July 30th, 2009
The American Psychological Association will hold its annual convention in Toronto next week, where the Task Force on Appropriate Responses to Sexual Orientation is due to issue its review of the current scientific research on therapies to change sexual orientation. That report is expected to lay the groundwork for a possible update to the APA’s 1997 policy statement on therapeutic responses to homosexuality. A group of anti-gay therapists known as the National Association for the Research and Therapy of Homosexuality (NARTH) are concerned that the Task Force isn’t sufficiently stacked with anti-gay activists, so NARTH sought to preempt the APA report by releasing a “journal” last June called the Journal of Human Sexuality.
As we said earlier, NARTH’s new journal contains just one 121-page article by James Phelan, Neal Whitehead, and Philip Sutton, titled “What Research Shows: NARTH’s Response to the APA Claims on Homosexuality.” NARTH brags that this article “examines over 100 years of professional and scientific literature as well as over 600 reports from clinicians, researchers, and former clients principally published in professional and peer-reviewed journals.” They described this effort as a new peer-reviewed study even though, as we already observed, it’s not new, not peer-reviewed, and not a study. It’s also unclear whether this “journal” is actually a journal. Instead, the article is a review of past studies, and a highly selective one at that. But even with their selective approach, they nevertheless included more than 700 source citations in their voluminous bibliography going back to the late 1800’s. That mountain of citations is intended to impress the reader with what NARTH considers to be overwhelming evidence that change in sexual orientation is not only possible, but also that it causes no harm in those who try it — a position that the APA appears unlikely to endorse entirely.
To try to make their case, Phelan, Whitehead and Sutton include just about everything but the kitchen sink regardless of its scientific merit. As expected, they dedicate several pages to the Jones and Yarhouse’s 2007 book, Ex-Gays? A Longitudinal Study of Religiously Mediated Change in Sexual Orientation, and they dedicate several more pages to Robert Spitzer’s 2003 study (Ex-Gay Watch examined that study here). But more curiously, PW&S dedicated some 14 pages to reports from various books and journals from 1882 through the 1970’s — a period when homosexuality was illegal and gays were regularly arrested and jailed, when they were prohibited from federal employment, and when they were even committed to psychiatric hospitals because the professional community regarded homosexuality as a serious mental illness. The literature from that period reflects those views, and this is the literature that NARTH believes is relevant to today’s discussion on attempts to change sexual orientation.
Phelan, Whitehead and Sutton’s historical review covers such broad therapeutic approaches as psychoanalysis, group therapy, hypnosis, sex therapies, pharmacological interventions, religiously-based methods, “spontaneous reorientation”, and cognitive and behavior therapies. That last category — behavior therapies — is especially troubling. PW&S blithely gloss over what that often entailed, but a sharp eye can spot it pretty easily. Hidden in those three pages lies western psychiatry’s darkest stain: aversion therapy.
Dr. Max’s Machine
Phelan, Whitehead and Sutton’s discussion of aversion therapy begins with this innocuous statement:
Behavioral-based therapists successfully treated not only unwanted homosexuality, but also a variety of sexual dysfunctions and paraphilias, including voyeurism, exhibitionism, and transvestic and other fetishism (Rachman, 1961). Aversion therapies aimed at changing the sexual behaviors of homosexuals were used as early as the 1930s (Max, 1935).
1935 is when it all began. Dr. Louis W. Max of New York University published a paper in the March 1935 edition of The Psychological Bulletin describing an apparatus which would become an important part of efforts to change sexual orientation throughout the 1950s and 1960s, and even through 1980s. That notorious apparatus was designed to administer a powerful electric shock to the client whenever the client was experiencing what was considered an inappropriate erotic stimulus (i.e. viewing a picture of someone of the same gender whom the subject found sexually attractive). In later experiments, that shock could be anywhere from 80 to 100 volts for a short period of time (although in some experiments it could be as long as five seconds). Max cautioned in his original paper that the jolt of electricity could be very powerful. “Where possible,” he wrote, “electrodes should be firmly fastened to the subject, especially when intense shocks are contemplated, as the subject’s ‘startle’ responses may dislodge an electrode.” Later work by others determined the optimal shape for the electrode to deliver the maximum level of shock to the patient while minimizing burns to the skin.
