Ego-dystonic sexual orientation
Ego-dystonic sexual orientation is an ego-dystonic mental disorder characterized by having a sexual orientation or an attraction that is at odds with one's idealized self-image, causing anxiety and a desire to change one's orientation or become more comfortable with one's sexual orientation. It describes not innate sexual orientation itself, but a conflict between the sexual orientation one wishes to have and the sexual orientation one actually possesses.
The World Health Organization (WHO) lists ego-dystonic sexual orientation in the ICD-10, as a disorder of sexual development and orientation. The WHO diagnosis covers when gender identity or sexual orientation is clear, yet a patient has another behavioural or psychological disorder which makes that patient want to change it. F66.1 The diagnostic manual notes that a sexual orientation is not a disorder in itself.
Similarly, the American Psychological Association has officially opposed the category of ego-dystonic homosexuality since 1987. In 2007, a task force of the American Psychological Association undertook a thorough review of the existing research on the efficacy of reparative therapy for. Their report noted that there was very little methodologically sound research on sexual orientation change efforts (SOCEs) and that the "results of scientifically valid research indicate that it is unlikely that individuals will be able to reduce same-sex attractions or increase other-sex sexual attractions through SOCE." In addition, the task force found that "there are no methodologically sound studies of recent SOCE that would enable the task force to make a definitive statement about whether or not recent SOCE is safe or harmful and for whom." The diagnostic category of "ego-dystonic homosexuality" was removed from the American Psychiatric Association's DSM in 1987 (with the publication of the DSM-III-R). Sexual disorders are still present in the DSM under the category of "sexual disorder not otherwise specified". One of the disorders under this category is "persistent and marked distress about one’s sexual orientation”, which can be considered similar to what WHO describes as ego-dystonic sexual orientation. The Working Group looking at changes for the ICD-11 (due for implementation in 2018) reports that the classifications in section F66 are not clinically useful and recommends its deletion.
The Medical Council of India uses the WHO classification of ego-dystonic sexual orientation. The Chinese Classification and Diagnostic Criteria of Mental Disorders includes ego-dystonic homosexuality.
When the WHO removed the diagnosis of homosexuality as a mental disorder in ICD-10, it included the diagnosis of ego-dystonic sexual orientation under "Psychological and behavioural disorders associated with sexual development and orientation". The WHO's ICD-10 diagnoses ego-dystonic sexual orientation thus:
The gender identity or sexual preference (heterosexual, homosexual, bisexual, or prepubertal) is not in doubt, but the individual wishes it were different because of associated psychological and behavioural disorders, and may seek treatment in order to change it. (F66.1)
The WHO notes that for codes under F66: "Sexual orientation by itself is not to be regarded as a disorder."
Patients are sometimes still diagnosed as having this problem. This is often a result of unfavorable and intolerant attitudes of the society or a conflict between sexual urges and religious belief systems.
There are many ways a person may go about receiving therapy for ego-dystonic sexual orientation associated with homosexuality. There is no known therapy for other types of ego-dystonic sexual orientations. Therapy can be aimed at changing sexual orientation, sexual behaviour, or helping a client become more comfortable with their sexual orientation and behaviours. Human rights groups have accused some countries of performing these treatments on egosyntonic homosexuals. Treatment may include sexual orientation change efforts or treatment to alleviate the stress. In addition, some people seek non-professional methods, such as religious counselling or attendance in an ex-gay group.
Gay affirmative psychotherapy helps LGB people to examine and accept their sexual orientation and related sexual relationships. Psychologists and the whole of mainstream medical professionals endorse that homosexuality and bisexuality are not indicative of mental illness. For many years, psychiatry viewed homosexuality as a mental illness; this began to change in 1973. Current guidelines instead encourage psychotherapists to assist patients in overcoming the stigma of homosexuality rather than try to change their sexual orientation.
Because some mental health professionals are unfamiliar with the social difficulties of the coming out process, particular to other factors such as age, race, ethnicity, or religious affiliation, they are encouraged by the APA to learn more about how gay, lesbian, and bisexual clients face discrimination in its various forms. Many LGBTQ people are rejected from their own families and form their own familial relationships and support systems that may also be unfamiliar to mental health professionals, who are encouraged to take into account the diversity of extended relationships in lieu of family. In gay affirmative psychotherapy, psychologists are encouraged to recognize how their attitudes and knowledge about homosexual and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated. Psychologists strive to understand the ways in which social stigmatization (i.e., prejudice, discrimination, and violence) poses risks to the mental health and well-being of homosexual and bisexual clients. Psychologists strive to understand how inaccurate or prejudicial views of homosexuality or bisexuality may affect the client's presentation in treatment and the therapeutic process.
For some clients, acting on same-sex attraction may not be a fulfilling solution as it may conflict with their religious beliefs; licensed mental health providers may approach such a situation by neither rejecting nor promoting celibacy. Douglas Haldeman has argued that for individuals who seek therapy because of frustration surrounding "seemingly irreconcilable internal differences" between "their sexual and religious selves... neither a gay-affirmative nor a conversion therapy approach [may be] indicated," and that "[just as] therapists in the religious world [should] refrain from pathologizing their LGB clients... so, too, should gay-affirmative practitioners refrain from overtly or subtly devaluing those who espouse conservative religious identities." Data suggest that clients generally judge therapists who do not respect religiously-based identity outcomes to be unhelpful.
