Transpositive Counseling Is

Humanistic,
Person centered,
Self-actualizing client expert on themselves,
Journey-guide counselor  holding lantern high…illuminating client’s path.

Non-judgmental,
Non-labeling,
Non-pathologizing,
Social advocating,
Hormone advising,
Life skills training,
Clothing/appearance/identity consulting,
Movement from empathic listening to steps-in-process and back.

Family systems,
Culturally competent,
Feminist,
Narrative post-modern challenge of the oppressive dominant script.

Warm hugs.

Laura Acevedo, 2006

My Thoughts on Counseling

My interest in the helping professions began years ago when I embarked on a course of self-reflection motivated by dissatisfaction with the direction of my career.  Like many individuals, I found myself doing work that presented itself to me, rather than following a vocation that I had selected based on my values and aptitude.  I discovered that I wanted and needed to be working in a profession that was more humanistic, nurturing, and caring. 

Meanwhile, my psyche was undergoing other changes as well.  Continued self-reflection led me to the conclusion that I needed to change more than just my vocation.  My dissatisfaction was deeper.  I needed to change my gender.  That topic is a whole other story, so I will only recount the aspect of this transformation that resulted in my becoming a counselor.  

There is a set of guidelines for those who wish to transform their bodies from one sex to the other, and for the medical professionals who facilitate this change.  These guidelines are known as the Harry Benjamin Standards of Care.  Within these standards are very specific requirements for psychological assessment and counseling. 

In addition, gender variance in our society brings with it a host of mental health challenges.  Transgender individuals are often rejected by their nuclear families, divorced from their spouses, and ostracized by their friends.  Many suffer tremendous losses in the process of gaining themselves.  Employment opportunities may be curtailed, and housing may be denied.  Higher than average rates of depression, suicide, substance abuse, and prostitution are problems.  There is a very real need for good psychological counselors who are willing and able to serve the transgender
community.

Unfortunately, there is a dearth of qualified mental health professionals who really understand, and can provide competent services to, transgender individuals.  This lack is a complaint that I heard from many in the community, and something that I experienced first hand.  I decided to become a part of the solution to this problem.

As far as my professional values go,  I am drawn to the work of Carl Rogers and person-centered counseling, and Abraham Maslow’s concept of striving for self-actualization.   I embrace the social/cultural critiques of Post-modernists, especially the feminist analysis of the role of gender in our society and the subsequent effect on individuals, and I incorporate Narrative Therapy in my practice.  My approach is that of the client-as-expert on her/himself, and I see my role more as a collaborator working with my clients to help them find and use their own inner resources rather than the authoritarian counselor-as-expert model.

With that thought in mind, I would say that I prefer to work with clients who are motivated to grow and change.  My primary goal is to provide services to those who are struggling with issues of gender identity and sexual orientation, but  I enjoy working with clients from all backgrounds and orientations who are experiencing issues regarding social marginalization and life transitions.  This is because my own status as a minority member and my personal transformational experience have given me insight and knowledge about, and empathy for, others experiencing the same.

I see my practice as an extension of my personal growth into an individual with an ability to listen and hear others as objectively as possible, with empathy and compassion, as I guide clients on their own paths of growth.  I also believe that I have much to learn from my clients, and I am open to the wisdom of lived experience that each client brings to the session.

       Laura Acevedo, 2006

 Narrative Therapy as an Effective Modality for Couples of Gender Identity Minority Status

Laura Acevedo, 2004

   Narrative Couples Therapy is a post-modern treatment method that is particularly well suited for couples in which one or both of the partners identifies as transgender.  In this paper I shall define transgender as a social construct, explore the unique issues that this construct creates for couples in our culture, advocate for the use of narrative therapy as a deconstructive method for dealing with those unique issues and explain why specific narrative techniques are particularly appropriate for issues of gender identity.

       Transgender, and indeed the concept of personal gender, are constructs created by social scientists and the medical community within the last century.  The modern study of what might be called transgenderism began with Magnus Hirschfeld (1868-1935) and the 1910 publication of his book, The Transvestites: An Investigation of the Erotic Desire to Cross Dress (Bullough, 2000). He argued that although the two sexes had usually been regarded as dimorphic, this was much too simplistic since there were many varieties of intermediates.  This was extremely progressive thinking
for the time, and is still not embraced by most in our culture. Hirschfeld developed a model of gender dissonance. He did not see it as separate from sexuality, believing there was a continuum of sexuality, and that transvestism and transsexualism (terms he coined in 1910 and 1923 respectively) were at the extreme end of this continuum, beyond homosexuality (Vanderburgh, 2000).  I concur with Hirschfeld’s construct of a sexuality continuum, however I conceptualize gender identity and sexual orientation as two separate but related continuums.  

       Another pioneer in investigating the topic was Havelock Ellis, who in his first paper on the subject published in 1913, used the term 'sexo-aesthetic inversion' instead of Hirschfeld's word 'transvestism' (Ellis, 1913).

       While Hirschfeld and Ellis were interested in gender variance from a philosophical perspective, those who wrote about the phenomenon after them were for many years dominated by psychotherapists of one kind or another whose mission was to find "cures" or "treatment" for those with gender dysphoria (Bullogh, 2000), which became a diagnosable disorder in the DSM.

       The major challenge to the psychiatric domination came from a new generation of social and behavioral scientists who challenged the dominance of the medical community as experts in sexology, and in the process, challenged the medicalization of much of sexual behavior. The key to the challenge was the development of the concept of gender (Bullogh, 2000). Gender is an old term that has been widely used in linguistic discourse to designate whether nouns are masculine, feminine, or neuter. It was, however, not normally used either in the language of social sciences or sexology until John Money adopted the term in 1955 to serve as an umbrella concept to distinguish femininity, or womanliness, and masculinity, or manliness, from biological sex (male or female)(Money, (1955).

       This opened the door for a new discourse about the personal expressions of gender.  By 1960, individuals such as Virginia Prince began developing social structures that challenged the dimorphic view of gender (Bullogh, 2000).  Her social group gave the members permission to identify as something other than the medically approved dimorphic male, female or transsexual.  The terms transsexual and transvestite were redefined by Harry Benjamin in 1964 to describe persons suffering from gender dysphoria (transsexuals) as different from persons who dressed in
cross-gender clothing without issues of gender identity (transvestites).

