It is difficult to think of a more contentious issue in today’s culture than the “healing” of homosexuality. To even raise the question already invites dismissal from some segments of society as “homophobic hate speech.” This is especially the case in the field of psychology, which happens to be the profession of the present reviewer. One unfortunate consequence of this cultural climate is the discouragement of true scholarship on the topic of healing homosexuality for those who seek to be free of this condition. Despite negative pressures and professional dangers, a few heroic psychologists have stepped up with the aim of honestly addressing the question of healing homosexuality from both academic and clinical perspectives. These courageous individuals include Mark Yarhouse, Stanton Jones, and Joseph Nicolosi, all of whom have authored recent, important works being reviewed in this essay.
Many readers of Humanum are likely aware of the controversial study by Robert Spitzer published in 2003 in the prestigious journal Archives of Sexual Behavior, addressing the question of whether some homosexual men and women can change their sexual orientation. Spitzer, it should be noted, was instrumental in the removal of homosexuality from the American Psychiatric Association’s Diagnostic and Statistical Manual, Third Edition, in the 1970s. He was moved to conduct his 2003 study because of an experience he had in which he was confronted by protestors who claimed to have left homosexuality and embraced heterosexual identities and lifestyles. Curious of their claims, he decided to study the question of whether change of sexual orientation was possible, so he recruited and interviewed 200 men and women who claimed to have experienced some degree of change from homosexuality to heterosexuality. Based on his investigation, Spitzer found that approximately 66% of males and 44% of females in the study seemed to have achieved some measure of “good heterosexual functioning,” though rates of complete reversal of sexual orientation were considerably lower.
Spitzer’s study was highly publicized, praised, and condemned. After several years of rancorous discourse around his study, Spitzer issued a public statement in 2012 recanting it, stating that it was severely flawed, that he wished he had never published it, and that he believes homosexual people cannot and should not try to change their sexual orientation. To be sure, his study was very weak methodologically; even if it showed enough rigor that theArchives of Sexual Behavior accepted it for publication. Despite Spitzer’s retraction, the findings, whatever their worth, still stand.
Many people are not aware of the fact that Spitzer’s study was not the first – nor the last – study to examine whether or not homosexual people can change. There are many older studies published in the psychological literature reporting therapeutic change from homosexuality toward heterosexuality using a variety of strategies. Most of these are from decades ago, when such research was more acceptable in the field. Similar to Spitzer’s, these earlier studies tended to suffer from severe methodological shortcomings. Despite these various published – though questionable – findings, the American Psychological Association as late as 2005 categorically proclaimed on its website that sexual orientation is not changeable. The APA went on to question the safety of attempts to change, strongly suggesting that attempts to do so are likely harmful to the homosexual person.
Enter Jones and Yarhouse. These evangelical Christian psychologists sought to conduct the first ever prospective, longitudinal study of adults attempting to change their sexual orientation by religious means. Specifically, they designed their study to answer two questions: (1) is homosexuality changeable, and (2) is the attempt to overcome homosexuality inherently harmful? They recruited 98 adults (72 men, 26 women) participating in the umbrella organization Exodus Ministries. All of these individuals were seeking to overcome homosexuality and achieve either chaste continence or healthy heterosexuality. Jones and Yarhouse utilized very rigorous assessment methods to gauge sexual identity, attraction, behavior, fantasy, and the like along with measures of psychological distress and pathology. These measures were utilized at the outset of the study (T1) and were repeated annually throughout the duration of the study (T2, T3, and so on). To date, they have published results regarding these longitudinal assessments 6-7 years (T6) after the start of the study.
While Jones and Yarhouse’s sample size is somewhat small by professional standards and has eroded over time (N=63 at T6), which is typical in longitudinal studies, their study design and rigorous, prospective assessments mean that this is the best attempt to date to study sexual orientation change. They found that over the course of study, on average, their sample experienced statistically significant change on various measures of sexual orientation away from homosexuality and toward heterosexuality. However, the overall magnitude of these changes was modest in size, suggesting more of a shifting along a continuum rather than a categorical change.
