want to turn from the policy
question, back to questions of medical ethics: what
should clinicians and researchers do, qua clinicians
and researchers, in respect of sexual reorientation
techniques? Should they provide them, if they are
ever developed? Should they participate in develop-
ing them? Should they test these therapies’ safety
and efficacy if others develop them?
SOCE have no place in contemporary medicine,
as all major health and mental health professional
associations make clear. SOCE are ineffective,
potentially harmful, sometimes coercive and always
deceptive (insofar as they offer to change some-
thing that cannot be changed). However, since
high-tech sexual reorientation would be none of
these things—it would be safe and effective, and
only used on willing adults (let’s stipulate)—it calls
for new reflection.
The paper addresses the questions, what should
clinicians do? and what should researchers do? in
parts I and II, respectively. We argue that sexual
reorientation poses a dilemma for clinicians, insofar
as they are bound, on the one hand, to benefit their
patients and respect their autonomy, and on the
other hand, not to bring about serious social
harms. We submit that clinicians’ special obligations
to patients generally take precedence over social
justice concerns, so that medical professional asso-
ciations should not prohibit their practitioners from
offering sexual reorientation, but that there should
be conscience clauses to accommodate clinicians
who are opposed to participating in the practice.
We further argue that researchers, insofar as they
are not bound by the same sorts of agent-relative
obligations, ought to give serious weight to the
1
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Clinical ethics
potential harms of sexual reorientation when it comes to con-
ducting research. We contend that while research into reorienta-
tion technologies is impermissible, basic research into sexual
orientation may yet be permissible, despite its potential to lead
to the development of sexual reorientation, given the social and
scientific value of understanding the determinants of sexual
orientation.
Before we begin, some definitions: by sexual orientation we
mean a set of dispositions to be or not to be sexually attracted
to certain sexes or genders.i This capacious definition includes:
‘heterosexuality’ and ‘homosexuality’ (disposition to be
attracted to people with the traditional ‘opposite’/same sex and
gender); ‘bisexuality’ (disposition to be attracted to both trad-
itional sexes and/or genders); the disposition to be attracted
towards trans* (non-traditionally sexed and/or gendered)
people);ii ‘pan-’ or ‘omnisexuality’ (disposition to be attracted
to all sexes and genders) and ‘asexuality’ (no disposition to
attraction; or to act on attraction). For short, we will generally
use the term ‘non-heterosexual people’ to refer to individuals
whose disposition is not heterosexual, but who may or may
not have come out as members of sexual minorities (thereby
including LGBTQ people and ‘closeted’ gays). Sexual reorienta-
tion, as we understand it, changes one’s basic sexual disposi-
tions from any orientation to any other, temporarily or
permanently (we are here thinking of permanent changes,
though nothing in our argument hinges on the irreversibility of
the change). That said, the kind of reorientation that concerns
us ethically is primarily that aimed at ‘converting’ from a
non-heterosexual orientation to a heterosexual one: this is the
kind of reorientation, we have and will argue, that poses
serious problems.
CLINICIANS
There is nothing intrinsically wrong with sexual reorientation
interventions. In an ideal society—one that has achieved full
sexual equality and gender justice—they could expand or
narrow the range of our sexual preferences and thus enhance
autonomy. They could be fun, interesting transformative experi-
ments. However, we worry about the effects of practices of
reorientation in our non-ideal, heterosexist societies, where
sexual minorities suffer significant disadvantages, from work
discrimination to physical and sexual violence. As we have
argued, however, in current heterosexist conditions, the option
to alter one’s sexual orientation, particularly the option to
‘convert’ to the majority orientation, risks harming sexual
minorities, in four ways.4 First, by hindering the progress of
pro-gay policies. Second, by generating pressures to ‘convert’ to
a heterosexual orientation. Third, by producing demands for
individuals to justify ‘keeping’ non-heterosexual orientation.
Fourth, by making ‘conversion’ a rational course of action for
the individual, leading to the dwindling of sexual communities.
For these reasons, we believe that it is better for sexual minor-
ities not to have the option to alter their sexual orientation, and
contend, contra Earp et al’s claim,3 ( p 10) that the prospective
development of high-tech ‘conversion’ therapy is cause for
alarm.
i
The basic account we use of the ordinary meaning of sexual orientation
is sufficient for our purposes. For an excellent pragmatic account of
sexual orientation, which makes no reference to one’s own sex and
gender, see Dembroff.5
ii
Money and Lamacz6 proposed the term gynemimetophilia to refer to a
sexual preference for trans women (MTF) and andromimetophilia to
refer to sexual orientation toward trans men (FTM).
