New Study on Sexual Reorientation Therapies

This is a more accurate title for my talk.

Sexual orientation refers to a sustained sexual attraction, sexual fantasy, desire for a romantic, emotionally intimate relationship and sexual behavior with excitement, directed primarily to the same or opposite sex.

Sexual orientation is multidimensional and each component is on a continuum.

There is a professional consensus that homosexual behavior can be resisted, renounced or relabeled.

However, homosexual orientation can never be changed.

I certainly shared this viewpoint, so how did Bob Spitzer, who played a central role in eliminating homosexuality as a mental disorder from DSM-II in 1973, come to have­ doubts about this consensus?  

The answer is that at the 1999 APA annual meeting in Washington I talked to several people who were picketing the meeting and claiming that, contrary to a recent  APA position statement, change of  sexual orientation was possible and should not be discouraged and that they, personally had changed from homosexual to heterosexual.  

I started to wonder, could it be that some homosexuals could actually change their sexual orientation?  After much thought, and realizing that previous studies claiming that such change was possible had all kinds of methodological flaws, I concluded that my curiosity would only be satisfied if I conducted  a study of my own.

The basic idea is simple.  Study the self-reported experiences of individuals who claim to have achieved a change from homosexual to heterosexual attraction that has lasted at least five years.

The basic study questions would be...
Can one find a substantial number of such individuals?

If yes, how often is such change accompanied by changes in other homosexual indicators?

Are there gender differences?

With the help of Dr. Richard C. Friedman, I developed a structured telephone interview so that it would be absolutely clear to others how we assessed our subjects.

We were surprised to realize that previous sexual orientation questionnaires and measures were quite inadequate in that they usually focused on a single variable of sexual attraction or identity, so that we had to largely develop our own questions and response categories.  

We kept revising the interview schedule ­during a pilot study of 40 individuals who had been referred to us as potential subjects.

During this developmental phase we asked questions such as:

„What kind of help did you receive?“, „What were you like before (change effort)?“, „How are you different now?“, „What ­aspects of your homosexuality remain?“

We developed specific questions for these key homosexual indicators.

Sexual attraction during a one year period on a subjective scale that goes from 100 (exclusively homosexual) to 0 (exclusively heterosexual).  The  subject picks any number from 100 to 0.

Lustful thoughts or daydreaming about having sex with the same sex - from never, a few times a year, a few times a month, a few times and week and  every day in a one year period.

Same sex fantasies during masturbation - the percent of occasions of masturbating

Same sex fantasies during heterosexual sex - the percent of occasions of sex.

Yearning for romantic emotional intimacy - again, from never to nearly every day.

Homosexual behavior with excitement.

The final study interview, which I personally administered to all subjects, took about 45 minutes.  I entered data directly into a Data Entry SPSS program as the interview progressed.

There are 112  closed ended questions with fixed response categories, and 9 open ended questions in which I directly entered the subject‘s answer.

Audio recordings of about a third of the subjects can be reviewed by other researchers and the entire study data set is also available.

When we attempted to recruit possible subjects we merely asked for individuals who had sustained some change in homosexual orientation for at least five years. However, the actual entry criteria ­were more restrictive. 
To be accepted into the study it was necessary for the subject in the interview to report:
Predominantly homosexual attraction...
We use the phrase „change effort“ rather than therapy, since some of the changes involved specific efforts, such as involvement in a mentoring relationship with a heterosexual, that the subjects usually did not ­regard as therapy.    

The individual had to have the goal of funct­ioning heterosexually.

It was also necessary, that after the change effort, there be a change of at least 10 points on our sexual attraction scale.  10 points is an arbitrary minimal change but at least reflects the subject‘s assessment that there has been some change in the object of sexual attraction.

In order to obtain 200 study subjects, which turn­ed out to be 143 men and 57 ­women, we interviewed 274 ­potential subjects that we found, with great difficulty over a period of 16 months.

