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Review Article | DOI: https://doi.org/10.31579/2637-8892/202
Educational and Scientific Institute of Postgraduate Education of Kharkiv National Medical University, Ukraine.
*Corresponding Author: Garnik S. Kocharyan, Educational and Scientific Institute of Postgraduate Education of Kharkiv National Medical University, Ukraine.
Citation: Garnik S. Kocharyan (2023), Conversion Therapy Reflections on the Topic. Psychology and Mental Health Care, 7(3):
DOI:10.31579/2637-8892/202.
Copyright: © 2023 Garnik S. Kocharyan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 15 March 2023 | Accepted: 29 March 2023 | Published: 17 April 2023
Keywords: ego-dystonic homosexuals; conversion therapy; prohibitions; groundlessness; effectiveness
Currently, there are two approaches to the therapy of ego-dystonic homosexuals. According to the first approach (gay affirmative therapy), they need to be adapted to their sexual desire. According to the second approach (conversion / reparative therapy), it is necessary to help patients change their sexual orientation in accordance with their desire and rejection of homosexuality and a homosexual lifestyle for themselves. Each approach has its supporters. Ego-dystonic homosexuality, which was included in the list of mental disorders in ICD-10, was not included in this list in ICD-11. In some parts of the world, conversion therapy is outlawed because homosexuality is supposedly inborn and its correction looks akin to trying to change racial or national identity. However, in many countries of the world such prohibitions do not exist. The conducted studies indicate the presence of only a slight innate biological predisposition to the formation of homosexuality, while the main role in its development is played by social and psychological factors. Data are given, according to which homosexuality cannot be congenital, but in some cases one can speak of an innate predisposition. However, predisposition is not predestination. Since homosexuality cannot be considered innate, this opens up opportunities for influences that prevent its formation and conversion therapy, which changes the direction of homosexual attraction to heterosexual. It is noted that sexual orientation can change even spontaneously without any efforts of both the person himself and a specially trained specialist. If this is so, then it is quite natural that it can be changed by applying certain psychotherapeutic efforts. The question of the immutability of sexual orientation, in particular, is refuted by the presence of the phenomenon of sexual fluidity. The issue of negative consequences of conversion therapy is considered. It is noted that the possibility of their occurrence is extremely exaggerated. They, in particular, can occur during the forced correction of homosexual attraction, which is currently not carried out in civilized countries. Often, attention is focused on the possibility of complications in the application of electrical discharges, the negative impact of which in this case is greatly exaggerated. When comparing the effects of their use with the effects of electroconvulsive therapy (where uses incomparably stronger electrical discharges), which is not prohibited and is used to treat severe mental disorders, it is concluded that there are double standards based on ideologically driven cognitive distortions. There are a large number of studies proving the effectiveness of conversion therapy. Methods of psychotherapy used to change the direction of sexual desire are named, as well as the experience of the author of the article on the use of conversion therapy. It is concluded that such therapy is effective and has the right to exist. It can be used in ego-dystonic homosexuals who want to get rid of their attraction. Refusal to provide this type of assistance is a violation of human rights.
Currently, there are two approaches to the therapy of homosexuals who deny their sexual orientation (homosexuals’ ego-dystonics). According to the first approach (gay affirmative therapy), which is based on the guidelines of the latest international (ICD-10 and ICD-11) and American (DSM-IV, DSM-V) classifications, they should be adapted to their orientation, since, according to the guidelines these classifications, it corresponds to the norm. That is, they must accept their orientation and adapt to it. According to the second approach (conversion, reparative, reorienting, differentiating therapy), it is necessary to help patients change their sexual orientation, which corresponds to their desire and rejection of homosexuality and a homosexual lifestyle for themselves. This approach is followed by a number of reputable scientists who believe that homosexuality cannot be attributed to the norm. Their main argument is that homosexual relations exclude the possibility of reproduction of the human race (Kocharyan, 2006, 2014).
Ego-dystonic homosexuality in the ICD
In accordance with ICD-10, patients who do not accept a homosexual orientation are recognized as sick on the basis that they experience distress in connection with the direction of their sexual desire and wish to change it. In particular, in the ICD-10 there is a code F66.1 (ego-dystonic sexual orientation), which refers to cases where “gender identity or sexual preference is not in doubt; however, the individual wants them to be different due to additionally existing psychological or behavioral disorders and seek treatment to change them” (International Classification of Diseases (10th revision), 1994, p. 218). In the context of the fact that homosexual orientation in the classification under consideration is not considered a pathology in itself, the desire to get rid of it, in fact, indicates the presence of some kind of abnormality. Thus, those persons who accept their homosexual orientation, and who are completely satisfied with it, are recognized as healthy, and those who want to get rid of it are recognized as sick. That is, if an ego-dystonic homosexual wants to have a traditional family or be in a traditional sexual partnership and have children, then he does not need help in achieving this desire.