2 Aas S, Delmas C. J Med Ethics 2016;0:1–8. doi:10.1136/medethics-2016-103562
Clinicians’ permission and obligation to provide sexual
reorientation
Does it follow that health and mental health providers should
not prescribe reorientation treatments? No—and, indeed, that is
precisely what is alarming about the prospect of safe and effect-
ive reorientation: while Earp et al claim that use of the technol-
ogy would rarely be permissible, we contend that clinicians
would often be permitted, and sometimes even required, to pre-
scribe reorientation to patients who suffer from their sexual
orientation, given the medical principles of beneficence and
respect for patient self-determination.
To start to see this, consider a paradigm seeker of safe and
effective reorientation interventions, say, a 35-year-old man, reli-
giously conservative and married to a woman, with children.
This man sees a psychiatrist competent to offer reorientation
interventions (suppose for now that these are pharmaceutical).
The man presents with serious psychological suffering from
unwanted same-sex desires, both as a result of internalised
homophobia and given his love for his family. He has tried reli-
gious counselling but found it ineffective; it remains very diffi-
cult for him to live the kind of family life he wants to live. His
psychiatrist first recommends psychotherapy as a way to help
him accept his orientation. The man refuses, insisting he wants
to eliminate, rather than accept, his same-sex desires.
We contend that this patient’s psychiatrist is definitely permit-
ted, perhaps even obligated, to provide reorientation treatment,
even if the psychotherapy the patient refuses is truly superior.
Patients’ right to refuse treatment and seek alternative, medically
inferior treatments that accord with their moral values, is well
accepted in medical practice. For instance, Jehovah’s Witness
patients who need life-saving surgery but refuse blood transfu-
sions are typically offered transfusion-free operations if these
have any reasonable chance of success; and it is generally
thought that surgeons should accommodate these patients’
requests to the extent possible, in order to show respect for the
Jehovah’s Witness’ conscientious convictions.7 8 iii
Objections and replies
Sexual reorientation does not cure a disease
One might object that the cases are disanalogous insofar as
sexual reorientation is neither a life-saving intervention nor a
cure for a disease. This is the first general argument against clini-
cians’ participation in sexual reorientation: it stresses that sexual
orientation, whatever its direction, is not a disease but a form of
human sexuality and concludes that reorientation is simply not
a medical treatment for a condition. To the extent that non-
heterosexual orientation need not be ‘fixed’, clinicians ought
not to accede to patients’ requests to alter their (non-hetero)
sexual orientation. Clinicians are not morally obligated to
realise their patients’ requests for medically futile and poten-
tially harmful interventions (say, amputating healthy limbs); and
reorientation might plausibly be deemed both of these things—
futile and potentially harmful. Per this objection, clinicians are
not bound to follow their patients’ wishes and in fact the ethical
standard of care arguably bars them from doing so.
In response, first, a case can be made that reorientation inter-
ventions do in fact treat a disease. Sexual orientation itself is
neither a disease nor a disorder, but excessive suffering from it
might be: the 2010 WHO’s International Classification of
Diseases10 (ICD-10) recognises it as ‘Egodystonic Sexual
iii
Some bioethicists deny that physicians have a moral obligation to
accommodate Jehovah’s Witness patients. See, for example, Blustein.9
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Orientation’. The American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders (DSM) declassified
homosexuality as a mental disorder in 1973, and eliminated
‘ego-dystonic homosexuality’ in 1987. But it does include con-
ditions that consist of excessive suffering from something that is
not itself a disease. For instance, grief is not a disease, but
‘Prolonged Grief Disorder’ is treated as a form of major depres-
sion disorder. And to reconsider the example above of an appar-
ently futile request, medical amputation of healthy limbs may be
viewed as an appropriate treatment for people with Body
Identity Integrity Disorder (BIID), who are at risk of serious
harm from medically unsupervised amputation attempts.11 12 iv
Under current American standards, however, suffering caused
by inability or unwillingness to accept one’s sexual orientation
may not be classifiable as a disease. We think there are good
reasons to resist treating such phenomenon as pathology, given
that orientation typically causes suffering only or largely as a
result of unjust social conditions. If, however, we resist the
pathologisation of suffering caused by heterosexist oppression,
does that mean that clinicians should not do anything about it?
We think not.