74 subjects were excluded, most commonly because there was a change in behavior and self-identity, but no change in sexual attraction, or the individual was not predominantly homosexual, or the change was less than 5 years duration.

Our 200 subjects were primarily recruited from ExGay religious ministries that offer a variety of programs to help homosexuals who want to overcome their homosexual feelings.

And from NARTH, the National Association for Research and Therapy of Homosexuality, a  group of mental health clinicians and lay people who by and large regard homosexuality as a treatable developmental disorder.

The „Other“ was largely other subjects, therapists who do sexual reorientation therapy, as well as responses to notices of the ­study on the radio and in newspaper advertisements.

The referral source, by various means, got in contact with potential subjects who then called my office to arrange for an interview.

About 90% of subjects reported using more than one kind of change effort.  The slide presents the answer to the question, „Which was most helpful?“

The mental health professional was most commonly a psychologist (23%),or pastoral counselor (12%). Rarely a psychiatrist (3%).

„Other“ included repeated meeting with a heterosexual role model, often referred to as „mentoring,“ self help books or what some subjects called „spiritual work“ - meaning changing one‘s relationship with God.

When results for males and females are very similar, the result for the total sample of 143 men and 57 women is shown.

About three quarters of the men and half of the women were currently heterosexually married.

About a fifth of the subjects were married before the change effort and often reported that homosexual behavior or attraction threatened their marriage.
Most were Caucasian and had completed college.

Most subjects were Protestant.

The vast majority said religion is „extremely“ or „very“ important in their lives.  

Many nonreligious therapists that we sought referrals from were reluctant to get in touch with former patients.  This may, in part, account for the unusually high proportion of our sample that was very religious.

The great majority of subjects had publicly spoken in favor of efforts to change homo­sexual orientation.  Indeed, the primary motivation for participating in the study for almost all subjects was their interest in providing evidence, from their own experi­ence,­ that homosexuality can be ­changed and to offer hope to others.

Why did the subjects want to change? These were the most commonly report­ed answers.  

Gay life-style not emotionally satisfying... Usually this referred to widespread promiscuity, stormy, painful relationships, often with extreme jealousy.

Religious conflict...

Desire to get or be able to stay married, particularly for the men.

Here is the average time line - almost identical for men and women. There was, of course, great individual variability. The onset of sexual arousal to same sex was about  12 years.     About 18 years later is  the beginning of the change effort that they found helpful (often preceded by one or more change efforts that were not help­ful... including, often, therapists who told  them they had no choice but to ­accept their homosexuality).

After two years into the change effort, they begin to feel different sexually. The vast majority of subjects reported this change as being gradual, and often starting with diminution of homosexual feelings and gradual emerging or intensi­fication of heterosexual feelings. Three years later, after about five years of the change effort, it ends for 78% of the subjects.  The remaining 22% report that the change effort continues up to the present time, usually referring to continuing to attend an ExGay support group or having a life-long struggle with the underlying issues that they believe caused their homosexuality.

How homosexual were these subjects before the change ­effort?  First, how often did they have same sex attraction as a teenager?

We use red for males, and pink for ­females.

To make the main points, in this slide as in many other slides, we show the extremes.

Many „often“ or „very often“ had same sex attraction as teenagers.

In contrast, most subjects as teenagers „never“ or only „rarely“ had any opposite sex ­attraction, particularly the male subjects.

With how many individuals did the subject have homosexual sex before the change effort?

A small proportion, even smaller for the females, had resisted homosexual impulses and never had homosexual sex.

As expected, a sizable proportion of men had had sex with a large number of men.

53% of  the ­males, and 33% of the females, had never had consensual hetero­sexual sex.

We assessed change in sexual orientation indicators by comparing the 12 months before the change effort - which we will refer to as „Before“ - with the past 12 months before the interview - which we will refer to as „After.“

The next group of slides, on various indicators, contrasts BEFORE, with AFTER.