Then the following attempts were made to completely exclude homosexuality from the category of mental disorders. In 2014, WHO appointed an ICD-11 development team that recommended deletion of section F66 “Psychological and behavioral disorders associated with sexual development and orientation”, which included ego-dystonic sexual orientation, which was done. This was guided by the assumption that although homosexual and bisexual people often experience higher levels of distress, this is due to their social rejection and discrimination, and they cannot be considered mentally ill. ICD-11, approved in 2019 and entered into force in January 2022, does not include any diagnostic categories that can be applied to people based on their sexual orientation.
Prohibitions on Conversion Therapy
It should be noted that a number of countries have introduced bans on conversion therapy, which threaten many negative consequences. Malta was the first country in Europe to officially ban reparative therapy. The law to ban it was unanimously approved by the Maltese legislators. According to this document, for “changing, suppressing and destroying a person’s sexual orientation or gender identity”, a fine of up to 10,000 euros or a prison term of up to one year is provided. The law also notes that no sexual orientation or gender identity can be considered a deviation or illness.
At the beginning of June 2020, it was reported that the Bundesrat (representation of the federal states of Germany) approved a law prohibiting reparative therapy. According to German Health Minister Jens Spahn, who presented the bill in the Bundesrat, the approval of the document will be an important signal for the Germans and will help society to accept people with different sexual self-identification. According to the document, methods aimed at deliberately changing or suppressing the sexual orientation of a patient, both a minor and an adult, become illegal. Punishment threatens both the organization offering the relevant services and parents or guardians who refer their wards to such treatment. Violators face imprisonment of up to 1 year, for advertising and mediation a fine of up to 30 thousand euros is imposed.
This therapy is currently prohibited by law for minors in 20 states and many municipalities in the United States, and efforts are being made to ban its use in adults (Sullins et al., 2021). The District of Columbia is the only US jurisdiction whose ban extends to adults. Also, legislation banning the use of conversion therapy was passed in Canada (December 8, 2021) and France (January 24, 2022).
These prohibitions essentially deprive ego-dystonic homosexuals of the opportunity to receive the help they seek and thus violate their rights. However, the use of conversion therapy is not prohibited in most countries of the world.
Is there congenital homosexuality?
It is argued that conversion therapy is ineffective and, in all cases, harms the body. When imposing a ban on conversion therapy, the argument about its innateness is used. However, as evidenced by the data of special literature, congenital homosexuality does not exist. When discussing the question of the validity of the opinion about its innateness, it is necessary to pay attention to the following well-known facts, which are reflected in our recently published articles (Kocharyan, 2018, 2020).
They report that even the Platonic (romantic) libido does not appear before 4-5 years, and in many cases much later. Thus, in the period that precedes the time of the awakening of the Platonic component of the libido, there is no need to talk about any sexual orientation, including homosexual. If we focus on the time of the awakening of the erotic, and even more so the sexual component of the libido, then the time interval from the moment the child is born to this awakening is even much longer.
So, according to the scale of the vector definition of the sexual constitution of women according to I. L. Botneva, the age interval for the appearance of their erotic libido is from 8 years and earlier to 17 years and later, and the time of awakening of the sexual component of the libido in men, in accordance with the scale of the vector definition of the sexual constitution according to G. S. Vasilchenko, ranges from 9 years and earlier to 17 years and later (Sexopathology: Reference book, 1990). Naturally, the sexual libido in women awakens later than the erotic, and on average later than in men.
Neil Whitehead (Neil Whitehead) reports that the average age when a homosexual realizes that he is attracted to people of the same sex is 10 years old, and two-thirds of all cases occur between 6 and 14 years. 12 published surveys show that the average age at which same-sex attraction first occurs is 9.4 ± 1.1 years for men and 11.1 ± 1.8 years for women (Whitehead, Whitehead, 2018).
Thus, we can only talk about an innate predisposition, which is far from being traced in all cases of homosexuality, but a predisposition is not a predestination. The conducted twin studies indicate that at present we can talk about a mild genetic predisposition to homosexuality, but the main role in its genesis is played by psychological and social factors. In this regard, the studies of J. M. Bailey et al. (2000), a meta-analysis of a large number of works on homosexuality by American psychiatrists and researchers Mayer & McHugh (2016), as well as a study conducted by a group of 20 scientists from around the world (Ganna et al., 2019) should be mentioned.
The authors of the last of these studies, which included almost half a million people, believe that genetics can explain only 8 to 25% of non-heterosexual behavior. The rest, they say, comes from environmental influences, which can range from exposure to hormones in the womb to social influences later in life. The mild influence of congenital factors on the formation of a predisposition to homosexuality is also evidenced by our analysis of twin studies of homosexuals (Kocharyan, 2019).