There is no consensus among healthcare professionals about
the proper ends of medicine.14 Yet many agree that the latter
includes more than healing, as countless routine medical inter-
ventions, such as male circumcision, orthodontic alignment of
teeth or contraception, suggest. Perhaps, the majority of inter-
ventions by cosmetic surgeons do not purport to heal, but
purport to benefit patients in other ways (generally by enhan-
cing their appearance and self-esteem). Much of geriatrics
involves long-term and end-of-life care rather than healing. For
instance, geriatricians assist patients in writing realistic living
wills, assess their functional decline and help them maintain
independence, to the extent possible. Interventions purporting
to enhance performance are gradually becoming accepted as
legitimate medical practices. Thus, soldiers in the military are
routinely prescribed wakefulness-promoting drugs such as mod-
afinil; and golfers and air pilots often undergo LASIK surgery to
achieve a 20/15 eyesight (see, eg, Savulescu et al15 on the ethics
of human enhancement). It is plausible to conceive of sexual
reorientation, by analogy with all these cases, as a legitimate
medical intervention.
A fortiori, it is very far from clear that doctors are permitted
to relieve suffering only if it is caused by a disease. For instance,
doctors help gay couples and single individuals have children,
even though they do not suffer from infertility. For another
example, many trans* people resist the pathologisation of their
experiences under the labels ‘Gender Identity Disorder’ (used in
both the DSM-IV and the WHO’s ICD-10) and ‘Gender
Dysphoria’ (in the DSM-V). Against a medical model, they insist
that they do not suffer from a disorder.16 Whether or not they
are right, we do not think that trans* people should have to
concede that they do in fact suffer from a psychiatric condition
in order to gain access to medical interventions like hormone
replacement therapy or genital surgery. By analogy with these
cases, we contend that clinicians have a pro tanto obligation to
provide suffering patients with sexual reorientation, on the basis
of their special responsibilities to benefit patients and respect
their autonomy, and regardless of whether patients are diag-
nosed with a medical condition.
iv
DSM-V does not recognise BIID but categorises it instead as
‘xenomelia’, ‘the oppressive feeling that one or more limbs of one’s
body do not belong to one’s self ’.13
Aas S, Delmas C. J Med Ethics 2016;0:1–8. doi:10.1136/medethics-2016-103562
Clinical ethics
Social beneficence and complicity with injustice
However, one may yet object that this obligation conflicts with
physicians’ duties to society at large, given how harmful a prac-
tice of reorientation would be for sexual minorities. Health and
mental health professionals have a responsibility to benefit the
patient ( particular beneficence) and society (general benefi-
cence) and to be concerned about justice; and so, they ought to
take into account the social impact of the procedures requested
by individual patients. For instance, one of the fundamental
principles of the American Psychological Association’s code of
conduct—justice—demands that psychologists ‘exercise reason-
able judgment and take precautions to ensure that their poten-
tial biases, the boundaries of their competence and the
limitations of their expertise do not lead to or condone unjust
practices’.17 Insofar as sexual reorientation risks engendering
serious social harms, and given that its provision might seem to
convey a tacit endorsement of the repressive norms that cause
patients’ distress in the first place, responsible clinicians ought
not to honour patients’ requests to convert from non-
heterosexual to heterosexual orientation. Here, the medical
principle of non-maleficence, applied to society at large, might
be taken to forbid clinicians to offer the treatment. Should
medical professionals prescribe and perform interventions to
alter non-heterosexual orientation, they would perpetuate
unjustly harmful social norms.
Little’s18 argument examining cosmetic surgeons’ complicity
in injustice is helpful here. Little argues that surgeons generally
ought to avoid offering cosmetic surgeries that help the patient
meet ‘suspect norms of appearance’ such as sexist and racist
standards of beauty, where these norms are part and parcel of a
broader unjust system. In her view, surgeons’ participation
would legitimate the norms in question by validating the
patient’s request, and thus contribute to perpetuating the unjust
system. Chambers similarly argues that the practice of cosmetic
breast implant surgery is motivated by an underlying social
norm of beauty and attractiveness which is discriminatory, since
it only affects women and casts them as inferior to men, and
harmful, since it disadvantages those who do not conform to it
and imposes pain and costs on those who undergo the
surgery.19 ( pp 186–190) Against this background, Chambers
proposes to prohibit the provision of breast implants.19 ( p 217)
The same kind of reasoning could apply to show that clinicians’
participation in sexual reorientation would objectionably legit-
imate, and contribute to perpetuating, antigay stigma, since it
would condone the underlying suspect social norms that fuel
patients’ distress about their orientation, and therefore that it
would be ethically impermissible.v
We are sympathetic with this line of objection and submit that
it highlights the dilemma that confronts clinicians: on the one
hand, they ought to benefit patients and respect their choices;
on the other hand, they ought to bear in mind social welfare
and not contribute to perpetuating social injustice. Each possible
course of action involves a real moral loss, either for the patient
or for society. Responsible clinicians should be aware of this loss
and feel qualms, if not agony, when facing non-heterosexual
patients’ requests to become straight.
