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• The counselling and psychotherapy profession was subject to unflattering media scrutiny earlier this year following the publication of research which found that a significant minority of mental health professionals in Britain are attempting to help lesbian, gay and bisexual (LGB) clients become heterosexual.
  
  Under the headline ‘British therapists still offer treatments to “cure” homosexuality’, the Guardian¹ reported that a survey (of 1,328 counsellors, psychotherapists, psychoanalysts and psychiatrists throughout the country) found that 222 practitioners had attempted to change at least one patient/client’s sexual orientation, while 55 said they were still offering the therapy. The fact that some of those practitioners are members of BACP prompted the following response from Phillip Hodson, BACP Fellow and Media Consultant, in the letters page of the Guardian the next day: ‘[BACP] is dedicated to social diversity, equality and inclusivity of treatment without sexual discrimination or judgmentalism of any kind, and it would be absurd to attempt to alter such fundamental aspects of personal identity as sexual orientation by counselling.’²
  
  And yet this is what a significant minority of counsellors working in Britain today are still attempting to do. ‘I think it’s probably the tip of the iceberg,’ says Michael King, Professor of Primary Care Psychiatry at University College London Medical School, and one of the three scientists responsible for the aforementioned research published in the BMC Psychiatry³ journal. ‘It was only a small minority, about four per cent, who said that they would treat someone who came and asked for help, but another 10 per cent said they would refer on to someone who would, so it looked like about 14 per cent thought it was an appropriate thing to do.’
  
  No decline in treatment offered
  Participants in the survey, which was sent to a representative sample of members of the British Psychological Society (BPS), BACP, the United Kingdom Council for Psychotherapy (UKCP) and the Royal College of Psychiatrists, were asked to give their views about treatments to change homosexual desires and describe up to five clients/patients each of whom they had treated in this way. One in six of them (17 per cent) reported having assisted at least one client/patient to reduce or change his or her homosexual or lesbian feelings. Counselling was the most common treatment offered and there was no sign of a decline in treatments in recent years.
  
  ‘We were cautious because we thought maybe some of them were describing what they did in the 1980s, rather than now,’ says King. ‘But we asked them the year in which they treated that client/patient, and found that it hadn’t declined at all – it was continuing at the same rate right up to the present time.’ Indeed, 72 per cent of the therapists who had provided such treatment thought that a service should be available for people who want to change their sexual orientation.
  
  These findings are of major concern because, as King and his colleagues argue, there is no evidence from the published literature to suggest that a person’s sexual orientation can be changed from homosexual to heterosexual, and indeed significant evidence that such treatment can cause harm. King is well placed to know because he has previously undertaken a systematic review of the literature on the history of treatments for homosexuality in Britain⁴ and, with a grant from the Wellcome Trust, has been involved in a project to gather the oral histories of patients who underwent such treatments and the mental health professionals who administered them.⁵
  
  A history of treatments
  Historically, LGB people have undergone a variety of treatments to try to become heterosexual – sometimes out of choice, but more often through family or social pressure or under threat of law. In the 1950s and 60s, aversion behaviour therapy was used to try to ‘cure’ gay men. Those who underwent it – often to avoid jail terms – were shown pictures of naked men and given a series of electric shocks or drugs to make them vomit. When they could stand it no longer, they were shown pictures of naked women as a relief from the pain.
  
  Psychoanalysis provided a more benign alternative to the brutalising effect of aversion therapy, but King’s research finds no evidence for the efficacy of either treatment and much evidence for their harm. Indeed many therapists later regretted their involvement in such treatments. Given the facts, therefore, how can we explain why, to this day, one in six psychotherapists, counsellors and psychiatrists still see fit to offer gay clients treatments that aim to make them straight?
  
  All groups questioned in King’s survey considered that a client/patient’s distress about their homosexuality was justification for intervention, with therapists paying attention to religious, cultural and moral values that might be causing internal conflict. Many therapists cited a responsibility to respect their client/patient’s autonomy, and self-determination was seen as an issue that might override a degree of professional unease. The qualitative data suggests that they made therapeutic decisions based on privileging client/patient choice where there was a wish to avoid the impact of negative social attitudes to same sex relationships. It is also important to point out that the most common reason for the referral was confusion about sexual orientation rather than an expressed desire to change it. It appears unlikely that therapists were responding straightforwardly to the demands of patients/clients, as direct requests for change were very rarely reported.
  