In addition to these “on average” findings of diminished homosexuality, Jones and Yarhouse tabulated rates of various outcome categories among their participants. Of their T6 sample 23% demonstrated “Success: Conversion.” These were individuals who established a fairly robust heterosexual identity and lifestyle. Another 30% achieved “Success: Chastity,” meaning that they were no longer acting out nor distressed by homosexual impulses but had not fully achieved a hetersosexual identity and lifestyle. Sixteen percent (16%) had experienced some progress and were “Continuing” to pursue change but had not yet achieved either form of “success.” Another 7% were regarded as “Nonresponse,” meaning that they are continuing to pursue change but had not experienced any progress. Lastly, there were two “Failure” categories: “Failure: Confused” and “Failure: Gay Identity.” The former characterized people who experienced no change of orientation and gave up on the attempt to change but had not embraced a gay identity. This comprised 5% of the T6 participants. The latter (“Failure: Gay Identity”) comprised 20% of the T6 sample and was characterized by individuals who had given up on the attempt to change and embraced a gay identity.
In summary, of the 61 participants who remained in Jones and Yarhouse’s study for the full six years, the sample as a whole showed statistically significant – though modest – change on several measures of sexual orientation away from homosexuality from T1 to T6. Further analysis showed that 53% achieved some version of “Success,” 25% resulted in either kind of “Failure,” with roughly 23% of the sample in between. As Jones and Yarhouse point out, rigorously documenting even one case of intentional sexual orientation change would suffice to refute the APA’s categorical statement that such change is impossible. They clearly have done more than that.
What of the question of psychological harm resulting from the attempt to change? Jones and Yarhouse used several measures of psychological distress at each time point over the six years of the study, including the SCL-90, a widely accepted measure in the field. Over the course of their study, Jones and Yarhouse found no change on most measures of distress, psychopathology, and well-being. In addition to the lack of any psychological deterioration, Jones and Yarhouse detected a statistically significant trend on two scales  of the SCL-90 in the direction of improved psychological health. In other words, on most measures there was no change regarding psychological distress, and on a couple of key indices, this sample seemed to get slightly healthier as a function of the efforts to change their homosexuality over a span of 6-7 years.
Jones and Yarhouse’s findings have received very little attention from the rest of the field of psychology. To be sure, there are limitations to their study, and much more research needs to be done. To their credit, in Ex-Gays? Jones and Yarhouse candidly discuss these limitations and arguments for and against dismissing their findings as well as provide great detail regarding each of the pivotal decisions required of them as they conducted the study. Regardless of whether the rest of the field of psychology takes notice, their achievement is a landmark one that hopefully will spark subsequent and even more rigorous attempts to study the healing of homosexuality.
As important as Jones and Yarhouse’s study is, it gives little insight into what helps those who seek to heal homosexuality. The ministries involved under the Exodus umbrella use a variety of spiritual, educative, and therapeutic methods. As a result, Jones and Yarhouse do not offer any particular guidance inEx-Gays? However, Yarhouse, in his book Homosexuality and the Christian, has offered a number of useful insights and much wise guidance for individuals struggling with homosexuality, their friends, families, spouses, and religious leaders. Yarhouse’s tone is clearly of one who has personally known many such people and developed a deep respect for them. He is pastoral and gentle while at the same time faithfully presenting an up-to-date understanding of the scientific literature.
For instance, on the controversial issue of the sources or causes of homosexuality, Yarhouse reviews the major areas of the literature in a clear and accessible way for the lay reader. He discusses possible genetic factors, prenatal hormones and other biological contributions. He reviews the fraternal birth order effect, which, having been replicated in many studies, shows that on average male homosexuals tend to have more older brothers than male heterosexuals. Yarhouse discusses childhood gender nonconformity and how this has been linked with later homosexual tendencies. He also discusses the issue of childhood sexual experiences. As Yarhouse shows, the research literature has substantiated a large link between childhood sexual abuse and later homosexuality among males, but not all male homosexuals have had such experiences. The situation for females is more mixed. Lastly, he discusses various views on parent-child relationships and family dynamics. While this last topic is perhaps of the most interest to therapists and parents, the research is severely lacking. In the end, Yarhouse explains that we know a few things about the above factors, but the most faithful scientific answer to the question of what causes homosexuality is “we don’t know.”
