Understanding Sexual Identity Therapy

This past year I’ve dealt with an interesting challenge that faces Christians who produce scholarship in controversial areas. My area is sexual identity, and I’ve been researching and providing services in this area for many years now. There are not many models for how to do integration in this area, and there are few people even doing it. So the challenges are plentiful.

Specifically, the topic I’m addressing is how to provide clinical services to people who are sorting out sexual identity issues. The model I’ve been developing (and the accompanying framework I’ve been co-developing with Warren Throckmorton) is referred to as sexual identity therapy (SIT). What is SIT and how did it come about?

SIT is essentially a client-centered and identity-focused approach to navigating sexual identity questions or concerns. It has often been contrasted to reorientation therapy and gay affirmative therapy. It is based on the idea of helping people reach congruence, so that they live and identify themselves in a way that is consistent with their beliefs and values. Sexual attractions or orientation may or may not change, but the overall emphasis is on identity.

How did this approach come about? My earliest involvement with SIT traces back to a concept paper published in 2001 that suggested an alternative model of sexual identity development, which refers to how the act of labeling oneself (as gay, lesbian, bi, or choosing not to do so) is experienced developmentally over time. I was particularly interested in people I was working with in my clinical practice who did not integrate their same-sex attractions into a gay identity. This led to a series of studies comparing people who experienced same-sex attraction and identified as Christian. I compared a group that integrated their same-sex attractions into a gay identity to a group that dis-identified with a gay identity and the people and institutions that support a gay identity.

At the same time I was working with clients who were either sorting out sexual and religious identity conflicts or had tried to change their sexual orientation through involvement in professional reorientation therapy or Christian ministries. The people I saw at that time did not experience as much success in their change effort as they were led to believe was possible. They were discouraged, and some would frame their experience in an “all or nothing” way, such that they either changed their orientation or they were gay. They did not feel another option was available to them.

So my involvement with SIT was to explore a way of doing therapy that provided these people with a professional approach that would respect their beliefs and values and would allow for direction or trajectory that was meaningful even if their orientation did not change. Many people who came to see me at that time were conservative Christians, and many at the end of what was developing into SIT chose not to identity publicly or privately as gay; rather, they formed a primary identity around other aspects of who they were as a person, such as their religious beliefs and values.

In my practice today, SIT revolves around four central concepts that came from that early concept paper and subsequent research: (1) a three-tier distinction between same-sex attraction, a homosexual orientation, and a gay identity, (2) weighted aspects of identity, (3) attributional search for sexual identity, and (4) congruence. First, the three-tier distinction is between same-sex attraction, a homosexual orientation, and a gay identity. The idea is that more people report experiencing same-sex attraction or having a homosexual orientation than the number of people who identify as gay. Being gay is a unique sociocultural phenomenon, and it is a self-defining identity label that not all people who experience same-sex attraction adopt. Such a distinction creates room for using descriptive language while exploring identity considerations. Most people I work with choose to describe their attractions rather than embrace a gay identity.

Second, I discuss weighted aspects of identity, by which I mean that people consider many factors when they make decisions about public and private sexual identity labels. These ‘aspects of identity’ include biological sex, gender identity, attractions, intentions, behaviors, and beliefs/values. People often decide that one or more of these aspects of identity are really important to them, such as behavior (e.g., choosing chastity) or beliefs and values (e.g., Christian morality), and they give it greater ‘weight’.

Third, I join people on what I refer to as an ‘attributional search’ for identity. This means exploring with clients the meaning that they make out of the fact that they are attracted to the same sex. I don’t assume that their attractions are the result of childhood sexual abuse, biological predispositions, parent-child relationships, or any other particular theory; rather, I discuss with them how they make meaning out of their attractions. Many will cite these theories; some will discuss “the fall” as the cause of their attraction to the same sex.

The fourth and final key concept for me is congruence. This means helping people line up their behavior/identity and beliefs/values. I have found this to be a natural result of the first three key concepts.