       The term transgender was coined in the late 1980s by men who did not find the label transvestite adequate enough to describe their desire to live as women (Prosser, 1997) yet felt  the term transsexual was deemed inappropriate because many nontraditionally gender-identified persons did not necessarily want to reconfigure their bodies surgically and hormonally and did not share the desire to "pass," or to fit into normative gender categories of male and female.

       Rather than a simple 'opposite sex' identity (most typical of Transsexual individuals), transgender individuals may have non-traditional and complex experiences of gender (Rachlink, 2002). It may be more appropriate to view these complex experiences as a continuum under the umbrella term of transgender.  Raj (2002) has compiled categories for various expressions on this continuum. These specific subpopulations include: transsexuals (TSs), transgenderists, transgendered people (TGs), androgynes, crossdressers, bigendered, 'two-spirit', intersexed and gender-variant (GV) individuals. Vanderburgh (2002) includes genderqueers, drag queens and drag kings. In Hawaii there are Mahu, Thailand has Katoey and in India the Hijra.

   It is important to note that some individuals who do not fit dimorphic gender identities prefer not to be labeled in any way.  It is also important to note that the partners of transgender individuals experience gender very differently than their gender-variant loved ones. Vanderburgh states that: "The trans person grows up with an awareness of gender, and of "difference," that is not the experience of their non-trans partner. The trans person can imagine changing gender roles and bodily sex, because they grow up with the perception of having been that "square peg in the round hole." To the non-trans partner, however, unaware of the pigeonhole, the concept of changing genders is unimaginable, in a very literal sense. The partner cannot imagine changing what they have grown up seeing as a fixed part of reality." (Vanderburgh, 2002)

       Being transgender is not in itself pathological or indicative of a need for psychiatric treatment. However, transgender individuals (and their partners) do experience a number of unique stressors and are no different from the rest of the population in their potential to experience emotional problems and other concerns which may lead them to seek psychotherapy (Rachlin, 2002). St.Claire (2002) posits that psychological distress in the transgender person is caused by psychological suppression of gender identity expression motivated by fear of social subjugation. She also cites social subjugation of the transgender person by individuals and institutions. She asserts that social subjugation of persons transgressing gender expression norms often leads to conflict between the instinctive desire to express one's gender identity and the desire to avoid the pain of social subjugation.  Vanderburgh (2000) suggests that this distress may result in isolation, paranoia, difficulty with intimacy, low self-esteem, substance
abuse as a form of self-medication, history of suicide attempts, estrangement from family, rejection of spirituality and religion (conservative religions vilify transsexuals, equating them with equally-vilified homosexuals), depression, hopelessness and PTSD (for those who were physically or sexually punished for not acting enough like boys or girls).

       Partners of transgender individuals may suffer unique stressors as well. Non-trans partners may face the perceived loss of a lover, and the accompanying grief, especially if they have been in the relationship for some time and the gender transition began after they met.  Imagine if your husband/wife or boyfriend/girlfriend changed so radically that you no longer felt a sense of sexual attraction.  It would be as if he or she had died, and someone else was now in their place.  What does that mean for the relationship? What about your sexual orientation? Vanderburgh explains:

       "The ramifications of changing sexual orientation are profound for the partner. One obvious consideration is homophobia. However, it's too easy to say of a heterosexual woman, "She’s against her husband transitioning because she's homophobic and afraid people will see her as a lesbian." If a heterosexual woman has qualms about being identified as a lesbian, one must take into account the legitimate question of whether or not her discomfort is justified. If she truly feels heterosexual and not lesbian or bisexual, why should anyone expect her to be joyful about her husband’s transition to female?" (Vanderburgh, 2002)

       What is needed is a therapeutic environment that addresses the unique circumstances of couples with a trans identified partner. Transpositive (i.e., gender-affirming) therapeutic support, as described by Raj (2002) speaks to the client's real-life, everyday needs (whether gender-related or not), in alignment with the client's stated goals, helps clients to consolidate their gender and sexual identities as transwomen and transmen, and enhances self-confidence. He believes that supportive therapeutic interventions which aim to affirm, rather than disaffirm, individual choices around self gender-identification are, by definition, transpositive, and as such, are urged as the treatment of choice over that of non-transpositive interventions (such as 'reparative' and 'conversion' therapies).  Vanderburgh (2000) believes that the clients know best and will make the best decision for themselves with the information available to them at the time. He states that the therapist’s job is to help clients uncover and bring to consciousness as much self-information as possible. Underlying this model is the belief that gender dissonance is not a psychological disorder to begin with, but an issue of core identity. Bocting (1997) asserts that treatment issues no longer center on assisting "gender dysphoric" persons in their adjustment to their new gender but include the possibility of affirming a unique transgender identity (Bockting, 1997). In this paradigm shift, the focus is not on transforming transgendered clients but rather transforming the cultural context in which they live. Bockting (1997) advocates that counselors assume a client-centered approach. Given the societal discrimination that transgendered persons must continually confront, the issue of trust is paramount when working with such clients. For this reason, constructivist therapy approaches are particularly helpful in working with transgendered clients. Laird (1999) advocates that practitioners assume a narrative stance in which clients fully tell their own stories unburdened by the prior assumptions of the therapist about gender and sexuality. She believes that counselors need to create an atmosphere in which the larger cultural narratives concerning heterosexism and gender are deconstructed. Laird recommends adopting an "informed not knowing" stance (Shapiro, 1996) in which the counselor leaves "behind her own cultural biases and pre-understandings, to enter the experience of the other" (Laird, 1999, p. 75). (Carrol, Gilroy & Ryan, 2002)

       My personal experience with couple therapy confirms these views.  I also believe that it is critical for a couple to learn how to bear witness to one another, to see and feel to the greatest extent possible the struggle of transition from the other's perspective.  I believe that couples facing the issues of gender transition in our culture need a therapeutic model that is client driven, that deconstructs the dominant transphobic cultural narrative about gender and affirms rather than marginalizes persons of minority status. What is needed is a method that allows for each partner to express their complex and multiple stories so that they may create unique identities and that encourages these stories to be witnessed by one another.  Narrative Couple Therapy is just such a model.

       Narrative Couple Therapy is a modality that developed in response to new ways of thinking about peoples’ problems.  In contrast to the “essentialist” view that dominated psychotherapy for decades, Narrative therapists suggest that we “construct” our realities through the stories that we hear and tell about ourselves (White, 2002).

