Running Head: ETHICAL DILEMMA REGARDING SOCE

Lai Yousheng Lester (A0124511X)

An Ethical Dilemma Regarding Sexual Orientation Change Efforts (SOCE)

1928 words
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This paper makes reference to the case vignette of Alex (see Appendix A), a 23-year-

old Christian male who is seeking treatment to “get rid” of his homosexuality. The paper

begins with a brief literature review of sexual orientation change efforts (SOCE) and its

efficacy. It proceeds with describing the ethical dilemma Alex’s psychologist faces, and

evaluates existing ethical codes to guide decision-making. Finally, it outlines steps that I, the

psychologist, can take to navigate this ethical dilemma.

Review of SOCE

SOCE refers to any form of conversion, reparative, or reorientation therapies which

aims at “changing sexual orientation or any of its parts” (American Psychiatric Association,

2021, pg. 1). SOCE have a long history, with early methods ranging from medical

interventions to remove unwanted sex drive (e.g., surgery on the spine, convulsive methods),

behavioural interventions such as aversion therapy, and cognitive interventions targeting

irrational thoughts towards heterosexual relationships. Current methods are arguably less

intrusive, and aim to reduce homosexual behaviours through avoidance, utilise accountability

groups to discourage engagement in homosexual behaviour, and religious methods such as

prayer (Beckstead, 2012; Przeworski et al., 2021).

Regardless of the method, SOCE are widely denounced by various ethical bodies

(e.g., American Psychological Association, Australian Psychological Society, Singapore

Psychological Society). Research on SOCE efficacy is reported to be fraught with multiple

methodological errors (e.g., sampling bias, social desirability on outcome measures, lack of

comparison groups, lack of longitudinal studies), limiting the conclusions that can be drawn

from studies reporting benefits. While some recipients of SOCE did report experiencing relief

and hope from ‘treatment’, the majority of others reported being misinformed about the

evidence for, and expected outcomes of the ‘treatment’ they were receiving, with some being

blamed by their therapist for the lack of progress. This has led to detrimental mental health
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outcomes (American Psychological Association, 2009; Beckstead, 2012). Additionally, as the

foundation of SOCE is based on the assumption that homosexuality is pathological, and can

be altered because it is a product of environmental influences, academics have cited that

endorsing SOCE reinforces existing prejudices against homosexuals. Taken together, these

factors highlight the reason for SOCE being considered not evidence-based and should not be

delivered.

In spite of this, there are a multitude of factors which may motivate an individual to

seek SOCE. Internalised homonegativity as a result of prevailing societal norms may bring

about dissonance should one start experiencing same-sex attraction (Beckstead, 2012).

Additionally, social advantages such as, in Singapore’s case, flexibility and eligibility of

purchasing public housing, or simply not being discriminated as a heterosexual can be strong

motivating factors for one to seek treatment. Pertinent to Alex’s case, majority of individuals

seeking SOCE do so due to conflicts between their religious and sexual orientation as well.

Defining the Ethical Dilemma

The ethical dilemma arising in Alex’s case is his belief that his religious and sexual

orientation are incompatible. As such, he is determined to change his sexual orientation and

preserve his religious identity. As psychologists, we are aware that SOCE is not an evidence-

base ‘treatment’ due to its propensity to cause harm. By adhering to the general principle of

Beneficence (Singapore Psychological Society, 2019), it would follow that we do not deliver

SOCE (assuming we have expertise to). However, if Alex believes SOCE is most effective,

would we be acting in non-beneficence not to deliver SOCE? It is acknowledged that client

self-determination has its limits, and as experts in mental health, we have the duty to

psychoeducate our clients about evidence-based treatments (Beckstead, 2012; Schroeder &

Shidlo, 2002). However, if Alex remains insistent that he wants to change his sexual

orientation, what would be the next logical step for the therapist to take?
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When religious and sexual orientation intersect, with the client motivated to negate

the latter, guidelines are non-specific, and at times conflicting. The principle of “do no harm”

from the American Psychological Association Code of Ethics is often referred to, which

parallels the aforementioned principle of Beneficence. Undoubtedly an important ethical

principle to bear in mind, it does not provide specificity needed in our ethical dilemma. This

begs the question – what about SOCE are harmful? It is perhaps clearer to see the harm

caused in early methods of SOCE as their effects are arguably less malleable to restoration

(e.g., surgery, decreased sexual arousal towards any stimulus), and at times infringe on

multiple other ethical guidelines (e.g., misinformation of therapeutic modality, blame).

Additionally, despite self-reports of detrimental mental health after receiving SOCE, there is

little information on contextual factors (e.g., motivation for change, reasons for seeking help)

that may mediate their harmful experience. In Alex’s case, it becomes less clear what the

impact of harm is if I do my due diligence to establish appropriate rapport, explain the

evidence-base of SOCE, and deliver a less intrusive means of SOCE. Furthermore, would

Alex’s motivation then negate some of the risks reported in SOCE research? These are

questions that remain unanswered.