  Whilst it might seem, therefore, that the majority of therapists were motivated by good intentions, King doesn’t see it that way. ‘There is no evidence that anyone can help,’ he says, ‘so I think it’s unethical to say it’s possible.’ What he is referring to here is the lack of scientific evidence that supports the claim that it’s possible to change orientation from homosexual to heterosexual. He does not discount the possibility that sexual behaviour can, and frequently does, change across an individual’s lifetime, but he argues that an adaptation in sexual behaviour does not amount to a fundamental change in sexual orientation.
  
  ‘I certainly don’t think that sexual behaviour is an immutable, fixed thing throughout your life,’ he says. ‘There is evidence that people move up and down to some extent on a spectrum. They might seem to live a heterosexual lifestyle for a period and then suddenly leave a marriage and join up with a same sex partner. But when you go into these cases you often find that people have been pushing themselves in a certain direction. For example, a woman who’s been married and then enters a lesbian relationship; we’ve studied some of these people in detail and you find that even though they were married and seemed to be heterosexually responding, it always felt somehow wrong to them and they didn’t know why.
  
  ‘Take men who go to prison,’ he continues, ‘when they’re deprived of women they will have same sex experiences, and they will be sexually aroused by those experiences, but when they go home they don’t think about it again, they go back to their wives and girlfriends. We’re obviously malleable beasts, but I’m talking about something far profounder than just behaviour. Sexual orientation isn’t just about what you do genitally, it’s about your whole life, the sort of person you might fall in love with.’
  
  So how he would respond to a client who is unhappy about his or her same sex attraction and seeking help to change? ‘I’ve encountered this often,’ he says. ‘What I try to do is explore with them what it’s all about, to try to understand where they’re coming from. Is the pressure self-generated? Is it religion? Is it their own shame and stigma, or is it coming from a wife or husband or family? It’s often other people who have the problem accepting it. I would never try to change them and I would never send them to someone to change them either because I don’t think it’s ethical.’
  
  Religious intolerance
  In King’s experience, the desire for and by LGB people to change their orientation is frequently motivated by religious intolerance, particularly from within the fundamentalist extremes of Christianity and Islam. The pressure is immense on young LGB people growing up within these faiths and traditions to conform to the heterosexual norm. In an interview with The Sunday Telegraph⁶ in July, a senior Church of England bishop Dr Nazir-Ali said: ‘The Bible’s teaching shows that marriage is between a man and a woman. That is the way to express our sexual nature. We welcome homosexuals, we don’t want to exclude people, but we want them to repent and be changed.’
  
  This restatement of the classic ‘love the sinner but hate the sin’ argument is a familiar one to King who, as a practising Christian, frequently gets drawn into debates with the religious right about what the scriptures have to say about homosexuality. ‘When people come at me with the Bible I’m usually quite astute at answering them,’ he says, ‘but it doesn’t make much difference because they’re usually so fundamentalist that I don’t get very far.’
  
  In April of this year, he was drawn into one such debate on the BBC World Service with the controversial American psychiatrist Joseph Nicolosi, who claims to offer a ‘cure’ for homosexuality. Nicolosi had been invited by the religious group Anglican Mainstream to speak at a conference in central London about his treatment method ‘reparative therapy’, which he claims can change an individual’s orientation from homosexual to heterosexual.
  
  Nicolosi is a leading exponent of the theory that same sex desires are a form of arrested psychosexual development that result from ‘an incomplete bond and resultant identification with the same sex parent’.⁷ Reparative therapy aims to fix this incomplete bond by reinforcing traditional gender roles. So a gay man, for example, is encouraged to participate in sports activities; avoid activities considered of interest to homosexuals (such as art galleries, museums and opera); avoid women unless it is for romantic contact; increase time spent with heterosexual men in order to learn to mimic heterosexual male ways of walking, talking and interacting with other heterosexual men; attend church and join a men’s church group; attend a reparative therapy group to discuss progress or any slips back into homosexuality; become more assertive with women through flirting and dating; begin heterosexual dating; engage in heterosexual intercourse; enter into heterosexual marriage, and father children.⁷
  
  A condition to be repaired
  The proponents of reparative therapy, and other so-called ‘gay conversion’ therapies like it, often argue that these techniques offer a choice to individuals who are unhappy with their same sex attraction and that they are not condemnatory of homosexuality per se. And yet, by definition, reparative therapy assumes the position that homosexuality is a condition that can and should be ‘repaired’; in other words – taking the etymology of ‘reparation’ from ‘repair’ – that it is innately damaged or faulty and therefore requires fixing in order to restore the individual to full working order (ie heterosexuality).
  