First, mean sexual attraction scores for males and females.  Remember, 100 is exclusively same sex, and 0 is exclusively opposite sex, BEFORE and AFTER.

Both males and females, on average, ­BEFORE, are in the very high homosexual range. AFTER, on average, they are in the high heterosexual range, even more so for the females.

Here, as in most of the remaining slides, note that the females often BEFORE are similar or less extreme on homosexual indicators, and AFTER are always more heterosexual than the males.

How many report­ed sexual attraction as  exclusively homosexual be­fore?  Almost half in males and ­females.

AFTER, 17% of the men, and considerably more of the females, 55%, report a score of 0, exclusively heterosexual.

Looking with lust at same sex or daydreaming ­about having sex with same sex, at least a few times a month.

This was the ­case for almost all subjects BEFORE, and for only a much smaller number AFTER, ­especially for the females.

Yearning for romantic emotional involvement with same sex, at least a few times a month.

Extremely common BEFORE, very unusual, AFTER.

Almost all of  the 138 men and 50 women who ­BEFORE masturbated, had same sex masturbatory fantasies on 20% or more masturbatory occasions.  

This was far less common in the 112 men and 39 ­women who masturbated AFTER, particularly for the women.

Opposite sex masturbatory fantasies, without ­making an effort to have such fantasies, among those who masturbated was unusual ­BEFORE, and quite common AFTER.

What proportion of subjects, AFTER, had absolutely ­none of these homosexual indicators - e.g., 0 on the sexual attraction scale and ­„never“ on the lustful thoughts scale.  

That would exclude someone who, for example reported 5 on the sexual attraction scale and a few times a year a same sex lustful thought.

This  - what we regard as an unrealistic criterion of absolutely no indicators, was the case for only 11% of the men, and a much larger proportion of the women, 37%.

We made a less stringent criterion which we call Only Minimal Homosexual Indicators.  For this we allow scores of 0 to 10 on variables that use a 0 to 100 scale and allow a frequency of „a few times a year“ on frequency variables. Now this applies to 29% of  the males and 63% of the females.

How often were the subjects able to achieve their goal of good hetero­sexual function­ing?

We defined this as requiring:

Last year in a loving heterosexual relationship.

Satisfaction from the emotional relationship with their partner, at least 7+ (1-10 scale where 10 is as good as it can be, and 1 is as bad as it can be).

Heterosexual sex at least monthly.

Physical satisfaction from heterosexual sex at least 7+ (the same 1-10 scale).

Never or rarely (<20%) think of same sex during heterosexual sex.

This was the case for 66% of the males and 44% of the females.  Many ­female subjects said they had dated and been sexually aroused but the rela­tionship did not end in marriage.

We expected that Good Heterosexual ­Functioning would not be achieved as ­often in ­su­bjects­­ who before the change effort were extreme on homosexual indicators. 

We defined this as:

No teenage opposite sex attraction

Never had heterosexual sex

Before: no heterosexual masturbatory fantasies

Before: attraction 95+ (homosexual)

We report the results for the 33 males who were in this group.  There were too few females, only 5, to report.

In these 33 males, good heterosexual funct­ioning was achieved by 67% of these subjects, much to our surprise.

56 subjects had regular heterosexual sex both BEFORE and AFTER, in almost all cases with the same person, their spouse.

We looked at three variables.

Satisfying emotional relationship (7+ on the 1 bad as it can be, -10 good as it can be scale) which went from 25% to 98%,

Sex physically satisfying (7+ on the 1-10 scale) which went from 43 to 100%.

Finally,  often (20+%) during sex think of ­same sex, which went from 52 to 6%.

These AFTER values are very similar to the values for these three variables on the 81 subjects  having regular heterosexual sex AFTER but who had not had regular heterosexual sex BEFORE.

Depression has been reported to be a common side effect of attempts to ­
chan­ge­ sexual orient­ation.  This certainly was not the case for our subjects, who were often „markedly“ or „extremely“ depressed BEFORE, and rarely so depressed AFTER.