Another problematic aspect of existing guidelines is the assumption that religious and

sexual orientations can be integrated and coexist, or if doing so is the most beneficial for the

client. For some, spirituality might be such an inextricable part of their identity that it might

be more realistic for them to change their sexual orientation (Haldeman, 2004; Miville &

Ferguson, 2004). Beckstead (2012) highlighted the importance of understanding the

idiosyncrasies in participants’ conceptualisation of sexuality when interpreting ‘successful’

reports of SOCE. I argue that a similar rigour should be more heavily emphasised in literature

when understanding conceptual idiosyncrasies of religion as part of multicultural

competency. Just as we should not pathologise homosexuality, we should also not devalue
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religious identities (Haldeman, 2004). What do we do if the prospect of delivering SOCE is

the option to minimise harm? On a related note, given that the existence of SOCE are viewed

as harmful in perpetuating prejudice against the homosexual community, if this approach is

beneficial for Alex, and if I disclaim that homosexuality is not a disorder, is that an ethically-

sound approach to rationalising the delivery of SOCE?

Finally, while it seems that a significant reason for recommendations against

delivering SOCE is the empirical evidence against it, Przeworski et al. (2021) posited that

whether or not SOCE has empirical evidence is secondary to whether a therapist should

ethically deliver it. In other words, should SOCE have some empirical evidence, are there

other ethical considerations psychologists should consider before delivering it?

Navigating the Ethical Dilemma

Should psychologists strictly adhere, and never deviate from their Code of Ethics?

Yes. Despite the absolute nature of the statement, general principles such as Beneficence and

“do no harm” allow for flexibility on how ethical dilemmas similar to Alex’s can be best

managed. Following the American Psychological Association's (2000) and Sue's (2001)

recommendations, it is imperative for psychologists to gain multicultural competence through

gaining awareness of self-biases, and understanding cultural experiences of their clients so as

to work most beneficially with them. The ethical dilemma presented highlights the

importance of having a multicultural understanding of sexual orientation and Christianity in

the context of Singapore.

Sexual Orientation

The formation of sexual orientation is complex and thought to be the result of

environmental factors (e.g., cultural norms, parental dynamics), and personal factors (e.g.,

gender identity, experience of sexual attraction, motivation to live with incongruence)

(Beckstead, 2012). As such, one should not take a reductionistic approach to understanding
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the development of homosexuality. The discussion of acceptance of homosexuality in

Singapore has been a divisive topic, and was centered around the repeal of Section 377A of

Penal Code criminalising homosexual behaviour. The Church has been a prominent opponent

to this, and has been a significant reason why the code of law has withstood multiple repeal

attempts (Mathews, 2009). Being part of the church, it is plausible that these experiences

could have impacted Alex’s decision to seek SOCE which should be explored. Additionally,

given that sexuality can be conceptualised on a continuum (Przeworski et al., 2021) it is

important to understand Alex’s perspective of it.

Christianity

The Singaporean Christian community comprises predominantly of conservative

Christian denominations, majority of which endorse that homosexual activity is sinful

(Mathews, 2009). As a psychologist who shares the same religious beliefs as Alex, it is

important for me to be mindful not to impose my extent of adherence or interpretation of

religious text on Alex. It is also important not to take for granted the multicultural

competency I perceive to know about Christianity and take an exploratory approach to that as

well. Approaching pastoral staff to learn about their perspectives of managing homosexuality

and Christianity, and learning from other individuals in similar positions as Alex would be

helpful in expanding my understanding of the challenges they face. Due to differences in

which one can interpret religious texts and define what adherence looks like (American

Psychological Association, 2009), it is also important to understand how Alex rationalises his

adherence to his religious practices.

While prior knowledge to these factors do not necessarily equate to acquiring full

multicultural competence, it provides the psychologist with some contextual understanding

which facilitates the continual acquisition of multicultural competency from the client, and

fosters the building of therapeutic alliance.

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Referring to the guidelines for appropriate responses to sexual orientation (American

Psychological Association, 2009), resolutions to conflicts in religious and sexual orientation

should be viewed as an individualised process, which perhaps explains the lack of concrete

ethical guideline available. This can be achieved through an affirming approach (Przeworski

et al., 2021) which is a framework defined as a set of approaches as opposed to a specific

therapeutic modality (Hinrichs & Donaldson, 2017). One of such ways outlined by Tan &

Yarhouse (2010) is the use of mindfulness to facilitate acceptance of Alex’s conflicting

identities in a non-judgmental way. Despite Alex having beliefs that both identities are

incompatible with each other, acceptance work places emphasis on the non-judgmental

awareness of having these incompatible orientations. I may also consider facilitating

discussions that allows for the option of an integration between religious and sexual

orientation as a starting point instead so as to encourage him to define his own definition of

sexual identity management (Beckstead & Morrow, 2004).