Nonetheless, we believe that clinicians’ special responsibil-
ities to their patients should plausibly take priority over
v
We address the question whether high-tech reorientation therapy
should be legally banned in ‘Sexual Re-Orientation in Ideal and
Non-Ideal Theory’. We argue that a ban would be justified for minors,
but not for adults.
3
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Clinical ethics
general considerations of social welfare.vi Imagine, for instance,
a physician concerned with the development of pharmaceuti-
cals via exploitative studies in the developing world. Still,
when a patient comes to her with a condition which can only
be treated with an unjustly developed drug, it is hard to deny
that she should prescribe it, even though in doing so she sup-
ports both the broader unjust system which exploits the most
vulnerable people, and the particular unjust actor (the big
pharmaceutical company) that has developed the drug in ques-
tion. This is so, even, if the patient’s need for the drug arises
because they have refused an alternative treatment (say,
because it involves blood products, to which they have reli-
gious objections). There are, to be sure, significant differences
between the case of reorientation therapy and the case of the
unjustly developed drug (including the facts that sexual
reorientation does not appear to treat a medical condition and
that the harms and benefits are distributed differently in each
case). But the drug case suggests the general point that while
something must be done about the background injustice,
the clinic does not seem to be where it should happen, given
the clinician’s obligation to focus on her particular patient’s
needs.
For this reason, we contend that medical professional associa-
tions should neither prohibit their practitioners from offering
sexual reorientation nor even officially condemn such services,
for instance in position statements (which generally provide no
enforcement mechanism). They should, however, take on a lead-
ership role in promoting the use of scientific knowledge for edu-
cation and enlightened public policy related to sexual
orientation and sexual reorientation therapies. Mental health
professionals should counsel toward therapy aiming toward self-
acceptance and stress the superiority of the latter intervention.
At the same time, the medical principle of non-judgemental
regard for patients demands health and mental health profes-
sionals offer sexual reorientation to patients who request it
without shaming them or making them feel morally inadequate
for refusing the self-acceptance route. Non-heterosexual and
LGBTQ patients should feel welcome and safe in the clinic; yet
studies show that they currently feel neither.20 To ensure posi-
tive outcomes for these patients, medical professional associa-
tions could offer to clinicians: sensitivity training, LGBT
bioethics competence-building, rounds, mentoring and consult-
ing, among other concrete methods that have been proven
effective.21 ( pp 61–63).
Conscientious objection
At the same time, true recognition of the deep moral ambiva-
lence that clinicians should feel toward sexual reorientation sup-
ports ‘conscience clauses’ to accommodate health and mental
health professionals who are especially concerned to avoid com-
plicity in the negative social impact of reorientation biotechnol-
ogy. Following Daniel Brock22 on conscientious objection for
physicians and pharmacists, we propose that clinicians opposed
to sexual reorientation should be exempted from prescribing it
to their patients so long as (1) they inform the patient about the
service which they refuse to administer, (2) they refer
the patient to another professional willing and able to provide
the service and (3) this referral does not impose an unreasonable
burden on the patient. The latter condition means that
the number of clinicians conscientiously refusing to provide
vi
Little denies that surgeons’ participation is generally ethically
impermissible for the same reason.18 pp 172–176
4 Aas S, Delmas C. J Med Ethics 2016;0:1–8. doi:10.1136/medethics-2016-103562
sexual reorientation must be limited enough that patients can
reasonably easily access the service.
In some cases, some physicians may not be able to meet con-
ditions 2 and 3—say, because they are the only one qualified to
provide reorientation in a reasonable geographic area. In those
cases, conscientious objection would not be allowed: the
patients’ right to interventions that relieve their particular suf-
fering trumps the physician’s right to avoid complicity. Still,
although conscience clauses may fail to assuage the profes-
sional’s concern with complicity, given his or her duty to facili-
tate the patient’s access to an allegedly objectionable service
(Brock22 addresses this concern at 2008: 197–199), we submit
that they constitute symbolically effective markers of medical
ambivalence. Such conscience clause protections would stand as
important reminders of clinicians’ professional dilemma vis-à-vis
sexual reorientation.
One could object that if conscientious physicians may be
exempted to prescribe sexual reorientation treatment so as to
avoid complicity, by the same principle then they should be
exempted, say, from providing assisted reproduction to LGBT
people, in order to avoid complicity in what they believe is
these patients’ sinful behaviour. Yet broad accommodations like
these are problematic insofar as they deprive patients of what is
owed to them and violate such core principles of medical ethics
as trust and respect for patients’ dignity. On this basis, Julian
Savulescu23 categorically opposes conscience clauses in health-
care: “If people are not prepared to offer legally permitted, effi-
cient, and beneficial care to a patient because it conflicts with
their values, they should not be doctors”.