What has been interesting is that this past year I have seen some people in the gay community claim that SIT is really reorientation therapy, and I have seen some people in the conservative Christian community claim that SIT is really gay affirmative therapy (at least functionally so at one stage in therapy). The first mischaracterization—that SIT is really reorientation therapy—came up this past year when a gay psychologist involved in the scientific review process attempted to portray SIT as conversion therapy to get other reviewers to reject proposals in which SIT was mentioned. This was resolved amicably when it was acknowledged that the recent APA task force report identified SIT as an identity-focused model and not as reorientation therapy.

The other mischaracterization—that SIT is really gay affirmative therapy (at least at one stage)—happened recently when someone in conservative Christian circles made the claim, and it is a statement worth responding to so that it is clear why this is a mischaracterization and not an accurate understanding of SIT.

Before I do that, let me offer one observation on this idea that I am defending SIT against assertions that it is either reorientation therapy or gay affirmative therapy. What’s interesting is that these are the two polarized positions in the models of therapy offered to sexual minorities today. The whole purpose of developing SIT was to offer an alternative to these two polarized positions. It is interesting to me that those most invested in this debate will not allow a third option to develop; rather, they appear to need to frame the debate in the two models they know.

The focus in SIT is sexual identity not sexual orientation. Again, much of my work is with people who have tried to change and had modest success with it, and so they are looking for other meaningful ways to grow and develop, and sexual identity is one way to do that, particularly for those who focus on other aspects of who they are as a person.

As to the charge that SIT is gay affirmative therapy. Gay affirmative therapy tends to assume that a person is gay, that they are discovering this about themselves. The therapist simply creates a safe place to discuss “coming out” and is mindful of issues such as bullying and family dynamics, etc., that make “being gay” difficult. It tends to rest on the metaphor of discovery. That is, a person discovers that they are gay—they have been all along. There is much more to gay affirmative therapy, but this gets at one way to understand it at least at a general level.

The way I practice SIT is based not on the discovery metaphor but on the metaphor of integration. People have choices to make about whether they integrate their same-sex attractions into a gay identity or not. If they choose not to, they often form a positive identity around other aspects of who they are as a person. One of the most salient aspects of identity for Christians is an identity that is “in Christ.” But in creating space in therapy for a person to make a genuine choice about identity, there is by necessity the option of making other choices (otherwise the choice was not a genuine one to begin with). So a person might choose to integrate same-sex attractions into a gay identity. That is a possible outcome when a person is given an opportunity to genuinely choose to dis-identify with a gay identity.

A related question is this: Is creating a space for people to make choices so unusual in therapy? I would answer no. People make choices all of the time in therapy, and some of those choices are not ones I would choose for them. For example, I provide a lot of marital therapy. I want the couples I work with to stay married. However, some decide to divorce. For them to genuinely choose to stay in their marriage means that they could also choose to dissolve the marriage. It is a choice, and it is not a choice that I make for them. This principle of client autonomy and self-determination is a central principle in how therapy is practiced today, and it is based on many things, including case law that established a patient’s right to informed consent to treatment in medical ethics.

The concern that has been raised about whether SIT is gay affirmative therapy raises a broader and more fundamental question about the place for Christians in the mental health fields. This is not limited to the topic of homosexuality. The question is: How ought Christians to position themselves in the field? Do they provide therapy in a direction toward a certain outcome? Do they provide information and opportunities for clients to make their own choices? If so, at what point might those choices run contrary to the values of the Christian mental health professional? This happens in many controversial areas, as well as areas that are not that controversial. It is more of a fundamental question about the role of the mental health professional, and there are legitimate disagreements among Christians in this area.

Some people will assume that Christians in the mental health field should function like they are a particular kind of pastoral care provider. Although there are many ways in which pastoral care providers practice, I see pastoral care providers as representing their faith tradition in a very intentional way. They hold up a standard and provide pastoral care to help people move toward that standard of orthodoxy (right belief) and orthopraxy (right practice). Orthodoxy and orthopraxy is not determined by the counselee but by the pastoral care provider in the sense that he or she represents the faith tradition and its doctrines out of which the care is being provided. Some people view licensed mental health professionals in the same way; that is, they should counsel in a specific direction because they represent Christian commitments in a particular way. This is a point for discussion among Christians in the field.