One of the emerging areas of research regarding gay affirmative psychotherapy is related to the process of assisting LGBTQ individuals from religious backgrounds feel comfortable with their sexual and gender orientation. Narrative analyses of clinicians' reports regarding gay affirmative psychotherapy suggest that the majority of conflicts discussed within the therapeutic context by gay men and their relatives from religious backgrounds are related to the interaction between family, self, and religion. Clinicians report that gay men and their families struggle more frequently with the institution, community, and practices of religion rather than directly with God. Chana Etengoff and Colette Daiute report in the Journal of Homosexuality that clinicians most frequently address these tensions by emphasizing the mediational strategies of increasing self-awareness, seeking secular support (e.g., PFLAG), and increasing positive communication between family members.
LGB support groups
Sexual orientation change efforts
A task force commissioned by the APA found that religious identity and how one outwardly identifies one's sexual orientation (see sexual orientation identity) can develop through life. Psychotherapy, support groups, and life events can influence how one identifies privately and publicly. Similarly, self-awareness, and self-conception may evolve during treatment. Some practitioners insist that improvement may be seen in emotional adjustment (self-stigma and shame reduction), and personal beliefs, values and norms (change of religious and moral belief, behaviour and motivation). However, such an approach to treatment is widely regarded as poorly-advised, risky and potentially damaging to the individual.
The American Psychological Association "encourages mental health professionals to avoid misrepresenting the efficacy of sexual orientation change efforts by promoting or promising change in sexual orientation when providing assistance to individuals distressed by their own or others’ sexual orientation and concludes that the benefits reported by participants in sexual orientation change efforts can be gained through approaches that do not attempt to change sexual orientation". The APA reviewed research into the efficacy of efforts to change sexual orientation, and concluded that there was insufficient evidence to show whether these were effective or not. Participants have reported both harm and benefit from such efforts, but no causal relationship has been determined between either the benefit or the harm. According to a recent APA study, participants who reported harm generally reported "anger, anxiety, confusion, depression, grief, guilt, hopelessness, deteriorated relationships with family, loss of social support, loss of faith, poor self-image, social isolation, intimacy difficulties, intrusive imagery, suicidal ideation, self-hatred, and sexual dysfunction. These reports of perceptions of harm are countered by accounts of perceptions of relief, happiness, improved relationships with God, and perceived improvement in mental health status".
No major mental health professional organization has sanctioned efforts to change sexual orientation and virtually all of them have adopted policy statements cautioning the profession and the public about treatments that purport to change sexual orientation.
The APA has roundly dismissed so-called conversion therapy (sometimes called "ex-gay" therapy) as unproductive and potentially harmful.
One version of conversion therapy, Gender Wholeness Therapy was designed by an ex-gay Licensed Professional Counselor, David Matheson. "The emphasis in Mr. Matheson's counselling is on helping men—all his clients are male—develop 'gender wholeness' by addressing emotional issues and building healthy connections with other men. He says he believes that helps reduce homosexual desires. In 2019, Mr. Matheson announced that he intended to divorce his wife of 34 years, and live the remainder of his life as an openly gay man.
Another variation of conversion therapy, "gender-affirmative therapy" has been described by A. Dean Byrd as follows: "The basic premise of gender-affirmative therapy is that social and emotional variables affect gender identity which, in turn, determines sexual orientation. The work of the therapist is to help people understand their gender development. Subsequently, such individuals are able to make choices that are consistent with their value system. The focus of therapy is to help clients fully develop their masculine or feminine identity".
Several organizations have started retreats led by coaches aimed at helping participants diminish same-sex desires. These retreats tend to use a variety of techniques. Journey into Manhood, put on by People Can Change, uses "a wide variety of large-group, small-group and individual exercises, from journaling to visualizations (or guided imagery) to group sharing and intensive emotional-release work." Weekends put on by Adventure in Manhood support "healthy bonding with men, through masculine activity, teamwork, and socialization." Though not specific to gay men, several gay men attended the New Warrior Training Adventure, a weekend put on by ManKind Project, which is a "process of initiation and self-examination that is designed to catalyse the development of a healthy and mature masculine self." Joe Dallas, a prominent ex-gay, leads a monthly five-day men's retreat on sexual purity titled, Every Man's Battle.
Several reparative therapies have been established, including:
- Sexual identity therapy was designed by Warren Throckmorton and Mark Yarhouse, and was endorsed by Robert L. Spitzer, prior to Spitzer's backing away from this belief that he had proven reparative therapy at times successful. Its purpose is to help patients line up their sexual identity with their beliefs and values. Therapy involves four phases: (1) assessment, (2) advanced or expanded informed consent, (3) psychotherapy, and (4) social integration of a valued sexual identity.