In response, it is important to distinguish between the claims
of conscience against complicity in same-sex behaviour and
claims against complicity in heterosexist oppression. Douglas
Nejaime and Reva B Siegel’s24 critique of the Supreme Court’s
decision in Burwell v. Hobby Lobby Stores (2015) equips us
with the tools to draw such distinction. The Court ruled that the
Religious Freedom Restoration Act exempted employers from
provisions of the Affordable Care Act that require employee
health insurance plans to include coverage of contraception,
insofar as providing such coverage would make the employers
complicit in what they view as sinful behaviour. However,
Nejaime and Siegel show that accommodating claims of con-
science of this kind risks imposing ‘material harms’ such as
blocked access to certain goods, and ‘dignitary harms’, including
stigma, on the third party who is denied a given service. The
latter harms would apply, in the healthcare setting, to accommo-
dations to anti-LGBT rights conscientious physicians, even where
constraints (1)–(3) above are satisfied, since the patient would
likely feel demeaned by the physician’s conscientious refusal. In
contrast, accommodating the conscience claims of pro-LGBT
rights physicians would not impose comparable dignitary harms
on patients denied sexual reorientation—telling a patient that
you do not share their values is not harmful in itself; telling her
that she cannot competently raise children surely is.
Besides this moderate defence of conscience clauses for health
and mental health professionals concerned with social justice,
let us recap our first conclusion: though widespread use of
sexual reorientation technologies would be harmful on the
whole, nonetheless clinicians would be very often permitted,
and sometimes obligated, to offer it to patients who suffer from
unwanted orientation. This produces a significant kind of moral-
political dilemma for the medical community: the clinical
imperative to relieve the suffering of particular patients, univer-
sally followed, could well worsen the heterosexist conditions
that produce patient suffering in the first place.
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Can the medical community help avoid this dilemma? We
think that they can, and should. In particular, to avoid the
serious problems that would arise were safe and effective
reorientation available, medical professionals should act to
ensure that it does not become available. Fortunately, they are
well positioned to do this. Whether high-tech reorientation
techniques would involve existing or (more likely) novel
medical interventions, physician involvement would surely be
essential to developing and testing proposed reorientation tech-
niques. Here, we will argue, is where ethical concerns about
broader harms of reorientation practices could be more decisive.
RESEARCHERS
Safe and effective reorientation techniques do not yet exist; sig-
nificant research will be required to develop them. As we argue
in ‘Sexual Re-Orientation in Ideal and Non-Ideal Theory’, exist-
ing ethical and regulatory standards for clinical research would
make it difficult to develop potential reorientation therapies, in
the USA at least. We speculated that such therapies would likely
emerge through privately funded research or in the hands of
scientists from other countries instead. Here, we want to turn
our attention away from questions of regulatory mechanisms
and focus on the role obligations of researchers qua researchers
vis-à-vis sexual reorientation.
General considerations
Clinicians’ role responsibility, we have argued, is to relieve the
suffering of their patients, even when doing so might make
them complicit in perpetuating injustice. Medical researchers,
however, are bound by slightly different, more general role obli-
gations. Researchers are, of course, legitimately concerned with
relieving the suffering of patients. But, as they decide which
course of research to embark on, they do not have particular
obligations to relieve the suffering of particular patients. Since
there are no agent-relative role obligations weighing against
justice, researchers are (and should be) more receptive to con-
cerns of justice than clinicians might (and should) be.
To repeat our argument from ‘Sexual Re-Orientation in Ideal
and Non-Ideal Theory’, the availability of reorientation prac-
tices could harm sexual minorities by hindering pro-gay policies
(to the extent that sexual orientation would fall within the
realm of individual control), by exerting pressures to ‘convert’
to heterosexuality, by placing a burden of justification on sexual
minorities to explain why they do not ‘normalise’, and by gener-
ally threatening the viability of queer communities.vii These
reasons, which explain why sexual orientation should remain
outside the individual’s control, ought to feature centrally in
researchers’ deliberation about which work to undertake, given
researchers’ fundamental role responsibilities.
We examine two kinds of research: (1) basic research into sexual
orientation itself and (2) applied research into sexual reorientation
technologies. We contend that applied research is not permissible,
given the expected negative social consequences of reorientation
biotechnologies. That said, we maintain, these arguments allow
that basic research into sexual orientation is permissible, despite its
potential to lead to the development of sexual reorientation, given
vii
These reasons, admittedly, only apply directly against reorientation
techniques that would allow ‘conversion’ to heterosexuality from
minority orientations. We are not sure what to say about technologies
that could only ‘expand’ orientation. We leave this issue aside, here, on
the assumption that plausible reorientation technologies would be ‘all
purpose’.