       Narrative therapists have developed several techniques to implement this paradigm in a clinical setting.  These include telling and witnessing (Freedman & Coombs), externalizing (Carey & Russel, 2002) (White & Epston, 1990), “unpacking” negative identity conclusions (White 2001),  questioning “thin” descriptions to encourage “rich” descriptions (Morgan, 2000) (White, 2001) and reflecting (White, 1995).

     Telling one’s story of self and having one’s partner hear it is the cornerstone technique of Narrative Couple Therapy.  Freedman & Coombs describe telling and witnessing as they practice it in their clinical work: "A rhythmic alternation between telling and witnessing characterizes narrative work.  We set up a structure early in our work with couples that we come back to over and over again.  We ask one member of the couple to tell his/her story while the other listens from a witnessing position.  Then we ask the witnesser to reflect on what he/she has heard.  Next we switch
positions, so that the partner who had been in the witnessing position can tell his /her story." (Freedman & Coombs, 2002)

       I believe that telling and witnessing is a vital step for couples dealing with gender transition.  Even partners who think they know one another well may not be aware of the other’s gender identity story.  As Vanderburgh (2000) has pointed out, trans and non-trans partners have very different life experiences and self concepts of gender.  This could be a source of couple discord that could be addressed by telling and witnessing.Once the pattern of telling and witnessing is established, Narrative therapists encourage clients to view themselves in alternative ways.  Carey &
Russel describe externalizing:

       "One of the key contributions of narrative therapy is the determination not to locate problems as internal to people, but instead to externalise problems and to understand that the ways in which problems are constructed and experienced are related to matters of culture and history (see Carey & Russell 2002; Epston & White 1990). Externalising conversations involve the identification of problems (separate from persons), locating the problem in history and in a storyline, and tracing the effects of the problem on the person’s life and relationships. Once a problem has been
externalised in this way it then becomes possible to identify unique outcomes (times and ways in which a person has resisted the influence of the problem) that can gradually be woven into alternative story-lines." (Carey & Russel, 2002)

       Externalizing helps the couple take the burden of discord off of one or both of them as persons and provides the opportunity to view the discord as a project that they can work on together.  Instead of blaming the trans partner for causing the problem, or blaming the non-trans partner for not being accepting enough, the problem can be externalized and named.  Then the couple can be encouraged to recognize how much of their discord is a result of the conflict between the trans partner’s identity and the cultural norms that they both have internalized (Carrol, Gilroy & Ryan,
2002).        

       This is what White (2002) has called unpacking negative identity conclusions.  He explains this unpacking as follows: "Often when describing and demonstrating the utility of externalising conversations, I have illustrated the extent to which these conversations can contribute to the unpacking of people’s negative identity conclusions – which I often refer to as thin conclusions (after Geertz’s thin description [1973]). In fact, I believe that one of the primary achievements of externalising conversations is this unpacking of the thin conclusions that people have about their
own and about each other’s identity. In this activity, these conclusions are deprived of the truth status that has been assigned to them – these conclusions cease to carry the authority that they did." (White, 2002)

       What are these thin descriptions in terms of Narrative Couple Therapy? Morgan and White describe thin description as follows: "Thin description allows little space for the complexities and contradictions of life. It allows little space for people to articulate their own particular meanings of their actions and the context within which they occurred.  Often, thin descriptions of people’s actions/identities are created by others – those with the power of definition in particular circumstances (e.g. parents and teachers in the lives of children, health professionals in the lives of those who
consult them). But sometimes people come to understand their own actions through thin descriptions. In whatever context thin descriptions are created, they often have significant consequences." (Morgan, 2000)  "Thin description often leads to thin conclusions about people’s identities, and these have many negative effects.  Thin conclusions are often expressed as a truth about the person who is struggling with the problem and their identity. The person with the problem may be understood to be ‘bad’, ‘hopeless’, or ‘a troublemaker’. These thin conclusions, drawn from problem-
saturated stories, disempower people as they are regularly based in terms of weaknesses, disabilities, dysfunctions or inadequacies." (White, 2002)

       I believe that the traditional medical/psychotherapeutic diagnosis of dimorphic gender dysphoria is a thin description of gender identity that leads to the thin conclusion that gender variant individuals are pathological.  This dominant narrative ignores the rich variety of gender expression that Raj (2002) and Vanderburgh (2002) have identified.  Unpacking the dominant narrative can help the couple develop a richer description of gender identity, which would depathologize the trans identified partner and allow both partners to understand more clearly their unique attributes.  
Carey and Russel describe rich description in their practice: "As narrative therapists, we believe that it is the rich description of the alternative stories of people’s lives that provides people with more options for action and therefore enables significant changes to occur. Life is not only about problems and difficulties, or for that matter ‘strengths’. It is also about hopes, dreams, passions, principles, achievements, skills, abilities and more. All of these aspects of our lives are up for exploration and rich description!" (Carey & Russel, 2002)

       Once a narrative pattern has been established and unique alternative stories are being developed, Narrative Couple therapists may choose to employ the technique of reflecting.  Reflecting can be done by the witnessing partner, the therapist or a reflecting team of outsiders brought in specifically for that purpose.  White (1995) describes the dynamics of reflecting in the context of a team using Barbara Myerhoff’s (1986) concept of definitional ceremony: "To the extent that the reflecting teamwork that I am describing here establishes ‘conditions that conspire’ to engage people
as ‘active participants in their own history’ and in ‘making themselves up’, I believe that Barbara Myerhoff’s ‘definitional ceremony’ provides a particularly appropriate metaphor for this work, and serves to clarify some of the processes involved in it." (White, 1995)

       Witnessing and reflecting definitional ceremonies deal with the problems of invisibility and marginality; they are strategies that provide opportunities for being seen and in one’s own terms, garnering witnesses to one’s worth, vitality and being. (Myerhoff 1986, p.267) Myerhoff calls attention to the critical role that the ‘outsider-witness’ plays in these definitional ceremonies. These outsider witnesses are essential to the processes of the acknowledgement and the authentication of people’s claims about their histories and about their identities, and to the performance of these claims. The participation of the outsider-witnesses in definitional ceremonies gives ‘greater public and factual’ character to these claims, serving to amplify them and to authorise them. The outsider-witness also contributes to a context for reflexive self-consciousness - in which people become more conscious of themselves as they see themselves, and more conscious of their participation in the production of their productions of their lives. The achievement of this reflexive self-consciousness is not insignificant - it establishes a knowing that ‘knowing is a component of their conduct’, making it possible for people to ‘assume responsibility for inventing themselves and yet maintain their sense of authenticity and integrity’, for people to become aware of options for intervening in the shaping of their lives. (White, 1995)