  This argument has its antecedents in psychoanalytic theory, for although Freud was unusually (and controversially) liberal for his time in stating that homosexuality ‘is nothing to be ashamed of, no vice, no degradation… [and] cannot be classified as an illness’, he nevertheless considered it to be ‘a variation of the sexual function, produced by a certain arrest of sexual development’.⁸ Or, in other words, the result of something having gone wrong in the ‘normal’ developmental process.
  
  The concept of homosexuality arising from dysfunction was enshrined in psychiatric thinking right up until 1973 when, amidst considerable dispute amongst members of the American Psychiatric Association, it was finally removed from the DSM-II classification of mental disorders. Despite this, however, it remained standard practice for LGB people to be excluded from analytic training right up until the late 1990s because they were considered to have unresolved psychopathology.
  
  In the US, the National Association for Research and Therapy of Homosexuality (NARTH) campaigns for the right of gay people to be given access to treatment, if they want it. The organisation points to research by psychiatrist Robert Spitzer, who claims 66 per cent of gay men and 44 per cent of lesbians achieved ‘good heterosexual functioning’ after undergoing therapy.⁹ King, however, claims that the research into the effectiveness of reparative therapy has demonstrated little evidence of efficacy^{9, 10} and considerable controversy¹¹ about the quality of the methods used: ‘They don’t take a random group or run a randomised trial. All have been post hoc evaluations of volunteers, often some years after receipt of treatment. One study even asked for volunteers who thought they had changed – so you can see the research is biased towards change.
  
  ‘When you go into it deeply,’ King continues, ‘they seem to be encouraging self-control; so whilst some people have stopped living a gay lifestyle, they’re certainly not living a full heterosexual life. There’s no collateral evidence that they’ve changed. No evidence that any scientist would accept. And there’s just as much evidence on the other side that it’s very damaging to people.’
  
  Lack of evidence on either side
  King’s critics often respond by saying that there is also a lack of evidence for the efficacy of gay affirmative therapy. ‘Absolutely, I agree with them,’ he says. ‘But they’re getting the point wrong because gay affirmative therapy is not about helping somebody to be gay. The term gay affirmative therapy just means therapy that’s knowledgeable of and respects gay issues. It’s not the opposite of reparative therapy.’
  
  Because he is an openly gay man, his detractors also frequently try to discredit him by claiming he is driven by a political agenda and that his research is scientifically flawed as a result. ‘I think it’s a derisory argument,’ he says. ‘If it was an issue about black men and psychiatry, if I was a black man you would see that as appropriate and possibly even advantageous compared to a white Anglo Saxon male doing that kind of research. But when I say I’m gay and I’m interested in gay mental health they say I’m going to be biased.’
  
  His research into the mental health of LGB people – which has found that they are twice as likely to attempt suicide, one and a half times more likely to experience depression and anxiety, and one and a half times more likely to abuse alcohol and drugs¹² – has been seized upon by right-wing religious groups to bolster their claim that homosexuality is psychopathological, and that the increased incidence of mental disorder and deliberate self-harm amongst LGB people is proof of that. ‘We’ve just analysed the first random survey of gays and lesbians in Britain and we’re finding exactly the same thing – raised levels of psychiatric disorder across the board on almost every count, even psychotic experiences,’ he says.
  
  And yet, King argues, the emotional and psychological distress of LGB people is more likely the result of societal hatred and intolerance than an innate predisposition to mental illness. ‘There’s a lot of good research to say that’s simply not true, that we can tell psychopathology from what are called soft neurological signs.
   
  ‘Most brain disorders have other accompanying signs and homosexuality has absolutely none of those, so it would seem to be a normal variant. Primarily I think it’s a result of the prejudice and bullying that people have suffered, either silently because they’ve been hidden or overtly because they’ve been open, particularly in schools and colleges where it’s extremely tough still to be open. Rejection by parents is also devastating to many people. To be born with a characteristic and then hated for it by your own family is enough to make anybody depressed or anxious.’
  
  To further counter the claims of the religious right, King goes one stage further to argue that although LGB people are at increased risk of developing mental health problems, they also seem to be stronger and more capable because of the personal and social pressures they’ve had to endure. ‘If you look at studies of older people, age 65 plus,’ he says, ‘gay men and lesbians seem to have stronger psychological health than heterosexuals, and there are several studies showing that.^{13, 14} They’ve done all their tough stuff – they’ve lost partners, they know what it’s like to endure prejudice – so they’re better equipped to weather the demands of old age.’
  