Others would view licensed mental health professionals as different than pastoral care providers in some important ways. They would see a licensed Christian psychologist, for example, as entering enter into a fiduciary relationship with the public, a relationship built upon trust, and part of that trust is built upon the assumption that the services provided are in keeping with the standards in the field as it is currently governed by the state in which the psychologist practices. So a group of one’s peers (psychologists, in this case, not Christian psychologists necessarily) would reflect on what is standard practice for addressing the topic of homosexuality in clinical practice. In this context, one might look at SIT as helping to provide a kind of therapy that the broader field can support, even as it stands in contrast to gay affirmative therapy (and reorientation therapy). This is important in part because gay affirmative therapy would be an unrealistic option for some religious clients.

Indeed, SIT provides an alternative that safeguards client autonomy and self-determination in making decisions about identity and behavior. With respect for client autonomy and self-determination comes the possibility that a client may make choices about identity that go against the values of the Christian mental health professional. But we can respect the client’s right to make that choice.

Note: This is cross posted on the ISSI web site here. Warren Throckmorton has offered his own perspective on the SIT Framework here.

9 thoughts on “Understanding Sexual Identity Therapy

  1. Dr. Yarhouse,

    I think you are oversimplifying the concerns of both sides.

    First, regarding those who think SIT is potentially gay-affirmative:

    SIT can never take the form of reorientation therapy whereas it can take the form of gay-affirmative therapy if the client takes it in that direction. This doesn’t mean it is definitionally “gay-affirmative therapy” in any case, but from the conservative Christian perspective (namely, those that believe in “change” through the power of Christ), SIT is biased toward possible affirmation of gayness, and biased against “change.” Maybe this perception is a result of folks refusing to acknowledge the “science” on orientation change (that “orientation change” is unlikely), which is why you seem to stress “identity.” But there was a time when “orientation” wasn’t (it’s as much a sociocultural phenomenon as the “gay identity” is), and a lot of the debate in conservative America isn’t about “orientation change,” per se, but about the notion that gays created both the “identity” AND the “orientation” to justify their “behavior” and, so, how is this situation to be rectified so that children don’t fall into the culture of gayness, the “homosexual lifestyle?” I think the concern is that SIT pretends itself to be in an ivory tower in this battle.

    From the other perspective, I can see how SIT is merely an extension of reorientation therapy, partly because gay-affirmative therapy does take into account that “orientation” is a sociocultural phenomenon. “Being gay,” on the one hand, is a process of “discovery,” a discovery of being “different from the norm” (or at least, having different feelings than the norm). But a lot of older gay folks realize that this discovery, in hindsight, is really the same that all human beings as sexual beings go through, only different because of the structure of the “closet” or “sexual orientation” in society. Thus, your teasing apart of the “attraction,” “orientation” and “identity” to create additional therapeutic space for people to “not be gay” if they want is the same song and dance of reorientation therapy, the only difference being that reorientation therapy was a failure, so folks are trying something else.

    I think that what you’re doing with SIT is noble, and works to an extent in light of the environment of the APA. But I also think that it is theoretically shaky.

  2. Alan,

    I appreciate your thoughtful engagement with SIT as I practice it and the SITF. Your interaction was exactly what we had in mind when we initially wrote it, posted it on a public web site, and sought feedback from others. So thank you for your thoughts.

    I don’t view the SITF from precluding the possibility of someone changing orientation or even necessarily from receiving services with that as a possible objective (in the context of a larger vision for therapy):

    Although, as we have noted, these recommendations are not treatment protocols for reorientation therapy, they can provide guidance for practitioners who work with clients who adopt a variety of objectives that address sexual and religious identity conflict. (p. 7)

    This quote comes right after a quote from Haldeman in which a number of possible objectives are envisioned. However, the concern raised in SITF is that clinicians avoid placing a theoretical template (with all of its a priori assumptions about etiology and change) on the experience of the client. I remember Warren at some point saying something similar (about the possibility of offering change of orientation therapy without all of the a priori assumptions), although I think he might say that he doesn’t know anyone who practices this way.

    Perhaps the confusion comes when we look at SITF as a framework and SIT as a form of therapy, at least as I practice it. SITF as a framework is to help clinicians responsibly approach the work they do with clients who are navigating sexual and religious identity conflicts. Toward that end, it is meant to help clinicians be more humble about what we know and what we do not know, and it does envision an identity synthesis as the ideal outcome. Of course, an identity synthesis says little (if anything) about whether orientation changes for those whose attractions are in conflict with their religious beliefs. It really can’t say much because there are many possible outcomes. But for those who experience such a conflict, I have been concerned about limiting the only possible positive outcome to heterosexuality.