       In her book What is Narrative Therapy? Alice Morgan summarizes the overall approach: "Narrative therapy seeks to be a respectful, non-blaming approach to counselling and community work, which centres people as the experts in their own lives. It views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments and abilities that will assist them to change their relationship with problems in their lives. Curiosity and a willingness to ask questions to which we genuinely don’t know the answers are important principles of this work. There are many possible directions that any conversation can take (there is no single correct direction). The person consulting the therapist plays a significant part in determining the directions that are taken." (Morgan, 2000)

       Further evidence of the appropriateness of Narrative Therapy for members of gender and sexual minority groups can be found in this announcement posted on the Dulwich Centre  Website, May 13, 2002: "We were recently contacted by someone in North America who informed us of the possibility that one or more therapy practitioners may be using narrative therapy techniques with the aim of ‘converting’ gay and lesbian
people to heterosexual lives. While there’s been no confirmation of this, the possibility of this occurring has greatly saddened us. There is a long history within the psychological and therapeutic fields of marginalising lesbian, gay, bisexual and transgender people. A part of this history of marginalisation has been, and continues to be, the use of ‘therapeutic approaches’ to attempt to ‘cure’, ‘treat’ or ‘convert’ homosexual desire. Dulwich Centre would like to publicly express that we are deeply troubled by any use of narrative therapy that constructs homosexual desire as in
anyway less acceptable than heterosexual desire. We celebrate lesbian, gay, bisexual and transgender choices and lifestyles." (Dulwich Centre, 2002)

       Given the above, I would recommend Narrative Couple Therapy for couples struggling with issues of gender identity.  This modality allows couples to deconstruct the social construct of gender that is so problematic for those who don’t conform, so that they may address issues of social subjugation.  It does not apply a medical model to gender variance, but rather depathologizes “variant” persons.  Non-trans partner’s concerns such as issues of sexual orientation and loss of attraction can be voiced, reflected on and honored.  It is more than nonjudgmental, it is affirming of
clients' minority stories and expressions.  It can help clients consolidate their gender and sexual identities through the unpacking of negative self identities and the construction of affirming identities.  It is antithetical to “reparative” or “conversion” therapies which aim to “cure” the “perversion” and have been shown to cause harm (Ford, 2001). That is why I incorporate Narrative Couple Therapy into my clinical work.

References

Benjamin, Harry (1964). "Trans-sexualism and Transvestism," in Transvestism: Men in Female Dress, ed. David Cauldwell New York: Sexology Corporation
Bockting, W 0. (1997). Transgender coming out: Implications for the Clinical Management Of Gender Dysphoria. In B. Bullough, V. L. Bullough, & J.Elias (Eds.), Gender Blending (pp. 48-52). Amherst, NY: Prometheus Books.
Bullogh, V.L. (2000).  Transgenderism and the Concept of Gender  International Journal of Transgenderism, Volume 4 Number 3, July - September 2000
Carey & Russel, (2002). Externalising – Commonly Asked Questions. International Journal of Narrative Therapy and Community Work, 2002 No.2
Carrol, L., Gilroy, P & Ryan, J. (2002). Counseling Transgendered, Transsexual, and Gender-Variant. Journal of Counseling and Development. Alexandria: Spring 2002. Vol. 80,
Ellis, H. (1913). "Sexo-Aesthetic Inversion," Alienist and Neurologist, 34, part 1 (May), 3-14; part 2 (August), 1-31.
Freedman, J. & Coombs, C., (2002). Narrative Couple Therapy in Gurman, A & Jacobson, N., eds. Clinical Handbook of Couple Therapy, Third Edition, New York: Guilford Press
Ford, (2001). Healing Homosexuals: A Psychologist’s Journey through the Ex-Gay Movement and the Pseudo-Science of Reparative Therapy, Journal of Gay & Lesbian Psychotherapy Vol. 5 No. 3 / 4, 2001, pp 69-86 The Haworth Press, Inc.
Geertz, C. (1973). ‘Thick Description: Toward an Interpretive Theory of Culture.’ In Geertz, C., The Interpretation of Cultures. New York: Basic Books.
Hirschfeld, M. (1991). The Transvestites: An Investigation of the Erotic Drive to Cross Dress.[Die Transvestiten]. Translated by Michael Lombardi-Nash. Buffalo:
Prometheus Books. [Originally Leipzig: Spohr, 1910]
Laird, J. (1999). Gender and sexuality in lesbian relationships: Feminist and constructionist perspectives. In J. Laird (Ed.), Lesbians and lesbian families: Reflections on theory and practice (pp. 47-89). New York: Columbia University Press.  
Myerhoff, B. (1986). ‘Life not death in Venice: Its second life.’ In Turner, V. & Bruner, E. (eds), The Anthropology of  Experience. Chicago: University of Illinois Press.)
Money, J. (1955). "Linguistic Resources and Psychodynamic Theory." British Jounal of Medical Psychology 28, 264-6.)
Morgan, A. (2000). What Is Narrative Therapy? Adelaide: Dulwich Centre Publications
Prosser,J. (1997). Transgender. In A.  Medhurst & S. R. Munt (Eds.), Lesbian And  Gay Studies. A Critical Introduction (pp. 309-326). Hemdon, VA
Rachlin K, (2002). Transgender Individuals' Experiences of Psychotherapy. International Journal of Transgenderism 6,1
Raj (2002) Towards a Transpositive Therapeutic Model: Developing Clinical Sensitivity and Cultural Competence in the Effective Support of Transsexual and Transgendered Clients [On-Line], Available:  http://www.symposion.com/ijt/ijtvo06no02_04.htm
Shapiro, V (1996). Subjugated knowledge and the working alliance: The narratives of Russian Jewish immigrants. In Session: Psychotherapy in Practice 1, 9-22.
St.Claire, R. (2000) How Being a Transgender Person Causes Stress [On Line], Available:  http://www.transgendersoul.com
Vanderburgh, R. (2000) Gender Dissonance: A New Paradigm (Masters Thesis) [On Line], Available: http://www.transtherapist.com/writings/thesis.html
Vanderburgh, R. (2002) For Partners Only [On Line], Available: http://www.transtherapist.com/writings/forpartnersonly.html
White, M. (1995). Reflecting Teamwork as Definitional Ceremony by Michael White, Chapter 7 from: White, M. 1995:  Re-Authoring Lives: Interviews and Essays. Adelaide: Dulwich Centre Publications
White, M. (2000). ‘Reflecting-Team Work As Definitional Ceremony Revisited.’ In White, M.: Reflections on Narrative Practice: Essays and Interviews Adelaide: Dulwich Centre Publications
White, M. (2001). ‘The Narrative Metaphor In Family Therapy.’ An Interview In Denborough, D. (ed): Family Therapy: Exploring The Field’s Past, Present & Possible Futures. Adelaide: Dulwich Centre Publications
White, M. (2001). Narrative practice and the unpacking of identity conclusions  
Gecko: A journal of deconstruction and narrative practice 2001 #1. Adelaide: Dulwich Centre Publications
White, M. & Epston, D. (1990): Narrative Means to Therapeutic Ends. New York: W.W.Norton.