As frustrating as the lack of hard scientific evidence is in explaining the development of homosexuality, Yarhouse does a wonderful job of pointing out a problem with the question of origins. He illustrates how many people – Christian, secular, or otherwise – tend to fall into the trap of “nothing-but-ism.” In other words, homosexuality is caused by nothing but [fill in the blank]. Yarhouse rejects this kind of thinking as both inaccurate and unhelpful. He chides religious people who get fixated on this question because they think it necessary to show that homosexuality is learned or chosen in order to uphold a moral conviction that the behavior is wrong. Rather, Yarhouse rightly shows that the moral question (e.g., are homosexual acts morally licit?) is distinct from the question of origin (e.g., where do homosexual tendencies come from?). Furthermore, he utilizes a Christian understanding of original sin (“the Fall” in his terms) to explain how people may come into the world with unchosen predispositions to engage in behavior that is contrary to God’s design. He considers homosexuality one such condition, and he shows great compassion for people who carry this burden.
Furthermore, in his discussion of the possibility of change, Yarhouse is very modest in explaining that change is possible for some, but likely not for all. Again, we are limited by our lack of understanding. Basing himself in the best psychological science, including the study by Jones and himself discussed above, Yarhouse concludes that with sustained effort and the right helps, some people can move along a continuum of decreasing their homosexual experience, but very few will fully emerge into a heterosexual identity and lifestyle. In his compassion and realism, Yarhouse seems to want to tell the struggling homosexual Christian that it may be possible to change if you want to try, but you need to accept the real possibility that these attractions may not go away. As a result, the Christian community is called to respond with realism, compassion, and acceptance.
Perhaps Yarhouse’s most helpful contribution is his “three-tier distinction.” Yarhouse distinguishes between three levels of homosexual phenomena: same-sex attraction, homosexual orientation, and gay identity. Same-sex attraction (SSA) is the most basic descriptive level of experience. Many people experience SSA some of the time. When a person consistently experiences SSA as the prominent way of being with others, then we can speak of it as an “orientation,” a persistent pattern of attraction. Yarhouse argues that people do not typically have a choice about what sort of attractions they experience and how those attractions cluster into an overall orientation. While some people can experience change at those levels through therapy or religious activities, many do not. However, Yarhouse argues that when we move from orientation to the level of identity, human freedom becomes much more explicitly involved. Identity is not a given, but is at least partly chosen. It entails a certain social status, values, and lifestyle choices.
Yarhouse seems to want to wake people up to the reality that even though they may experience SSA and/or are stuck with a homosexual orientation, they do not need to center their identity on this. He offers a helpful alternative to the cultural “gay script” that says that these attractions reveal your true self and that in order to be happy, one must identify with them, embrace them and live them out. Rather, Yarhouse suggests that SSA is but one element of a person’s experience, and each person can choose whether or not to center their identity and lifestyle around that experience. Instead of centering their identity on SSA, Yarhouse argues that people can establish their identities on other things such as their gender as a man or a woman, their spousal or familial roles, or their spirituality (e.g., a disciple of Christ). In so doing, such a person can learn to live with unwanted SSA with an attitude of acceptance while still embracing and pursuing more central values, such as their faith in Christ. Yarhouse goes on to apply this framework to numerous situations such as when a child, adolescent, young adult, or even a spouse announces a gay identity. Many will find his guidance extremely helpful.
What of those for whom living with SSA as a persistent feature of their lives is not adequate? After all, the Christian faith teaches that in the beginning it was not so, that man was created for woman and vice versa so that the two can become one flesh. For those individuals who struggle with SSA and desire a deeper level of healing, there exists a scattered network of reparative therapists. The leader of this movement is Joseph Nicolosi, whose writings on the subject have shaped the field and whose recent book Shame and Attachment Loss is the main textbook for the theory and technique of reparative therapy. Nicolosi’s goal is clear: to heal homosexuality and enhance heterosexual potential. While acknowledging that biology may play a role in predisposing certain people for developing SSA, he places greater emphasis on experiential factors, principally in the family of origin. His is the most detailed and nuanced theory regarding the development of male homosexuality. Drawing on attachment research, family systems theory, psychodynamic theory, and interpersonal neurobiology, Nicolosi provides a highly nuanced and plausible account of the development of male homosexuality.