Aas S, Delmas C. J Med Ethics 2016;0:1–8. doi:10.1136/medethics-2016-103562
Clinical ethics
the social and clinical value of scientific understanding of the
determinants of sexual orientation. Our central point, then, will
be that the likely harms of high-tech reorientation therapy provide
strong arguments against reorientation research, without thereby
precluding all research into sexual orientation.
In making these points, we hope to shed light, both, on the
specific questions of the prospective harms and benefits of
research into sexual (re)-orientation; and, on more general
issues concerning moral evaluation of the outcomes of biomed-
ical research. Both basic orientation research and applied
reorientation research pose distinctive and interesting problems
in research ethics.
Basic research into sexual orientation presents what is called
‘dual use’ risk, insofar as its findings could be used in either
beneficial or harmful ways. A paradigm case of dual use risk in
bioscience is research into infectious diseases, which involves
modifying select agents to respond to outbreaks. Select agents
like the Avian influenza virus, the Ebola virus and the Bacillus
anthracis (anthrax) pose a severe threat to the public as they can
be used to produce bioterrorist weapons.25 26 Basic research
into sexual orientation poses a dual use risk insofar as, on the
one hand, gaining scientific understanding of sexual orientation
is beneficial; on the other hand, the findings could be used to
produce reorientation technologies—a bad outcome given the
four kinds of harms previously identified. It could also be used
to provide prenatal genetic testing to predict for and screen
against homosexual dispositions in fetuses27 ( pp 9–10)—a prac-
tice likely to threaten sexual diversity.28
Applied research aiming directly at safe and effective reorien-
tation raises a somewhat different set of issues. The primary
concern here is not that this technology may be used for good
or bad purposes (‘dual use’), but rather that it has a single use
(changing sexual orientation) which is good in some ways
(it relieves the suffering of some patients) but bad in others
(it harms sexual minorities in general): its use has ‘dual valence’,
we might say—although, we have and will argue, in present
conditions the negative valence of applied research is much
more powerful than the positive.viii
Applied research into sexual reorientation
The Belmont Report, which regulates the use of human subjects
in experimental research in the USA, outlines three core princi-
ples: respect for persons, beneficence and justice (45 CFR 46).
Each of these principles demands taking seriously the social
effects of sexual reorientation. Respect for persons demands
protecting vulnerable subjects, to wit, members of sexual minor-
ities, who are already disadvantaged and could be further mar-
ginalised. Beneficence requires protecting persons from harm,
especially, from the collective harms previously identified.
Justice demands ensuring a fair distribution of burdens and ben-
efits, and thus prohibits the imposition of additional burdens on
sexual minorities (in the form of pressures to ‘convert’ and
demands of justification).
Researchers have long recognised special obligations to be
careful of the effects of their research on ‘vulnerable popula-
tions’, per articles 19 and 20 of the Declaration of Helsinki.29
To be sure, some (dissenting from the Declaration) might take
these obligations to apply only to harms against specific subjects
enrolled in particular studies. Even then, the fact that reorienta-
tion research would no doubt enrol many members of sexual
viii
There are dual use concerns as well, since reorientation techniques
might be used in straightforwardly bad ways: forcibly, for instance.
5
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Clinical ethics
minorities gives researchers a reason to be especially concerned
about the harmful effects of reorientation.
One might further suggest that conducting research involving
members of a vulnerable group requires one to be especially
concerned about the welfare of that group as a whole. So, for
example, US research regulations require that studies that are
not beneficial to particular enrolled children benefit children in
general (45 CFR 46.407). Similarly, we would suggest, those
who choose to do research on members of vulnerable sexual
minorities, qua members of those minorities, acquire especially
strong obligations to avoid harms to these individuals and
minorities. Furthermore, researchers should be concerned about
the harms to non-heterosexual people not just in their own soci-
eties, but in other countries too.27 ( p 10) To that extent, the
progress made on LGBTQ issues in the developed world could
not be enough to alleviate researchers’ concern with sexual
injustice.ix
Thus, concerns about the potential harmfulness of sexual
reorientation produce a strong prima facie case against applied
research. Researchers should avoid embarking on any research
that could make it substantially more likely that techniques for
safely and effectively changing orientation will be developed in
the near-term; even more so, if the research in questions
involves members of sexual minorities.
Research that seeks to test techniques developed by others
(eg, privately funded scientists) presents further complexities.