Is “Reparative” Therapy Ethical?

by Laura Acevedo

December 2, 2005

Introduction
       When a client’s same-sex attraction does not agree with his or her religious convictions, counselors face an ethical dilemma.  Douglas Haldeman states the problem succinctly: "The major mainstream mental health organizations have all issued policy statements affirming that homosexuality is not a mental disorder and disavowing treatments based upon this premise. Diversity in religious expression is also supported by organized mental health. So what of the individual whose religious beliefs are at odds with an LGBT orientation? Should practitioners always view
such individuals as having simply internalized homophobic doctrine and therefore limit access to the treatment that may facilitate an adaptation to a more ego-syntonic style of living on the basis of religious beliefs? How are the rights to treatment of such individuals supported without negating the gay-affirmative stance of organized mental health and endorsing homophobic treatments?" (Haldeman, 2002, p260)
       
       Advocates of “reparative” therapy believe they have the answer.  According to Spitzer (2003), “..."reparative” or “conversion” (the terms are used interchangeably) therapists believe that same-sex attractions reflect a developmental disorder and can be significantly diminished through development of stronger and more confident gender identification. “Reparative” therapists say that their gay male patients (who comprise the majority of their caseload) suffer from a lifelong feeling of “being on the outside” of male activities and “not feeling like one of the guys.”  When therapy succeeds in demystifying males and maleness, they claim, romantic and erotic attractions to men diminish and opposite-sex attractions may gradually develop.  

Background
       Medical, psychotherapeutic, and religious practitioners have long sought to reverse unwanted homosexual orientation through various methods, including electric shock, nausea-inducing drugs, psychoanalytic therapy, prayer and spiritual interventions, hormone therapy, surgery, masturbatory reconditioning, rest, visits to prostitutes, and bicycle riding (Murphy, 1992). Early attempts to reverse sexual orientation were founded on the unquestioned assumption that homosexuality is an unwanted, unhealthy condition  (Socarides, 1978).

       Behavioral programs designed to reverse homosexual orientation were based on the premise that homoerotic impulses arise from faulty learning (Haldeman, 1994). These “therapies” sought to countercondition the “learned” homoerotic response with aversive stimuli, replacing it with the reinforced, desired heteroerotic response. The aversive stimulus, typically consisting of electric shock or convulsion- or nausea-inducing drugs, was administered during presentation of same-sex erotic visual material. The cessation of the aversive stimulus was accompanied by the
presentation of heteroerotic visual material, supposedly to replace homoeroticism in the sexual response hierarchy.

       The psychoanalytic approach has been that homosexual orientation represents an arrest in normal psychosexual development, most often in the context of a particular dysfunctional family constellation (Bieber, I., Dain, Dince, Drellich, Grand, Gundlach, Kremer, Rifkin, Wilbur, & Bieber, T., 1962). According to this view, such a family featured a close-binding mother and an absent or distant father. Despite the relative renown of this theory, it is based solely on clinical speculation and has not been empirically validated (Haldeman, 1994).

       Psychoanalytic treatment of homosexuality has been exemplified by the work of Bieber, who advocates intensive, long-term therapy aimed at resolving the unconscious anxiety stemming from childhood conflicts that supposedly cause homosexuality (Bieber et al. 1962), and Socarides, another psychoanalyst who, it is well-known, always disagreed with the decision to remove homosexuality from the DSM (Socarides, Kaufman, Nicolosi, Santinover, & Fitzgibbons, 1997). Bieber and Socarides see homosexuality as always pathological and incompatible with a happy life.

       Fundamentalist Christian groups, such as Homosexuals Anonymous, Metanoia Ministries, Love In Action, Exodus International, and EXIT of Melodyland (also known as “ex-gay”  ministries) are the most visible purveyors of “conversion” therapy. Their workings are well documented by Blair (1982), who states that, although many of these practitioners publicly promise change, they privately acknowledge that celibacy is the realistic goal to which gay men and lesbians must aspire.

       Most groups across the various Christian ministry programs view homosexuality as learned behavior, suggesting environmental, psychological, and spiritual components (Yarhouse, Burkett, & Kreeft, 2002). Although there is no one clear statement concerning the etiology of homosexuality for all persons, Exodus literature, for example, points towards various emotional hurts and deficits as playing a prominent role in the etiology of same-sex attraction. Although these deficits are not specified, they suggest that homosexuality is more of a psychological and spiritual issue shaped in many ways by one's environment rather than caused by one's genes or other predominantly biological variables.  

       The Homosexuals Anonymous (HA) literature also dismisses the biological hypotheses for the etiology of homosexuality (Yarhouse, et. al., 2002). Emphasis is placed on homosexuality being a learned preference that can be traced to three primary causes: spiritual, intra-psychic, and relational. The intrapsychic and relational factors are discussed in the HA literature and reference is made to the work of Bieber et al. (1962), and Socarides (1978). From HA's perspective, same-sex attraction can occur when attachment to the parent of the same sex is not achieved.
Homosexual identification, according to the HA literature, is an attempt to meet legitimate developmental needs for same-sex intimacy.