Is conversion therapy effective?
If, as the above data suggests, homosexuality cannot be declared innate, then this opens up opportunities for influences that prevent its formation and conversion therapy that changes the direction of homosexual attraction to heterosexual. However, there are claims that such therapy not only cannot be effective, but is also extremely harmful. Such statements began to appear after homosexuality was excluded from the list of mental disorders, first in the American (1973-1974) and then in the international (1990) classification of mental disorders. But both before and after that, conversion therapy was and remains effective, as evidenced by both the data of the specialized literature and our clinical experience (Ellis, 1959; Kocharyan, 2016, 2020, 2021, 2022; Lysov, 2019; Nicolosi et al., 2000; Sullins et al., 2021; Spitzer, 2003).
With regard to the ineffectiveness of conversion therapy, which, in fact, is based on the idea of the impossibility of changing sexual orientation, the following should be noted. Sexual orientation can change even spontaneously without any effort of both the person himself and a specially trained specialist. This, in particular, is evidenced by the article by Lisa M. Diamond & Clifford J Rosky (2016), which deals with the phenomenon of sexual fluidity. The authors make three claims. They note that, first, arguments based on the immutability of sexual orientation are unscientific. Secondly, in the light of US legal rulings (in which the courts have used grounds other than immutability to protect the rights of sexual minorities), arguments based on the immutability of sexual orientation are not needed. Third, arguments about fixed sexual orientation are unfair because they imply that same-sex attraction is inferior to attraction to people of the opposite sex. In addition, they favor sexual minorities who perceive their sexuality as fixed over those who perceive it as fluid. The conclusion that the argument about the fixed sexual orientation is unscientific, which was outlined in this article, is especially important, since one of the authors of the article is Lisa Diamond, a lesbian rights activist and professor of developmental psychology and health psychology at Utah State University (USA). Based on the above data, the following question quite naturally arises: “If the direction of sexual desire can change even spontaneously, then why can’t it be changed by making certain psychotherapeutic efforts?” The answer to this question is absolutely obvious.
In my clinical practice, I came across a case where, in a patient with the most severe obsessive-compulsive syndrome, sexual orientation, according to him, changed very quickly over short periods of time. So, at one of the sessions, he reported that at the beginning of the day he had a predominance of the homosexual component of libido (80%) over the heterosexual one (20%), and in the evening of the same day this ratio was reversed (the heterosexual component was 80%, and the homosexual component was 20%). He doesn't know why this is happening.
After the last session of hypnosuggestive therapy, conducted 4 days ago, the heterosexual component of libido was 100% expressed during the evening and night (did not sleep well, intermittently). The next day, the ratio of homosexual to heterosexual libido was 80% to 20. On the following day, the ratio between homosexual and heterosexual libido changed from 100% heterosexuality to 80% homosexuality with the inclusion of 20% heterosexuality.
Sometimes in the intervals between these states there was bisexuality, and sometimes jumps in the change in the expressiveness of individual components of the libido were sharp. In January-February 2022, there was complete heterosexuality. Then, due to the fact that all thoughts were absorbed by military operations in Ukraine, he did not think about it and did not track his sexual orientation (he first contacted me for medical help on 11/15/2022, since he considered himself bisexual). In the summer of 2022, the homosexual and heterosexual components of libido were expressed by 50 percentage each, but sometimes there were periods of complete heterosexuality. In October 2022, 100% heterosexuality took place. I told the patient that he had sexual fluidity. In cases such as this, direct correction of the orientation of sexual desire should not be carried out. I associated these changes in the patient’s sexual orientation, in particular, with his obsessive-compulsive syndrome, which was represented by various obsessions, including those in the sexual sphere. Ideologically oriented statements about the impossibility of changing sexual orientation It is necessary to give an argument explaining why homosexuality is being presented as an exclusively innate condition. This is the basis for putting conversion therapy on a par with attempts to change the racial identity of people of the black race, the national identity of people of “Caucasian nationality” and Jews. Thus, those who believe that it is possible to change the sexual orientation of homosexuals are trying to stigmatize, putting them on a par with racists, anti-Semites and, in general, with all kinds of xenophobes. The ideological background of this comparison is obvious. However, such attempts cannot be considered adequate, since the question of the normality or usefulness of any race or nationality and getting rid of signs of race and nationality cannot be raised because of its complete absurdity. Through this stigmatization, opponents of conversion therapy simply want to portray its supporters in an extremely unsightly way (Kocharyan, 2020). The following statement is of interest in this respect. A well-known American psychology textbook (Atkinson et al., 2000) notes that, according to a recent study of sexuality, 2.8% of men and 1.4% of women in the United States consider themselves homosexual (gay and lesbian) or bisexual. In its frequency, this is close to the proportion of people of Jewish