Later that fall, Dr. Max gave a talk at a meeting of the American Psychological Association in which he described the “cure” of a homosexual man — even though he also admitted the man was “backsliding.” The November edition of The Psychological Bulletinbriefly describes Dr. Max’s talk, which Phelan, Whitehead and Sutton cited as one of many success stories:
A homosexual neurosis in a young man was found upon analysis to be partially fetishistic, the homosexual behavior usually following upon the fetishistic stimulus. An attempt was made to disconnect the emotional aura from this stimulus by means of electric shock, applied in conjunction with the presentation of the stimulus under laboratory conditions. Low shock intensities had little effect but intensities considerably higher than those usually employed on human subjects in other studies, definitely diminished the emotional value of the stimulus for days after each experimental period. Though the subject reported some backsliding, the “desensitizing” effect over a three month period was cumulative.
Despite that mixed result, a new therapeutic approach was born. Today we are justifiably horrified to imagine the suffering that thousands of gay men and women endured to try to rid themselves of their same-sex attractions (sometimes under court order or while confined to a psychiatric hospital), Phelan, Whitehead and Sutton thinks nothing of trumpeting the “successes” of this barbaric form of therapy in staking out their position.
But PW&S do appear to understand that these reports are disturbing. Curiously absent from their article is any mention of what these forms of therapy entailed — at least not in any language that laymen are likely to understand. (And make no mistake, it’s lay persons who are the target audience for this report, not professionals.) There is one lone mention that “aversion therapies are no longer used for sexual reorientation because of ethical considerations,” but those thirteen words are obscured by the nearly 44,000 words that make up the rest of the article.
No, you have to delve deeply into the professional literature itself, directly, before you can get a sense of the horrors that these clients must have gone through — horrors that PW&S chose to ignore and few others have the resources to discover. My favorite part of a report like this is the bibliography. I guess you could say that looking up references at our local university library is something of a passtime for me. Call me a nerd if you will, but it’s a worthwhile endeavor because it reveals the vast gulf between how PW&S describe these articles and what the articles themselves reveal.
“Success” and Failure
For example, here’s how Phelan, Whitehead and Sutton describe one such report:
Mather (1966) reported that of 36 homosexuals treated with behavioral and aversion techniques, 25 were considered much improved on the Kinsey scale.
Pretty simple. A brief description and a result. Twenty-two words in one sentence is all the space that PW&S give to this study from the October 1966 edition of Medicine, Science and the Law.(Remember, homosexuality was still against the law in most states.) Already we have one problem: Dr. Northage Mather described the 25 as simply improved, not “much improved” — and there wasn’t much of a definition for what constituted improvement.
But besides that bit of obfuscation, that lone sentence hid a lot. Dr. Northage Mather’s “scientific” paper was replete with the distinctly unscientific stereotypes of the day. Mather justified his need to cure clients of their homosexuality by calling it “responsible for many antisocial acts such as larceny, blackmail, robbery with violence and murder” — hence the legal justification. Of the 36 subjects, 14 were directly or indirectly referred by a court, and six more were patients at a psychiatric hospital. Only sixteen appeared to be there of their own accord. Eight more beyond the 36 dropped out. One of the dropouts was “so frightened of the treatment that he only attended twice.” Another insisted that he receive electric shock therapy under an anesthetic, which of course would have negated the effects of the treatment.
Phelan, Whitehead and Sutton also cited several studies by the renowned team of Malcolm MacCulloch and M.P. Feldman. They were some of the pre-eminent experts in the field of aversion therapy in the 1960’s. In one citation, PW&S claimed that MacCulloch and Feldman “successfully treated 43 homosexual men.” Five paragraphs later, PW&S cited a 1971 book by Feldman and MacCulloch, Homosexual Behavior: Therapy and Assessment. This time, they wrote that the authors “worked with 36 patients,” and described it as though it were a separate study. One wonders if Phelan, Whitehead or Sutton read either work. If they had (as I did), they would have noticed right away that the two references were reporting on exactly the same study. The 1967 paper was titled “Aversion therapy in management of 43 homosexuals,” but MacColloch and Feldman explained:
Thirty-six patients had the full course of treatment, and seven failed to complete it. Six of the seven terminated treatment after one or two sessions, and one terminated it after six sessions.
That sentence is repeated virtually verbatim in Homosexual Behavior on page 31.