       Another program that is loosely based on the psychoanalytic formulation has been developed by Joseph Nicolosi (2000) for those he calls “non-gay” homosexuals, individuals who report being uncomfortable with their same-sex orientation.  He too believes that homosexuality is a reaction to a defect in the masculine self. Nicolosi's clinical experience is based on patients who are frequently devout Christians and who seek to change their sexual orientation either for religious reasons or because they disapprove of a  “gay life-style”.  Like the orthodox psychoanalysts of
the 1950s and 1960s, Nicolosi uses clinical samples to make generalizations about all homosexual people.   “Nature made man complementary to woman, and to cling to the sameness of one's own sex is to look at the world with one eye,” he writes in his book Reparative Therapy of Male Homosexuality,  “I do not believe that the gay life-style can ever be healthy, nor that the homosexual identity can ever be completely ego-syntonic
[and] I do not believe that any man can ever be truly at peace in living out a homosexual orientation.” (Nicolosi, 1991, p13)

       As a result of political activism and accumulating empirical evidence that failed to link homosexuality with emotional disorder, in 1973 the American Psychiatric Association voted to remove homosexuality from the psychiatric nomenclature (Garnets & D’Augelli, 1994). Not until more than ten years later, in 1987, was the remaining reference to sexual orientation, ego-dystonic homosexuality (homosexuality which causes personal distress), eliminated from the diagnostic manual. Following the decision of the American Psychiatric Association, the American Psychological
Association in 1975 adopted a resolution which states, in part, that “Homosexuality per se implies no impairment in judgment, reliability or general social and vocational capabilities.” In addition, APA urged psychologists “to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientations” (Conger, 1975). Another landmark event occurred in 1976, when the president of the Association for the Advancement of Behavior Therapy urged that efforts to modify sexual orientation be terminated, arguing that they were ethically suspect (Davison,
1976). This effectively truncated the long-standing interest of most mental health professionals in “conversion” therapy (Garnets & D’Augelli, 1994).

       To date all major North American mental-health associations have declared that homosexuality is not a mental illness, issuing resolutions, policy statements, and revised ethical codes to this effect (Spitzer 2003). Despite these mainstream moves, there has been "a discernable 'movement' of clinical dissenters" since the early 1990s (Zucker, 2003, p399). These dissenters founded the U.S. National Association for Research and Therapy of Homosexuality (NARTH) in 1992 (Zucker, 2003). NARTH describes itself as "a nonprofit, educational organization dedicated to affirming a complementary, male-female model of gender and sexuality". Its aim is to advance the conservative intellectual, political, and ideological position that clients who want to change their homosexual orientation should have their wish respected and treated. NARTH claims about 1,000 members who are either orthodox psychiatrists or associated colleagues from other professions. While this number is very small (Spitzer 2003), they are well organized with exceptional communications networks (Grace 2005). Many of these practitioners still adhere to the officially debunked
“illness” model of homosexuality, and many base their treatments on religious proscriptions against homosexual behavior. Still others defend sexual reorientation therapy as a matter of free choice for the unhappy client, claiming that their treatments do not imply a negative judgment on homosexuality per se. They seek to provide what they describe as a treatment alternative for men and women whose homosexuality is somehow incongruent with their values, life goals, or psychological structures (Haldeman, 1994).

       NARTH members have argued on the op-ed page of The Wall Street Journal that individuals unhappy about their homosexual feelings should have the right to seek treatment for change (Socarides, Kaufman, Nicolosi, Satinover, & Fitzgibbons, 1997). Their claims of supporting homosexual civil rights notwithstanding, sexual “conversion” therapists filed affidavits in support of Colorado's antigay Amendment Two (Socarides, 1993). They also supported unsuccessful defenses of sodomy laws in Tennessee in 1995 and Louisiana in 1998 (Cohen, 1998). Why do these therapists want to criminalize homosexuality, even though they believe it to be an illness? NARTH's president (Nicolosi, 2000) has said, “We believe harm would be done if our laws were to affirm homosexuality as indistinguishable from heterosexuality”.

       Not surprisingly, the discourse between NARTH and its critics has been extremely heated. The rhetoric about “reparative” therapy has far exceeded any empirical evidence about its efficacy, or lack thereof, and has largely focused on ethics and sexual politics (Zucker 2003).  In an attempt to provide such empirical evidence, Robert L. Spitzer authored a controversial study that he presented at the 2001 APA conference, in which he reported finding 200 successful “reparative” therapy cases.  This study was hailed by proponents as important new empirical information and criticized by opponents as seriously methodologically flawed.

       It is important to keep in mind, when reviewing Spitzer’s data, that in 1973, it was Spitzer's suggestion that the DSM-II (American Psychiatric Association, 1968) replace homosexuality with a new diagnosis, sexual orientation disturbance (SOD) (Drescher, 2003). According to SOD criteria, only those “bothered by,” “in conflict with,” or who “wished to change” their homosexuality had a mental disorder. SOD, however, had two conceptual problems. First, the diagnosis could apply to heterosexuals, although there were no reported cases of unhappy heterosexuals seeking psychiatric treatment to become gay. In 1980, with Spitzer chairing the Task Force on Nomenclature and Statistics, SOD was modified in the DSM-III and replaced by ego-dystonic homosexuality (EDH) (Drescher, 2003). This new diagnosis, however, did not resolve the second, thornier issue of making patients' subjective distress about homosexuality the determining factor in making a diagnosis. Although SOD and EDH were a compromise in the 1973 debate, they were incongruous with an evidence-based approach to psychiatric diagnosis. In 1987, with Spitzer's reluctant approval, EDH was
removed from the DSM-III-R (Drescher, 2003). Jack Drescher observes: "If Spitzer did not previously believe in the possibility of changing homosexuality, why did he invent the DSM disorders of SOD and EDH? In 1984, I heard Spitzer speak at a New York conference on homosexuality where he defended the still-extant EDH diagnosis, saying "If a guy comes to me and says he wants to change his homosexuality, I believe he should have the right to try and change." Thus, despite what the “conversion” therapy publicists would have the media and the public believe, it seems
unlikely that Spitzer himself has undergone the conversion he now claims. Clearly, he has always supported trying to change same-sex attractions."  (Drescher, 2003, p449)

Does It Work?        
       In the aforementioned study, Spitzer claimed that: "Some gay men and lesbians, following reparative therapy, report that they have made major changes from a predominantly homosexual orientation to a predominantly heterosexual orientation. The changes following “reparative” therapy were not limited to sexual behavior and sexual orientation self-identity. The changes encompassed sexual attraction, arousal, fantasy, yearning, and being bothered by homosexual feelings. The changes encompassed the core aspects of sexual orientation. Even participants who only made a limited change nevertheless regarded the therapy as extremely beneficial. Participants reported benefit from nonsexual changes, such as decreased depression, a greater sense of masculinity in males, and femininity in females, and developing intimate nonsexual relations with members of the same sex." (Spitzer, 2003, p 446).