  And, in a final challenge to religious orthodoxy, King asks: ‘Why do they assume that God didn’t make homosexuals? How do they know? We don’t know what role in evolution homosexuality could possibly have – and we’ve also looked at this in our research. Why is it so universal across mankind? If it is some kind of aberration or perversion, why doesn’t it go up and down in frequency? Why aren’t there eras when it seems to be absent? There is no in-depth thinking about what this thing in nature could be about. There’s just a blank refusal to accept it.’
  
  Because he speaks out on these issues, King is often the butt of hate mail. ‘I got a lot of “burn in hell” emails over this latest paper,’ he says. ‘It’s a constant reminder that people don’t like me very much because I say these things.’ Despite this, however, he is an optimist and believes the progress of the last decade – in which LGB rights in Britain have finally been legally enshrined through an equal age of consent, civil partnerships, immigration equality, adoption rights, anti-discrimination legislation etc – will continue apace.
   
  ‘I’ve witnessed a revolution in my lifetime,’ he says. ‘I grew up in New Zealand where you could go to prison for any gay sexual contact right up until 1984, so it’s pretty recent history. My hope is that homosexuals and heterosexuals will become indistinguishable. In the West at least, unless there’s some terrible theological and religious return to fundamentalism, I think this is quite possible within the next 20 to 50 years. In other countries though it’s very bleak – in China and countries in the Gulf, there’s a huge way to go.’
  
  In conclusion, given this rapid pace of change, King believes it’s hardly surprising that there is still ignorance amongst mental health professionals about LGB issues: ‘Gay and lesbian people were invisible until the last 15 years, so it’s no surprise that psychotherapists are not very knowledgeable. It’s just something that they need educating about. But what I’m more worried about is the people who seem to positively launch themselves into cures, when there’s no evidence that they work, and plenty of evidence that they can cause harm.’

• References:
  

  1. Sample I. British therapists still offer treatments to “cure” homosexuality. The Guardian. 26.3.09. www.guardian.co.uk/science/2009/mar/26/homosexuality-gay-cure-treatment-orientation
  
  2. Hodson P. Letters. The Guardian. www.guardian.co.uk/theguardian/2009/mar/27/letters
  
  3. Bartlett A, Smith G, King M. The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation. BMC Psychiatry. www.biomedcentral.com/1471-244X/9/11
  
  4. Smith G, Bartlett A, King M. British psychiatry and homosexuality. The British Journal of Psychiatry. 1999; 175:106-113.
  
  5. Smith G, Bartlett A, King M. Treatments of homosexuality in Britain since the 1950s – an oral history: the experience of patients. British Medical Journal. 2004; 328.
  
  6. Wynne-Jones J. Change and repent, bishop tells gays. 4.7.09.  www.telegraph.co.uk/news/newstopics/religion/5744559/Change-and-repent-bishop-tells-gays.html
  
  7. Haldeman DC. Gay rights, patient rights: the implications of sexual orientation conversion therapy. Professional Psychology: Research and Practice. 2002; 33(3).
  
  8. Freud S. Letter to an American mother. American Journal of Psychiatry. 1951; 107:787.
  
  9. Spitzer RL. Can some gay men and lesbians change their sexual orientation? 200 participants reporting a change from homosexual to heterosexual orientation. Archives of Sexual Behaviour. 2003, 32:403-17. www.biomedcentral.com/sfx_links.asp?ui=1471-244X-9-11&bibl=B5
  
  10. Shidlo A, Schroeder M. Changing sexual orientation: a consumers’ report. Professional Psychology – Research & Practice. 2002; 33:249-59. www.biomedcentral.com/sfx_links.asp?ui=1471-244X-9-11&bibl=B6
  
  11. Peer commentaries on Spitzer. Archives of Sexual Behaviour. 2003; 32:419-68.
  
  12. King M, Semlyen J, Tai SS, Killaspy H, Osborn D, Popely D, Nazareth I. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry. www.biomedcentral.com/1471-244X/8/70/abstract
  
  13. Bybee JA, Sullivan EL, Zielonka E, Moes E. Are gay men in worse mental health than heterosexual men? The role of age, shame and guilt, and coming-out. Journal of Adult Development. 2009; 16:144-154.
  
  14. King M, McKeown E, Warner J, Ramsay A, Johnson K, Cort C, Wright L, Blizard R, Davidson O. Mental health and quality of life of gay men and lesbians in England and Wales: controlled, cross sectional study. British Journal of Psychiatry. 2003; 183: 552-558.