nationality living in the United States (2-3%). The ideological background of such a comparison is beyond doubt (Kocharyan, 2020). Is conversion therapy harmful? Negative effects can be expected with the forced correction of homosexual attraction, which is currently not carried out in civilized countries. Often, attention is focused on the possibility of complications when using electrical discharges, the negative impact of which is greatly exaggerated. In this regard, it should be noted that low-intensity currents were used during conversion therapy, which were not passed through the head, as in electroconvulsive therapy (ECT). Attention should be paid to the following information regarding the treatment of homosexuals: “The electric current is produced by a device operating on a 9-volt battery, where the patient himself sets the discharge level tolerable for him, which is supplied through the cuff electrode to the biceps or lower leg area (in no case to genital area)” (Lysov, 2019, p. 228). If the danger of such therapy were so great, then these devices would not be given to patients for self-use at home. Although this type of treatment, which is aversive, cannot be classified as electroconvulsive therapy (ECT), intimidation by its use has become widespread. However, today ECT itself is used to treat severe depression (when other methods fail), catatonia in patients with schizophrenia, sometimes (less often) manic syndrome (most often as part of bipolar affective disorder), and other conditions. In this case, as a rule, a voltage of 70 to 120 volts is used, and the electric current acts directly on the patient's brain, since the electrodes are applied directly to his head. During ECT, a grand mal seizure develops. Naturally, nothing of the kind occurs when electric discharges are used to correct homosexual attraction. In addition, it is informed that ECT can lead to serious memory impairment. Being an extreme type of therapy, used only for the treatment of patients resistant to its other methods, ECT is still used in clinical practice. From the above material, it follows that in assessing the use of electrical discharges to correct the direction of sexual desire, double standards are used, based on ideologically determined cognitive distortions (Kocharyan, 2020).
Methods of psychotherapy that are used in conversion therapy and the experience of the author
It should be noted that conversion effects are carried out, in particular, using hypnosuggestion, autogenic training, psychodynamic, behavioral, cognitive, group therapy, and religiously oriented effects. Also, for this purpose, the technique of “desensitization and processing by eye movements” (Carvalho, 2009), developed by F. Shapiro (1998), is used. For correcting the direction of sexual desire, I use cognitive-oriented, hypnosuggestive, behavioral therapy, including sexual-behavioral training (sexual therapy), as well as neurolinguistic programming. This correction is carried out only on a voluntary basis to persons who wish to change their sexual orientation. In these cases, the patient most often does not consider himself healthy, and the direction of his sexual desire causes him distress, since he does not accept this direction and would like to change it to heterosexual. As our observations show, some adolescents who seek medical help do not consider themselves sick, but they would like to be heterosexual, since in this case they will be able to create a family and have children in the future. Some married bisexual men also do not consider themselves to be either sick or sinners, but they are afraid that their homosexual contacts will destroy their family, and they will lose the opportunity to fully communicate with their children (Kocharyan, 2020). Denial of these categories of patients in the implementation of the conversion impact is nothing more than a violation of human rights to receive medical care.
I (Kocharyan 2021, 2022) have developed a certain stereotype for correcting the homosexual orientation of sexual desire, which includes:
During hypnosis, the following suggestion is carried out, which includes 5 structural components:
When conducting hypnosuggestive therapy, after a series of sessions, as a result of which it was possible to sufficiently increase the heterosexual component of libido, we, in addition to the suggestions presented, carried out a suggestion aimed at modeling sexual intercourse in a hypnotic state. The patient sees that he is in a room with a woman he likes. They kiss and caress each other. At the same time, he has a pronounced sexual desire, he experiences pleasant voluptuous sensations, accompanied by increasing sexual arousal, which fills the penis with blood, makes it large and hard. After that, he inserts a member into the vagina, produces frictions, while experiencing pleasant, voluptuous sensations, which are accompanied by increasing sexual arousal. These sensations and this excitement spread to the entire body, covering it completely, and in this stream of voluptuousness and growing sexual arousal, he performs sexual intercourse (Kocharyan, 2021, 2022).
When masturbating, pornographic scenes (masturbating women, lesbian sex, heterosexual contacts) were used (when the patient was a male). In the latter case, in a hypnotic state, we carry out suggestions that the male patient during masturbation focuses specifically on the woman. In a hypnotic state, suggestions are also carried out for the purpose of enhancing sexual desire, pleasant voluptuous sensations, sexual arousal and erection, brightness and strength of orgasm during these types of masturbation (Kocharyan, 2021, 2022).
The presented correction model is effective and gives fast results.
It should be emphasized that conversion therapy is effective and has a right to exist. It can be used in ego-dystonic homosexuals who want to get rid of their attraction. Refusal to provide this type of assistance is a violation of human rights.
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