Should Alex persist in wanting sexual orientation change, I would not proceed

without clearly explaining to him the available what the definitions of SOCE are, the

evidence-base for SOCE, and the reported distress others might experience from it (Shidlo &

Schroeder, 2002). I would also brainstorm how feasible the ways in which others have

integrated religious and sexual orientation (Fjelstrom, 2013) are for him. A thorough

discussion of what he anticipates he would gain or lose out of his decision for SOCE, and

how he would cope with this is also necessary. This would be crucial in understanding what

decision to take that would be acting in beneficence for him. Haldeman (2004) has suggested

facilitating behavioural experiments on how to ‘take on’ a fully Christian or fully gay identity

as a form of exploration for aspects of dissonance he may face. As this may be distressing for

Alex, apart from ensuring prior therapeutic alliance is built, it is also helpful to reflect on

aspects of Christianity emphasising God’s loving nature as a means of guided exploration to

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understanding how he balances his perceived sinful nature, and attaining forgiveness.

Seeking supervision preferably from a psychologist who has experience working with such

cases is also necessary to determine if my decision-making is sound. Additionally, I would

also consider advising Alex to explore options of speaking to pastoral staff anonymously in

his church, or other churches which share the same doctrinal beliefs as his.
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References

American Psychological Association. (2000). Guidelines for psychotherapy with lesbian,

gay, and bisexual clients. 55, 1440–1451. https://doi.org/10.1037/0003-

066X.55.12.1440

American Psychological Association. (2009). Appropriate Therapeutic Responses to Sexual

Orientation.

American Psychological Association. (2021). APA Resolution on Sexual Orientation Change

Efforts.

Beckstead, A. L. (2012). Can We Change Sexual Orientation? Archives of Sexual Behavior,

41(1), 121–134. https://doi.org/10.1007/s10508-012-9922-x

Beckstead, A. L., & Morrow, S. L. (2004). Mormon Clients’ Experiences of Conversion

Therapy: The Need for a New Treatment Approach. The Counseling Psychologist,

32(5), 651–690. https://doi.org/10.1177/0011000004267555

Fjelstrom, J. (2013). Sexual Orientation Change Efforts and the Search for Authenticity.

Journal of Homosexuality, 60(6), 801–827.

https://doi.org/10.1080/00918369.2013.774830

Haldeman, D. C. (2004). When Sexual and Religious Orientation Collide: Considerations in

Working with Conflicted Same-Sex Attracted Male Clients. The Counseling

Psychologist, 32(5), 691–715. https://doi.org/10.1177/0011000004267560

Hinrichs, K., & Donaldson, W. (2017). Recommendations for Use of Affirmative

Psychotherapy With LGBT Older Adults. Journal of Clinical Psychology, 73.

https://doi.org/10.1002/jclp.22505

Mathews, M. (2009). Christianity in Singapore: The Voice of Moral Conscience to the State.

Journal of Contemporary Religion, 24(1), 53–65.

https://doi.org/10.1080/13537900802630505
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Miville, M. L., & Ferguson, A. D. (2004). Impossible “Choices”: Identity and Values at a

Crossroads. The Counseling Psychologist, 32(5), 760–770.

https://doi.org/10.1177/0011000004267568

Przeworski, A., Peterson, E., & Piedra, A. (2021). A systematic review of the efficacy,

harmful effects, and ethical issues related to sexual orientation change efforts.

Clinical Psychology: Science and Practice, 28(1), 81–100.

https://doi.org/10.1111/cpsp.12377

Schroeder, M., & Shidlo, A. (2002). Ethical Issues in Sexual Orientation Conversion

Therapies: An Empirical Study of Consumers. Journal of Gay & Lesbian

Psychotherapy, 5(3–4), 131–166. https://doi.org/10.1300/J236v05n03_09

Shidlo, A., & Schroeder, M. (2002). Changing sexual orientation: A consumers’ report.

Professional Psychology: Research and Practice, 33, 249–259.

https://doi.org/10.1037/0735-7028.33.3.249

Singapore Psychological Society. (2019). Singapore Psychological Society Code of Ethics.

Sue, D. W. (2001). Multidimensional Facets of Cultural Competence. The Counseling

Psychologist, 29(6), 790–821. https://doi.org/10.1177/0011000001296002

Tan, E. S. N., & Yarhouse, M. A. (2010). Facilitating congruence between religious beliefs

and sexual identity with mindfulness. Psychotherapy: Theory, Research, Practice,

Training, 47, 500–511. https://doi.org/10.1037/a0022081

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Appendix A

Case Vignette

Alex is a 23-year-old Singaporean Chinese male who grew up in a Christian family,

and is himself a devout Christian. He reported having “feelings” for boys which start in early

childhood, and developed stronger attractions by adolescence. However, as practising a

Christian, he knows that homosexual behaviour is not condoned by his religious teachings.

This has caused him distress, which prompts him to explore options to “get rid” of his

homosexuality. He is intrinsically motivated to seek treatment, and denies external pressures

influencing his decision. He is seeking treatment at a secular private clinic as he is unsure if

word may spread about his sexuality if he discloses this to a pastor in his church. It is

assumed that I, the psychologist, has some knowledge of delivering SOCE.

Adapted from case vignettes from Haldeman (2004).