This kind of research, at present, seems clearly valuable:
debunking unsafe and ineffective SOCE helps in discrediting
them. But at some point, as more effective techniques are
(impermissibly) developed, scientifically serious studies that test
proposed reorientation methodologies become much more eth-
ically fraught, since research will eventually show that some
sexual reorientation interventions are safe and effective. At that
point, clinicians will be permitted, and even obligated, to
provide them to patients requesting them.
This might suggest a case against research testing existing
interventions. Nonetheless, to the extent that reorientation tech-
nologies are actually in clinical use, it will be better to know
whether they work, or not, so that patients and clinicians can
make informed decisions about them.x So a rule of thumb
might be: test techniques to the extent that they are, either or
both (a) very likely unsafe or ineffective and (b) in widespread
use; and avoid testing techniques that are both (c) not already in
widespread use and (d) likely to be safe and effective.
Hence, researchers’ professional responsibilities bind them to
take into account the prospective harms of sexual reorientation
in their research agenda. All in all, we submit, these harms
weigh significantly against most kinds of applied reorientation
research.
ix
According to the Federal Bureau of Investigation, gender identity and
sexual orientation accounted for more than a fifth of all hate crimes
perpetrated in 2013. See https://www.fbi.gov/news/stories/2014/
december/latest-hate-crime-statistics-report-released. See also Gay &
Lesbian Advocates & Defenders on anti-LGBT discrimination: https://
www.glad.org/rights/topics/c/anti-lgbt-discrimination. For worldwide
data, see, for example, the United Nations Human Rights Office of the
High Commissioner report on anti-LGBT discrimination: http://www.
ohchr.org/en/issues/discrimination/pages/lgbt.aspx.
x
An analogous case might be found in the widespread off-label use of
Adderall and other common Attention Deficit Hyperactivity Disorder
medications, especially among students, to improve productivity and
focus. Insofar as they are so widely used, though not medically
recommended, it is important to test their safety and efficacy in the
short-term and long-term.30
6 Aas S, Delmas C. J Med Ethics 2016;0:1–8. doi:10.1136/medethics-2016-103562
Basic research into sexual orientation
By contrast, we do not think that the prospective harms of
sexual reorientation technologies weigh decisively against basic
research into sexual orientation itself. Although the latter might
someday, somehow be used to develop reorientation techniques
and prenatal genetic screening, basic orientation research pro-
mises at least two very significant benefits which count against
these prospective harms.
First, understanding the biology of orientation has clear scien-
tific value, both in itself and because of its relation to other
important scientific questions. Sexual desire is a central part of
the human condition; to understand what factors shape basic
sexual preference is, therefore, to understand something central
about human beings. Furthermore, sexual preferences affect
human behaviour in a myriad of ways, so that understanding
sexual preference may increase our understanding of other
complex human behaviours. Murphy31 showed that much of
sexual orientation research had been bad science, involving
questionable motives, flawed assumptions and unsound method-
ology. However, in 2016 there is reason to hope that there can
be a good, methodologically sound, bias-free science of sexual
orientation. This kind of work can be expected to produce
important scientific knowledge.
Second, understanding the causes of basic sexual preference
promises to aid progress on sexual justice. It could bolster the
public basis of acceptance for sexual minorities by replacing the
currently scientifically defective, but publically effective, ‘born
this way’ argument32 with a scientifically correct (and, hope-
fully, no less publically effective) version that would show why
variation in basic sexual preferences is biologically normal and
broadly unchosen, even if not necessarily innate or immutable.2
Schüklenk et al27 warn against this goal. In their view, the
ethical status of gays and lesbians does not in any way hinge on
the ‘naturalness’ or ‘normality’ of same-sex orientation; and to
think otherwise is to commit the naturalistic fallacy (deriving
‘ought’ from ‘is’).27 ( p 10) We agree with the ethical point—the
‘born this way’ argument is not convincing in itself. However,
their critique targets mainly research into the ‘gay gene’, while
ignoring research into other determinants of sexual orientation.
More sophisticated research might produce explanations that
have more ethical relevance. Thus, as Kantin33 points out, pro-
viding detailed accounts of the aetiology of orientation can pre-
clude pseudo-scientific accounts that cast non-heterosexual
orientations in an unflattering light: arguing, say, that homo-
sexuality is the pathological result of childhood sexual trauma, a
form of arrested psychosexual development, or a form of ado-
lescent rebellion destined to pass. Thus, even if basic orientation
research cannot, by itself, normatively justify any particular
orientation, it can help us refute perceptions about the aetiology
orientation that have and will be used to justify intolerance of
or disrespect for sexual minorities.