Nicolosi regards homosexuality as a shame-based system. Because of problems in the family of origin – including the relationships with mother, father, and the marital relationship – the young boy experiences his attempts to individuate from his mother to bond with his father and thereby identify with his masculine role as failures. These failures are met with disapproval and disconnection, leaving the boy in a state of shame. Furthermore, he feels that this shame is somehow his fault, that it is a reflection of who he truly is. As a result, he gives up on this important developmental task and instead develops a “false self” such as the “nice little boy” in order to keep some semblance of an attachment to his parents alive.
Reparative therapy derives its name from Nicolosi’s notion of homosexuality as a reparative drive. He theorizes that homosexuality is a maladaptive attempt to make up for the developmental failure described above and finally achieve a secure masculine identity and acceptance in the world of men. It is a striving to finally get it right and is most likely to arise when those early shame states are triggered in the adolescent or adult male’s life. When this occurs, he is likely to feel depressed and worthless. Homosexual behavior then looms large as a shortcut to masculine identity and attachment security, but according to Nicolosi, it fails to deliver. Nicolosi’s approach to therapy involves helping the individual experience and understand the underlying emotional states such as shame that drive his homosexual desires and behavior and gradually help him to see the futility in trying to fill up what was lacking in the family of origin through homosexual means. Rather he needs to stop defending against a deep sadness and despair about what should have been but what was not. In a word, he needs to grieve.
Through emotion-focused therapy, grief work, and resolving childhood traumas, Nicolosi aims to help his male patients more consistently achieve a healthy assertive stance in relating to others and experience truly intimate friendships. In doing so, the true self is restored and the false self abandoned. Gradually, the homosexual compulsion is weakened and a secure masculine identity is strengthened.
Nicolosi’s work is masterful in terms of detail and clarity. He frequently draws on his 20+ years of treating male homosexuals by providing reflections from his patients and extensive transcripts from sessions to illustrate aspects of the theory and the therapy. While there is little published research to support his views or therapeutic strategies – a fact which, in the eyes of the psychological establishment, justifies their marginalization – Nicolosi has done a laudable job of developing the academic and clinical foundations of reparative therapy. They deserve study by any psychologist or other academic or professional motivated to understand how family experiences may contribute to the development of homosexuality, and how psychotherapy may help to resolve it for those who wish to be healed.
 Their book Ex-Gays provides the most detailed account of the study, its conception, the participants, the methodology, and the results through T3. However, subsequent reports provide further results as the study has continued. Jones and Yarhouse’s 2009 paper entitled “Ex Gays? An Extended Longitudinal Study of Attempted Religiously Mediated Change in Sexual Orientation,” given at the Sexual Orientation and Faith Tradition Symposium at the American Psychological Association Convention and available online, reports findings through T6 as does their recently published article “A Longitudinal Study of Attempted Religiously Mediated Sexual Orientation Change,” which appeared in issue 37 of the Journal of Sex & Marital Therapy(pp. 404-27) in 2011.
 These two scales were the GSI (Global Symptom Index – a measure of overall distress) and the PSDI (Positive Symptom Distress Index – a measure of intensity of distress).
 Even though these data do not substantiate psychological harm as the rule for individuals who attempt to heal their homosexuality, it is still possible that some individuals may be harmed by their attempts to do so. Indeed, it is well known in psychology that some patients do not respond positively to psychotherapy, and indeed a small but significant portion tend to experience harm or deterioration due to therapy. Nonetheless, the psychological community has not reacted by universally banning psychotherapy because, when conducted well, it is helpful to the vast majority of people who participate in it. Indeed, Jones and Yarhouse (2011) are careful to point out that despite their findings of improved average psychological functioning among their participants, “We cannot conclude that particular individuals in this study were not harmed by their attempt to change, and those claims may be legitimate, but although it may be that the attempt to change orientation caused harm by its very nature, it may also be that the harm was caused by particular intervention methods that were inept, harsh, punitive, or otherwise ill-conceived, and not from the attempt to change itself. Our findings mitigate against any absolute claim that attempted change is likely to be harmful in and of itself” (Journal of Sex and Marital Therapy, 37, pp. 424-5).