With controversy continuing to swirl around the issue of whether sexual orientation can be changed through psychotherapy, the APA Board of Trustees agreed last month to strengthen and expand APA’s 1998 position statement on so-called "reparative" or conversion therapies. The amended statement is designed to clarify many of the related issues for both the general public and professionals.

The statement reiterates APA’s long-held position that homosexuality is not a mental illness and emphasizes that to classify it as such stems from no scientific evidence but rather "from efforts to discredit growing social acceptance of homosexuality as a normal variant of human sexuality." Moral and political issues have obscured science, the statement cautions.

The amended statement, which was developed by the APA Commission on Psychotherapy by Psychiatrists (COPP), strengthens the Association’s stance that "there are no scientifically rigorous outcome studies to determine either the actual efficacy or harm of ‘reparative’ treatments." What literature does exist on the topic "consists of anecdotal reports of individuals who have claimed to change and then later recanted those claims," the statement notes, and "actively stigmatizes homosexuality."

The 1998 APA statement emphasizes that the risks of undergoing therapies aimed at changing sexual orientation are not inconsequential and can include "depression, anxiety, and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient." These conversion therapies inevitably fail to inform the patient that he or she "might achieve happiness and satisfying interpersonal relationships as a gay man or lesbian," the statement notes.

The revised statement the Board adopted in March adds a warning to therapists against influencing the course of therapy "either coercively or through subtle influence," a situation that has been reported in conjunction with conversion or "reparative" therapies. Because of an absence of evidence of efficacy after 40 years of studies on the topic, the statement recommends that "ethical practitioners refrain from attempts to change individuals’ sexual orientation, keeping in mind the medical dictum to ‘First, do no harm.’ "

"Reparative therapy is the laetrile of the mental health professions, and until there is further legitimate scientific study, which the APA position statement calls for, it should be treated accordingly," commented Jack Drescher, M.D., who helped craft the revised statement. Drescher is the liaison to COPP from the Assembly’s Caucus of Lesbian, Gay, and Bisexual Psychiatrists and president-elect of APA’s New York County District Branch.

The members of COPP thought that a statement from APA on conversion therapies that elaborates on the implications for psychiatry and people grappling with sexual orientation issues would be especially timely, Drescher told Psychiatric News, "in light of the recent campaign by religious conservative organizations to portray homosexuality as something that can be ‘healed,’ which is a religious metaphor for saying it can be ‘cured.’ "

In 1993, in the midst of an upsurge in lawsuits filed by adults who during psychotherapy "recovered" memories of childhood physical or sexual abuse, APA adopted an official position statement on therapies designed to bring these memories to the surface.

In the glare of an intense media spotlight, reports had begun to surface of psychiatrists and mental health professionals using questionable techniques that influenced patients’ recollections of childhood abuse and in some cases even planted the seed of such "memories."

APA responded to the controversy with recommendations for psychiatrists—particularly about the dangers of prejudging the cause of a patient’s symptoms and failing to conduct a comprehensive assessment—and an explication of the scientific evidence on psychiatric treatment of abuse victims and aspects of human memory.

The statement that the Trustees adopted last month to replace the 1993 one provides a "more succinct and focused position statement that emphasizes clinical issues and avoids background information and theoretical overtones," according to a report to the Board from COPP, which reviewed and revised the new statement. Its focus is on specific techniques designed to elicit childhood abuse memories. It does not address cases in which individuals have already recovered abuse memories or in which there is corroboration that the abuse actually occurred.

The new "Position Statement on Memories of Childhood Physical and Sexual Abuse" discusses the appropriate role of psychotherapy where abuse may be an issue and makes four recommendations:

• Regardless of issues of childhood abuse, all patients should receive a complete psychiatric evaluation. Psychiatrists should maintain an empathic, nonjudgmental, neutral stance toward reported memories of sexual abuse. As in the treatment of all patients, care must be taken to avoid prejudging the cause of the patient’s difficulties or the veracity of the patient’s reports. A strong prior belief that physical or sexual abuse or other factors are or are not the cause of the patient’s problems is likely to interfere with appropriate assessment and treatment.

• When no corroborating evidence is available to confirm or refute reports of new memories of childhood abuse, treatment may focus on assisting patients in coming to their own conclusions about the accuracy of their memories or in adapting to uncertainty regarding what actually occurred. The therapeutic goal is to help patients understand the impact of the memories/abuse experiences on their lives and to reduce the impact of these experiences.

• When asked to provide expert opinion involving memories of abuse, psychiatrists should refrain from making public statements about the historical accuracy of individual patients’ reports of new memories based on observations made in psychotherapy.

• Further research and education regarding memory and childhood abuse are required to enhance psychiatrists’ ability, on the basis of empirical evidence, to assist patients struggling with these profoundly difficult issues.