During the pilot study we noted the common ways that subjects reported they had been help­­­­ed by the change effort. This shows­ how often subjects reported these ways of being helped when asked close ended questions during the study.
...feeling more [masculine, feminine]
...developing nonsexual relations with same sex.

Of course the big question is, given that these are subjects high­ly motivated to provide support for the value of reorientation change efforts, to what extent are their reports merely self deception, or gross exaggerations?  Lacking any objective evidence of change, like penile changes while viewing opposite sex erotic stimuli, there is no way to be certain that their reports are, by and large, accurate.  How­ever the following reasons suggest to us that they cannot easily be dismissed.

Complexity and range of change reported.

The wide range and limited nature of the out­comes that were reported and the fact that very few reported total change lends some credibility to their reports. Subjects had no difficulty providing detailed answers when they were asked to describe various outcomes, such as exactly what their opposite sex masturbatory fantasies were.

The gradual nature of the change, and the frequent pattern of less homosexual feelings followed by more heterosexual feelings, indicate it is not a simple made up story.

The  gender differences -  e.g., the greater ease with which the women subjects were able to change, and the women‘s reports of often being more heterosexual to begin with - are consistent with the literature. It would be difficult to explain why, if no one really changed, the women subjects would report more change than the men.

In answer to the question, „How did you translate what you learned in the change effort to changing your feelings?“ subjects reported the following change strategies that are generally recognized in the literature as components of effective psychotherapy efforts:

Narratives linking childhood or family experiences to sexual feelings.

Building on an intense emotional relationship to effect change in sexual feelings,  e.g., many men reported that they only developed heterosexual arousal after they became intensely emotionally involved with a women.

Group or individual support, as in Ex-gay ­support groups.

Thought stopping, e.g., „when I get such thoughts, I don‘t go down that route.“

 Avoiding situations that triggered homosexual feelings.

These are techniques that are commonly considered effective in psychotherapy, ­lending plausibility to their claims. We can imagine the mechanisms by which these techniques might work.

We conclude that, contrary to conventional wisdom, some highly motivated individuals, using a variety of change efforts, can make substantial change in multiple indicators of sexual orient­ation and achieve good heterosexual function­ing.

Subjects that made less substantial changes still believed that such changes were extreme­ly beneficial.

Complete change - which is generally con­sidered an unrealistic goal in psychotherapy  - is uncommon, particularly in male subjects.

Although therapists who do this kind of therapy claim similar results in approximately a third of patients that they treat, the difficulty finding subjects suggests the likelihood that the substantial changes reported by our subjects are relatively uncommon in all individuals who make a change effort.  

On the other hand, other factors, such as reluctance of subjects to be interviewed and resistance of therapists to contacting former clients may also have played a role in the difficulty that we experienced in finding 200 ­suitable subjects.  

The many potential subjects rejected from the study indicates that some individuals who claim to have changed sexual orientation, ­have changed only their identity or over thomosexual behavior.

However for these individuals such limited change was experienced as substantial improvement as it fulfilled self-identified goals of behavioral control and a shift in identity, even though the change was less than they had wished for.

A better way to conceptualize „sexual reorient­ation“ is to see it as diminishing of unwanted ­homosexuality and an increase in heterosexual potential - recognizing that change for some is possible along a multidimensional continuum.

We are concern­ed that... about the misuse of our study results.

The first is to assume that ­homosexual ­orientation is changeable for most highly motivated individuals.

The second is to dismiss the value to some conflicted homosexuals of a shift in sexual identity and unwanted sexual behavior, even when sexual orientation is not substantially changed.

The third is that the study results could be used to justify coercive treatment and the denial of civil rights to homosexuals.

I end by recalling what several subjects said spontaneously:  

„I have no problem accepting that most gays have no interest in changing.  I wish they could also acknowledge that I have a right to change, and that I have.“