    I think I remember reading an exchange on Warren’s site in which you thought of me as a “both/and” person in terms of allowing for people to pursue change of orientation and allowing for people to pursue personal congruence. (If I’ve confused you with someone else, I apologize.) I support the right of the consumer to have as much information in their hands as they make a decision about therapy, and I support the right to choose among treatment options. This seems in keeping with medical ethics today. In my own practice of SIT, it is just not the focus (orientation change). The emphasis on it seems to truncate the person, reducing them to only their attractions/orientation, and it seems to me that it would lead to hypervigilance about it. But I work with a lot of people who have attempted change and not had as much success with it as they would have liked. I try to help them with the identity aspects that lead to a meaningful life in light of their faith commitments (typically conservative Christian) and ongoing experiences of same-sex attraction.

    Again, I appreciate your thoughts on the framework and on SIT as I practice it. I can tell you that clients I’ve worked with who had been in reorientation therapy previously do tell me that their experience in SIT is different (not the ‘same old song and dance’). But I think I understand your perspective on why it may seem that way to you. Your comment on it being “theoretically shaky” is also worth exploring further, as more research is needed on the assumptions and key constructs associated with it. I would say that of each type of therapy in this area, whether we were discussing change of orientation, gay affirmative, or sexual identity focused, would benefit from additional study and more in depth reflection.

  3. Hi Mark,

    What I’m gathering from what you’ve said above is that the SITF doesn’t assume “orientation.” Of the three tiers — attraction, orientation, identity — the SITF only gives “ontological presence” to the attractions (given that if those were nonexistent, then the client wouldn’t be seeking out therapy in the first place). From there, everything else sounds client-directed: questions of orientation and identity (or, as you’ve said elsewhere: “sexual orientation identity”). Is this a correct assessment?

    With regard to the “both/and” discussion that arose on Warren’s blog, I understand what you’re saying and believe that you are serious when you talk about “truncating the person” if the clinician becomes “hypervigilant” about orientation change. Yet, I was quoting your (and Jones’) longitudinal study of ex-gays, in which you (and Jones) made some specific comments about the “possibility of orientation change” in the context of the APA asserting that there is no possibility. Page 11 of the summary states: “In conclusion, the findings of this study would appear to contradict the commonly expressed view of the mental health establishment that sexual orientation is not changeable.” Now, perhaps Warren says it best: that saying “orientation change is never possible” would be “unscientific” — but my feeling is that any assertion about “change” (whether it is possible, impossible, or even impossible to say either way) is “unscientific” because the notion of “orientation” is theoretically unsound.

    In any event, your/Jones’ ex-gay study has been taken up by Evergreen International (LDS) as demonstrating that “orientation change is not only possible, but sustainable.” (I concentrate on the Mormon context because this is my site of study.) I know you don’t have full control over how your work is interpreted at every site, but as has been discussed on Warren’s blog, some religious faiths (such as Latter-day Saints) likely paradigmatically require “orientation change.” If SIT can be put in service of such faiths, then it will be. I believe you yourself have mentioned elsewhere that “practicing homosexuality” is an ethical question before it is a scientific one. For some, “being a homosexual” is also an ethical question. As Shirley Cox (LDS, who has written alongside Dean Byrd on this topic) writes regarding SIT: “Perhaps the most important contribution of Throckmorton and Yarhouse is their successful battle over whether or not homosexuality is an ethically treatable condition. They developed guidelines for practice with clients who experience sexual identity conflicts and desire therapeutic support for resolution” (Understanding Same-sex Attraction, Salt Lake City: Foundation for Attraction Research, 2009: 228; my italics). This might not sound so bad, but in the Mormon context, SIT is always toward orientation change — that “change is possible, but not predicable” (ibid, 210), thus leading to my comment above about the “same song and dance.” I’m just trying to be informative here, not combative.

  4. What is a gender identity? gender identity is a psychological aspect of sex? The biological components are present in gender identity?

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s