One can only imagine the reaction of those who terminated electric shock treatment “after one or two sessions.” MacCollough and Feldman are characteristically mum about the distress they must have endured. But we do know is that MacCullough and Feldman had some rather odd definitions for success. In the Appendix of Homosexual Behavior, they defended Series Case 2 as “improved,” even though on follow-up he was found to have a regular boyfriend and had no further desire to change. The authors chalked it up to “a weak-willed personality disorder.” It’s unclear whether Series Case 41 was ultimately classified as a success, but the authors were very optimistic about him. He was kicked out of the hospital after he was caught engaging in “some horseplay” with a female patient. They didn’t classify him as a failure and they didn’t include him among those who failed to complete the treatment, even though they immediately lost track of him following his discharge and had no idea where he was. So much for clarity and follow-up. MacCullough and Feldman were considered giants in the field, but this is what passed for science in those days, a standard which is apparently very impressive to PW&S.
MacCullough and Feldman weren’t the only ones with odd definitions of success. PW&S cited a 1969 paper by B.H. Fookes in the British Journal of Psychiatry which defined success this way:
In the homosexuals I also required the unrefuted, and where possible, supported claim to have enjoyed heterosexual coitus on more than one occasion.
I can just imagine an Exodus or NARTH-affiliated therapist demanding that kind of evidence today.
Several PW&S sources revealed the dark side the aversion therapy if you were actually able to get your hands on the material and read it. But good luck trying to discover what that dark side might be in the PW&S article alone. For example, PW&S cited a 1964 paper by Dr. J.G. Thorpe and colleagues, but didn’t give it much discussion. But the paper itself revealed that all the subjects in that study were patients at the Banstead Hospital in Sutton, U.K., and their particular form of aversion therapy involved delivering electric shock through the soles of their feet. Not all of the patients were treated for homosexuality. One, for example, was an Irish girl of 21 — In Britain in those days, it was customary to single out the Irish for special mention in cases like this — who was being treated for compulsive over-eating. Her treatment didn’t go very well:
Depression recurred following the eighth treatment session and was accompanied by violent gastric pains. She claimed she could not face any more treatment, preferring drugs. At this point her diagnosis was changed by the psychiatrist in charge from one of “recurrent depression” to one of “hysteria”. Treatment was discontinued.
Another paper by Dr. Thorpe from 1963 gave a much more vivid example of “therapeutic failure in a case of aversion therapy.” Funny how Phelan, Whitehead and Sutton chose not to mention this one, which, again, involved delivering electric shock through the soles of the subject’s feet through specially-designed shoes:
Three conditioning sessions of 15 min each were given over a period of two days, the picture being changed before each new session. For a period of about 30 min following these sessions the patient was extremely disturbed, and wept bitterly, and he doubted whether he could continue with the treatment. He presented himself for the fourth session, entered the treatment room, put on the shoes, but after a few seconds took them off, burst into tears, came out of the room, put on his own shoes (i.e. there was no generalization), and continued to weep bitterly.
That patient discontinued his therapy at that point.
It Gets Worse
As bad as electric shock aversion therapy was, it was mild when compared to another more extreme form of aversion therapy that was also being developed in the same period. This involved the use of emetics like apomorphine, powerful drugs which produces instantaneous and extreme nausea. Emetics were sometimes combined with other drugs to induce diarrhea. The subject was given the drugs and then shown pictures representing a “homosexual stimulus.” The idea behind this was that the patient would associate the “homosexual stimulus” with a gut-retching nausea.
Phelan, Whitehead and Sutton cited a 1969 study by Nathaniel McConaghyin Sydney, Australia, which employed apomorphine therapy. That brutal treatment program was compounded in a later 1972 study by McConaghy and colleagues when they combined apomorphine with electric shock. And if that wasn’t barbaric enough, they added another humiliation: their patients’ penises were connected to plethysmography devices to measure their erections to determine whether the treatment was successful or not. In another 1973 paper published in the British Journal of Psychiatry— which Phelan, Whitehead and Sutton also publicized as a success story — McConaghy summarized how this all worked:
With aversion-relief the patient read aloud a series of phrases descriptive of homosexual activity and immediately received a painful electric shock. Each patient experienced over 1,000 pairings of phrases and shocks during the course of treatment. With apomorphine therapy the patient was shown slides of males he found attractive on 28 occasions, each occasion being associated with nausea produced by apomorphine injections. With avoidance conditioning the patient was presented 420 times with similar slides of males, with the possibility of rejecting the slide and so avoiding a painful electric shock on two-thirds of the presentations; on the remaining occasions the patient could not avoid the shock.