       Kenneth Cohen and Ritch Savin-Williams have serious concerns about Spitzer’s methodology however.  They ask: "Who were Spitzer's subjects and how could this collective effect the internal and external validity of his findings? In terms of venue, volunteers were recruited through "repeated" notices to ex-gay religious ministries, therapies, and political organizations that promote biasing conditions. Subjects were clearly not blind to the study's hypothesis or purpose and most, if not all, had compelling motivations to provide data that would prove the hypothesis correct.
Indeed, subjects could not participate in the study unless their perceived experience supported the study's hypothesis. Thus, subjects had a strong desire to change (including 19% who were directors of ex-gay ministries or mental health professionals), strong desire to witness to others (e.g., 78% publicly spoke in favor of efforts to change homosexual orientation, often at church functions), strong desire to affirm their religiosity (93% reported that religion was "very" or "extremely" important to them), and strong desire to believe that their own “conversion” was successful. These biasing conditions are not conducive or even normative to scientific investigations. The intent to eliminate or at least reduce social desirability as a potentially damaging influence on the veracity of results is standard fare for scientific research and yet it appears that Spitzer did everything within his power to promote if not ensure his intended responses. Thus, it is exceedingly difficult to take at face value the independence of the study's data." (Cohen & Savin-Williams, 2003, p420)

       Contrary to Spitzer’s findings are the reports of those who have been involved and are less impressed.  Founders of an aforementioned ex-gay ministry, Exodus International, have denounced their “conversion” therapy procedures as ineffective. Michael Busse and Gary Cooper, co-founders of Exodus and lovers for 13 years, were involved with the organization from 1976 to 1979. The program was described by these men as “ineffective … not one person was healed” (Newsbriefs, 1990, p. 43). They stated that the program often exacerbated already prominent feelings of guilt and
personal failure among the counselees; many were driven to suicidal thoughts as a result of the failed “reparative” therapy (Haldeman, 1994).  Michael Johnston of Kerusso Ministries, an "ex-gay" who was portrayed in one of the religious Right's full-page ads in the Wall Street Journal, has dismissed many of the claims for “reparative” therapy made by others in the ex-gay movement, arguing that real change is not a matter of rational thought or rational discussion but of divine intervention. In an interview in The Village Voice, (Schoofs, 1998) Johnston stated, “I don't believe men
and women can go into therapy and come out the other end heterosexual.” In response to the argument that ex-gays are simply repressing their homosexual orientation, Johnston has forthrightly replied, “There is a kernel of truth in what they say, that those of us who have chosen to follow Christ are repressing. ... What comes naturally to us is not righteousness, it is sin” (Pietrzyk, 2000).

       Spitzer’s unsuccessful attempt to provide empirical evidence points out the challenge one faces in assessing these therapies.  That is, studies to date appear to be biased and based on self-report. This author’s search of the literature for sound research supporting or refuting “reparative” therapy claims was fruitless.  

Ethical Arguments
       Christopher H Rosik (2003) believes that “reparative” therapies are an ethical option for clients struggling with differences between their religious convictions and their sexual orientation.  It is his position that if clients are provided with informed consent in a noncoercive environment, some individuals with homoerotic attraction will want to pursue change-oriented therapy.   Because many of these clients are motivated to attempt change as a result of deeply held religious convictions, allowing them to pursue such therapy, he argues, respects religious diversity.  Others have
countered, however, that it constitutes a cure for a condition that has been judged not to be an illness.

       As noted earlier, the American Psychiatric Association's 1973 decision to remove homosexuality from its Diagnostic and Statistical Manual of Mental Disorders marked the official passing of the illness model of homosexuality (Haldeman, 1994). The American Psychological Association (APA) followed suit with a resolution affirming this anti-illness perspective, stating, in part, “… the APA urges all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientations” (APA, 1975). Homosexuality was
replaced with the confusing “ego-dystonic homosexuality” diagnosis, which was dropped altogether in 1987. Proponents of “conversion” therapy continue to insist, in the absence of any evidence, that homosexuality is pathological. This model was rejected because of a lack of such evidence (Haldeman, 1994).

       Another ethical concern is that “reparative” therapy promotes homophobia, which is bad for clients and society: it reinforces a prejudicial and unjustified devaluation of homosexuality.   Herek explains that: "Homophobia is defined as the irrational fear of people and things related to lesbians and gay men (Weinberg, 1972).   There are two kinds of homophobia, externalized and internalized. Externalized homophobia comes from the heterosexual community who dislike or fear homosexuals. Conversely, internalized homophobia comes from within the lesbian or gay man. From an
early age, most lesbians and gay men internalize society's ideology of sex and gender roles. As a result of these ideal expectations, they usually experience a certain degree of negative feelings about themselves when they are aware of their same sex attractions. (Herek, 1996, p101)

       Davison (1976, 1978, 1991) has detailed many of the ethical objections to “conversion” therapies. A behavior therapist once well known for his program to change sexual orientation, Davison believes that a disservice is done to the gay or lesbian individual by offering sexual orientation change as a therapeutic option. In Davison's view, “conversion” therapy reinforces antigay prejudice. He asks, “…how can therapists honestly speak of nonprejudice when they participate in therapy regimens that by their very existence—and regardless of their efficacy—would seem to condone the current societal prejudice and perhaps also impede social change?” (Davison, 1991, p. 141), and Murphy adds: "There would be no reorientation techniques where there was no interpretation that homoeroticism is an inferior state, an interpretation that in many ways continues to be medically defined, criminally enforced, socially sanctioned, and religiously justified. And it is in this moral interpretation, more than in the reigning medical theory of the day, that all programs of sexual reorientation have their common origins and justifications." (Murphy, 1992, p. 520)

       Others are concerned that it is based on an outdated and biased theoretical foundation.  Yeoman (1999) points out that, to Nicolosi and his followers, gay male sexuality derives from a poor relationship between a boy and his father. If a father isn't a strong influence on the family, and if he doesn't provide emotional support and physical affection, they say, then the child won't learn to identify with adult men. As he grows older, the boy will start looking for the maleness he never acquired, and his search will take on sexual overtones.  "People are gendered. We are naturally
gendered into male and female. So the male homosexual is trying to find his unfulfilled masculinity," Nicolosi declares. "His homosexual attractions are a symptom of his desire to find his masculine identification and same-sex emotional needs." (Nicolosi, 1991, p110)

       Critics consider this a deeply flawed argument. Andrew Sullivan, former editor of The New Republic and a gay man, notes that if distant fathers were the cause, then most of the generations born between 1930 and 1980 would be homosexual. (Yeoman,1999, p26).