- Group psychotherapy uses group sessions led by a single psychologist and focuses on conflict surrounding homosexual expression.
- Context Specific Therapy was designed by Jeffrey Robinson. It does not work with any one theory of homosexuality, but uses several theoretical backgrounds according to the client's need, and is based on phenomenological research. It does not seek to change the client's orientation, but instead focuses on diminishing homosexual thoughts and behaviours. It works within the client's own view of God, noting that "individuals who are successful at overcoming homosexual problems are motivated by strong religious values".
- MAP Therapy is designed for both the individual with ego-dystonic sexual orientation and their family members. There are four main paths that clients may choose to take: (1) they can affirm an LGB identity, (2) they can foster a lifestyle of celibacy, (3) they can work on developing heterosexual attractions, or (4) they can explore their options.
For some ex-gay groups, choosing not to act on one's same-sex desires counts as a success whereas conversion therapists tend to understand success in terms of reducing or eliminating those desires. For example, some ex-gays in mixed-orientation marriages acknowledge that their sexual attractions remain primarily homosexual, but seek to make their marriages work regardless. Ex-gay advocates sometimes compare adopting the label "ex-gay" to the coming out process. Some conservative Christian political and social lobbying groups such as Focus on the Family, the Family Research Council, and the American Family Association actively promote to their constituencies the accounts of change of both conversion therapies and ex-gay groups.
Some ex-gay organizations follow the tenets of a specific religion, while others try to encompass a more general spirituality. Although most ex-gay organizations were started by American evangelical Christians, there are now ex-gay organizations in other parts of the world and for Catholics, Mormons, Jews and Muslims. According to Douglas Haldeman, "This modality is thought to be one of the most common for individuals seeking to change their sexual orientation." Ex-gay ministries typically are staffed by volunteer counselors, unlike reorientation counselling, which is conducted by licensed clinicians.
Ex-gay groups use several different techniques. Love in Action hosts workshops on "child development, gender roles, and personal sexuality," one-on-one Biblical guidance, "a structured environment help[ing] establish new routines and healthy patterns of behaviour", "challenging written assignments and interactive projects," "family involvement to improve communication... and to facilitate marital reconciliation," and "hiking, camping, canoeing, and rafting." Exodus International considers reparative therapy to be a useful tool, but not a necessary one. Evergreen International did not advocate or discourage particular therapies and states that "therapy will likely not be a cure in the sense of erasing all homosexual feelings."
Robert L. Spitzer reported in 2003 that individuals who reported experiencing a change in sexual orientation had felt depressed or even suicidal prior to treatment "precisely because they had previously thought there was no hope for them, and they had been told by many mental health professionals that there was no hope for them, they had to just learn to live with their homosexual feelings." Spitzer's study, however, is widely considered disreputable in the therapeutic and mental-health community. The American Psychiatric Association enumerated many flaws in Spitzer's methods and analysis, and an American Psychological Association task force likewise scrutinized Spitzer's work and found it seriously flawed. The degree to which Spitzer's claims were treated as authoritative by news media has been examined and found problematic. Ultimately, Spitzer himself came to realize that his study had serious flaws, and rescinded the claims that he had made.
The APA has specifically advised against sexual orientation change efforts and encourages practitioners to aid those who seek sexual orientation change by utilizing affirmative multiculturally competent therapy that recognizes the negative impact of social stigma on sexual minorities and balances ethical principles of beneficence and nonmaleficence, justice, and respect for people's rights and dignity. If a client wants to change their sexual orientation, the therapist should help the client come to their own decisions by evaluating the reasons behind the patient's goals.
Relationship to religion
The terms egodystonic and egosyntonic are used within the Roman Catholic Church in that, according to gay-rights advocate Bernard Lynch, priests who are gay but egodystonic, that is "hate their homosexuality", are acceptable, whereas egosyntonic candidates for the priesthood, those who accept their own sexuality, cannot be considered.
Some churches publish specific instructions to clergy on how to minister to LGBTQ people. These include Ministry to Persons with a Homosexual Inclination, produced by the Catholic Church, and God Loveth His Children, produced by The Church of Jesus Christ of Latter-day Saints. In 1994, a church in the Presbyterian Church (USA) held a conference entitled “The Path to Freedom: Exploring healing for the Homosexual.” The APA encourages religious leaders to recognize that it is outside their role to adjudicate empirical scientific issues in psychology.
Mental health practitioners can incorporate religion into therapy by "integrating aspects of the psychology of religion into their work, including by obtaining a thorough assessment of clients’ spiritual and religious beliefs, religious identity and motivations, and spiritual functioning; improving positive religious coping; and exploring the intersection of religious and sexual orientation identities." Researchers have found that for some clients who have 'identity conflicts' these can be reduced by reading religious texts that increase self-authority and allow them to reduce their focus on negative messages about homosexuality. Researchers also found that such clients made further progress if they came to believe that regardless of their sexual orientation, their God still loves and accepts them.
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- Homosexuality and psychology
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- Internalized homophobia
- Minority stress
- Sexual maturation disorder
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