Let’s just pause here and think about what those patients endured: more than 1,000 shocks, 28 sessions with apomorphine, and a guessing game of whether the he would be shocked 420 more times.
McConaghy’s work with aversion therapy was so notorious that his 1970 talk before the American Psychiatric Association was interrupted by outraged gay activists in what was described by Time magazine as a near-riot. Gay activists weren’t the only ones scandalized by this barbaric approach. When McConaghy’s 1972 study appeared in the Archives of Sexual Behavior, it drew a blistering response from sexologist John Money — who himself was no stranger to controversy; his theories on gender identity had very tragic results. In an accompanying article in that same issue, Money wrote:
McConaghy, Proctor, and Barr could have designed an experiment in which they took ordinary men or women and punished them every time they responded erotically to a heterosexual erotic stimulus but not to a homosexual stimulus. There is no special reason to believe that these men and women would have become homosexual. It is rather more likely that they would have become sexually inhibited, anxious, or sexually apathetic.
Money closed his argument with the observation that “[t]herapeutic zeal in the absence of effective therapeutic technique produces charlatanism.” Nearly forty years later, it’s hard to find a more appropriate description for NARTH today.
Interestingly, McConaghy finally admitted in 1977 that “[a]s a therapist who uses behaviour therapy for homosexuality, I do not believe it is possible to alter a homosexual orientation.” He nevertheless defended aversion therapy in a 1981 paper in the journal Behaviour Research and Therapy, in which he treated twenty subjects “to reduce compulsive homosexual urges.” Phelan, Whitehead and Sutton included that study in their paper as well, while omitting McConaghy’s repeated denial of the possibility of altering sexual orientation. PW&S claimed that McConaghy and colleagues did this simply “to evaluate behavior therapy for homosexuals in response to ethical objections of such treatment” — but they omitted naming McConaghy’s continued practice of aversion therapy which drew those very same ethical objections. As I said, Phelan, Whitehead and Sutton were highly selective in what they presented, and you would have to go to the original source documentation to find out what the authors really said.
Those therapies proved to have lasting negative consequences for many who endured them, although researchers and clinicians at the time were loathe to admit it. Phelan, Whitehead and Sutton at one point reassured their readers that one aversion therapy researcher reported that “no harmful effects of aversion treatments were discernible.” But if there were no harmful effects, why is aversion therapy today considered unethical? A 2004 article in the British Medical Journalprovides several answers. They interviewed 29 people who had undergone therapies to change their sexual orientation, along with two relatives of those who underwent therapy. The brother of one participant died in the hospital due to side effects of apomorphine. As for the others:
With the decriminalisation of certain homosexual acts in 1967 and more tolerant social attitudes, most participants were able to explore their sexuality and several found fulfilling, same sex relationships. However, most never spoke to their partners, friends, or families about their treatment. One man was content to remain celibate when treatment failed to change his orientation, asserting that the main enjoyment in his life had been his hobbies. Three other men also avoided sex altogether but unhappily claimed it was the result of treatment. Other participants married in the hope this would complete their cure. Some marriages lasted many years and resulted in children. All except one—which was essentially a sexless marriage—ended in divorce on the grounds of sexual incompatibility.
This BMJ article is not a survey, but a descriptive oral history. It’s hard to draw statistical conclusions about the efficacy of aversion therapy. But it’s worthy to note that all of those marriages would have been counted as successes in the articles of the day. But besides that, the harms are clear.
History is replete with examples of professionals abusing the trust of patients (and sometimes prisoners) in order to carry out appalling experiments. Aversion therapy is one such example. It’s hard to imagine anyone pointing to that sort of legacy as justification for their own misguided policy aims. But that is exactly what NARTH has done. This example is probably the worst aspect of Phelan, Whitehead and Sutton’s work, but that’s not where the problems end. We’ve only examined four pages of their 121-page work. There’s so much more to delve into. And so we will.
To be continued…
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