In these ways and others, basic orientation research has some
potential to accelerate increased acceptance for sexual minor-
ities. This produces benefits to weigh against the harms that
might come, where this basic research to be used to develop
reorientation techniques. Furthermore, recall that reorientation
biotechnology is only harmful in contexts of heterosexist injust-
ice. In an ideal world, it would be a good thing to be able to
determine the direction of one’s own attractions. To the extent
that basic orientation research helps to bring about a better
world, it also helps to make the prospect of application in
reorientation technologies less fearsome.
All that said, we stress that even basic reorientation research
poses significant risks, in the world we live in. Certainly, we
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cannot assume that its positive effects will be so effective, so
quickly, that researchers need not worry about hastening the
emergence of reorientation biotechnologies. Given this dual use
risk, it makes sense to apply a moderate form of the precaution-
ary principle (as in other cases of dual use research—see Kuhlau
et al 2011 for a defence of the precautionary principle against
common objections). The principle would caution the scientific
community to develop and nurture a ‘culture of dual use
responsibility’, as it pursues projects that (like basic orientation
research) pose dual use risks.34 ( p 50)
Examples of precautionary measures that researchers should
take to prevent harm include: raising awareness within the sci-
entific community about the potential harms of sexual reorienta-
tion; highlighting researchers’ professional responsibilities to
avoid these harms and facilitating ethical competence-building
among researchers. Kuhlau argues that ethics education, rounds,
mentoring and consulting constitute effective concrete methods
to achieve ethical competence-building.21 ( pp 61–63)
Developing, encouraging and publicising research in LGBT bio-
ethics would also contribute to fostering individual researchers’
ethical competence.35 For a last example, institutionalising dual
use deliberation, say, by establishing scientific advisory boards,
can be an effective way to raise awareness and promote respon-
sible research within professional organisations.21 ( pp 63–65)
Finally, it is important to note that there are many directions
of research related to orientation in health and mental health
sciences which do not raise dual use risks and would benefit
sexual minorities, including research into the aetiology of sexual
prejudice, the deleterious effects of homophobia on LGBTQ
individuals’ mental and physical health, and assisted reproduct-
ive technologies. A case can be made that public funds should
be allocated to research projects like these; perhaps even in pri-
ority to basic orientation research, given the risks that pose and
the uncertainty of its benefits. Still, we will not take a stand on
this weighting here: our broader points about research are
simply (a) that there are strong reasons to believe that much
applied reorientation research is impermissible and (b) that
these reasons weigh much less decisively against basic orienta-
tion research.
CONCLUSION: OUTLOOK
Technological measures meant to change sexual orientation are,
we have argued, deeply alarming, even, and indeed, especially, if
they are safe and effective. This is, in part, because they produce
a distinctive kind of ‘clinical collective action problem’: a treat-
ment which evidently relieves the suffering of particular patients,
but in the process contributes to a practice that substantially
worsens the conditions that produce this suffering in the first
place. The role obligations of clinicians to relieve the suffering
of their patients put them in a poor position to solve this
problem; they can, to be sure, take measures to avoid complicity
in the harms that would result from widespread use of individu-
ally safe and effective reorientation biotechnology. But in the
end the clinical community as a whole still seems obligated to
provide these measures, if they become technologically feasible.
Medical researchers are in a better position to prevent the
harms that would result if reorientation techniques were safe,
effective and widely available. As we argued, they should not
seek to develop these techniques; and they should take precau-
tions to prevent their emergence. Sad to say, these precautionary
measures do not guarantee against the premature arrival of safe
and effective reorientation techniques. Better understanding of
the genetics and neurobiology of sexual orientation may, indeed,
make it much easier to develop reorientation techniques, easy
Aas S, Delmas C. J Med Ethics 2016;0:1–8. doi:10.1136/medethics-2016-103562
Clinical ethics
enough that it would take little or no malfeasance on the part of
researchers for these to emerge. Clustered Regularly Interspaced
Short Palindromic Repeats and other genetic technologies may
allow for relatively easy translation between knowledge about the
genetic bases of sexual orientation and techniques for modifying
them. Better understanding of the brain, and better techniques
for modifying it, may make for similarly worrying intersections
of clearly permissible research: a point may come where it is a
short step from understanding the neural basis of orientation to
neurologically changing orientation.
There may, therefore, be no way in the end for the medical
community to definitively prevent the harms that would come
from reorientation biotechnologies, in our heterosexist societies.
All the more reason, then, for medical professionals to work
however they can against heterosexist prejudice, in the lab, in
the clinic, at home, and abroad.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
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The ethics of sexual reorientation: what

should clinicians and researchers do?
Sean Aas and Candice Delmas

J Med Ethics published online May 4, 2016

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