       Nicolosi's understanding of gay people is severely compromised by his personal negative belief system about homosexuality. For example, he stated that: "The inherent unsuitability of same-sex relationships is seen in the form of fault-finding, irritability, feeling smothered; power struggles, possessiveness, and dominance; boredom, disillusionment, emotional withdrawal, and unfaithfulness. Although he desires men, the homosexual is afraid of them. As a result of this binding ambivalence, his same-sex relationships lack authentic intimacy. Gay couplings are characteristically brief and very volatile, with much fighting, arguing, making-up again, and continual disappointments." (Nicolosi, 1991, p110)

       But Friedman (1997) insists that there is no scientific evidence this depiction of gay relationships is valid. His 25 years of clinical experience with individuals and couples has impressed him with the similarities between heterosexual partnerships and those between men. “Such differences as do exist”, he said, “do not provide evidence that homosexual relationships are intrinsically more or less psychologically healthy than heterosexual relationships” (Friedman, 1997, p225).

       Some “reparative” therapy methods raise ethical eyebrows as well.  Hicks (2000) cites  electrical shock therapy, chemical aversive therapy, drug and hormone therapy, homophobic counseling, religious propaganda, isolation, unnecessary medication (including  hormone treatment), subliminal therapies designed to inculcate "feminine" or "masculine" behavior, and "covert desensitization" therapies that teach a young person to associate homosexual feelings with disgusting images as a few of the controversial methods employed by “reparative” therapists.

       Considering the nature of such methods, it is not surprising that reports of harm have surfaced.  Even ardent supporters such as Yarhouse et. al. (2002) admit that there have been instances of sexual misconduct among some leaders of Christian ministry groups.  Homosexuals Anonymous has been particularly infamous in this regard (Haldeman, 1994).  An investigator attempting to research the efficacy of this program was denied access to counselees on the basis of confidentiality (Lawson, 1987).  Nonetheless, he managed to interview 14 clients, none of whom reported any
change in sexual orientation. All but two reported that the founder had had sex with them during treatment.

       According to Haldeman, (1994) individuals undergoing “conversion” treatment are not likely to emerge as heterosexually inclined, but they often do become shamed, conflicted, and fearful about their homoerotic feelings. He insists that it is common for gay men and lesbians who have undergone aversion treatments to notice a temporary sharp decline in their sexual responsiveness, with some subjects reporting long-term sexual dysfunction. Similarly, he says, subjects who have undergone failed attempts at “conversion” therapy often report increased guilt, anxiety, and low self-esteem. Some flee into heterosexual marriages that are doomed to problems inevitably involving spouses, and often children as well.

Discussion
       While both sides argue over the ethics of reparative therapy, issues remain unresolved.  First, there is the problem of empirical evidence.  As has been mentioned earlier, virtually all data available regarding efficacy and possible harm appears to have been gathered from self-report based studies.  There appears to be a need for properly designed and executed experimental research, but so far, social scientists have considered this too expensive or unethical to undertake (Spitzer, 2003).  

       Second, there is the question of the nature of sexual orientation.  Whether sexual orientation can or should be changed is at the center of this debate.  What is often not mentioned, however, is that the polarized straight/gay view that both supporters and detractors depend on to defend their positions is not universally accepted (Vasey, & Rendall, 2003).   Most notably with the work of Kinsey, Pomeroy, and Martin (1948),   it has become clear that not all individuals can be categorized dichotomously as either gay or straight: hence, the concept of bisexuality (Cornelson, 1998, Stokes, Miller, & Mundhenk, 1998) .

       Andre Grace has this to say about  the outdated and exclusionary language used in the discourse surrounding “reparative” therapy": "In my other research I predominantly use the term queer to represent the spectrum of sex, sexual, and gender differences that lie inside and beyond heterosexualizing discourses. However, transformational ministers and “reparative” therapists tend to use just the binary descriptors heterosexual/ homosexual and male/female. When they use gay, it is usually in a pejorative sense, particularly when they talk about the dangers of the so-called gay agenda. They usually ignore bisexuality or dissolve it into gay and lesbian, thus avoiding consideration of the complexities of desire, need, and expression shaping that complex orientation and identity. As well, they evade mentioning transgender identity or transsexual issues in their “conversion” discourse. Thus categories like bisexual, trans-identified, and queer are too expansive and fluid descriptors to portray the narrowly construed sex, sexual, and gender differences taken up in this interrogation." (Grace, 2005, p146)

       So if sexual orientation and gender identity are not a matter of either/or, perhaps the entire debate is out of focus.  Perhaps the focus could be shifted to expanding acceptance of sexual orientation and gender identity fluidity.  

     One possible solution to the ethical dilemma of counseling the spiritually and sexually conflicted client may be found in such an accepting stance.  John Bancroft provides the following guidance: "Every now and then, I see someone in my clinic who presents himself (and, more occasionally, herself) as confused or conflicted about sexual identity. Sometimes they are struggling with the idea of
bisexuality. "Does bisexuality exist?" they might ask. In some cases, their sexuality is compartmentalized (e.g., "I find certain types of men very sexually arousing, but I can't imagine being in a loving sexual relationship with another man")--what might be described as a failure to incorporate one's sexuality into one's capacity for a close dyadic relationship, a problem by no means confined to those with homosexual orientation. How do I react to such patients after a career of reflection on this issue? I now have no doubts about how to respond and this involves some crucial sequential steps:"

       "Step 1. Make it absolutely clear that, whatever the patient's values or beliefs might be, I have no difficulty whatsoever in accepting and valuing either a homosexual or a heterosexual or a bisexual identity. The issue is which is right for that person. In so far as I have personal values, they apply to issues of responsibility and the use of sex to foster intimacy in a close ongoing relationship. Neither is dependent on the gender of those involved. It behooves the therapist to be explicit about her or his moral values as they impact on the treatment process so that the patient can choose whether to work with that therapist or not."

       "Step 2. Make it clear that in order to find out what type of sexual relationship works best, it may be necessary to experience more than one type of relationship, involving partners of either gender. Furthermore, during a lifetime, more than one successful relationship may occur, involving same sex and opposite sex partners at different times."

       "Step 3. Emphasize the need to take time to work out what is right. The therapist, who is better designated as a counselor in this context, facilitates this process of search and discovery as appropriate. This may involve helping the patient to identify the different "compartments" of his or her sexuality, and how to incorporate them into a sexually rewarding, intimate, and loving relationship. This is more education than therapy." (Bancroft, 2003, p460)  

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