Scaffolding around Sexuality

In the mid 1980s Universal Building Supplies, Inc., was contracted to create a scaffolding for work that was to be done on the Statue of Liberty. At their web site, the company offers some unique perspective on how they responded to several of the challenges they faced in taking on such a daunting task.

This past week I spoke at a local church that had just completed a series on sexuality. They asked if I would do a training with their staff on how to respond to issues that arise within the local Body of Christ. The image I drew upon was that of scaffolding, an intentional framework that is set in place around a structure so that work can be done to restore that structure to its original design. When the scaffolding is removed, the structure stands on its own. One limitation in this metaphor is that the Body of Christ need not be absent in the life and struggle of the individual congregant. Rather, a scaffold can always be in place. But there are times when people benefit form more structure, more support, as they work through an issue in their life.

We first discussed the kinds of issues that are being seen in the local church. These include issues with pornography, affairs, sexual addiction, sexual identity concerns, gender identity concerns, and other issues. A similar list could be generated at nearly every large church in the U.S., I imagine.Whenever a church does a series on sexuality, there is inevitably a “flare up” of issues. Not that these are new, but rather that they come to the surface as the topic has been discussed. People may seek help for the first time. People may see this as a time to finally make some headway in an area where they have previously felt stuck.

We then discussed the common fears congregants have around even talking with a staff member about sexual issues. The include fear that no one can help them (which is fundamentally a question about competence – can YOU help ME?), fear of exposing secrets (an affair, for example), fears related to sharing one’s values (and the subsequent fear of being judged), and fear that they are talking about a topic that “no one will understand” (for example, an issue that they believe is rare, such as perhaps a fetish or other concern).

I then did a little teaching on a biopsychosocial/spiritual perspective on sexual concerns, identifying ways in which each of these can be “weighted” differently for different people and different concerns. Unfortunately, mental health fields often emphasize biopsychosocial considerations to the neglect of spiritual considerations. The opposite can also be true: churches emphasize spirituality to the neglect of biological, psychological, and/or sociocultural considerations. Good science in this area complements a Christian worldview. So not only is there complexity here in presentation that should be understood and discerned, but how a staff person thinks about an issue and the language that the staff person uses may be important.

We then discussed local community resources, including those within this specific church. We discussed local clinicians who provide individual, couple, family, and group therapy options. We discussed local ministry options.

We also talked about practical ways in which you meet someone where they are, recognize the nature of the struggle, use “parts” language to identify their ambivalence (as most people have mixed feelings about “giving up” something that has met their felt needs), and then help to “grow” the part of them that is wanting to make meaningful changes in this part of their life.

Scaffolding around sexuality means providing structured support. The local church community is in a unique position to do this and to work with others in the community to offer a framework for recovery, healing, and restoration in many areas related to sexuality.

New Spitzer Interview

The sponsoring organization that made this video is trying to ge more mileage out of Robert Spitzer’s change of heart regarding his 2001 study (later published in Archives of Sexual Behavior in 2003). In this interview, Spitzer shares several thoughts that range from how he responded to his own doubts about the study to whether others should show a video of Spitzer talking about his study initially.

It is difficult to know what to say about this interview, but let me offer a few thoughts:

Citing the study. On the question of whether others should cite the study, I can appreciate Spitzer’s desire that others not cite the study, but that is beyond any researcher. The findings are what they are, limitations and all. And many people have pointed out the limitations of the study (see the original publication in ASB and the 20+ commentators). As the editor of ASB noted, retractions and regrets are two different things.

“Seeding” the study. A comment is made by the narrator on how a reparative therapist “seeded” the study with his clients. That sounds more like a design issue for Spitzer. If the researcher solicited participants from reparative therapists, then I don’t see the issue with a reparative therapist informing his patients of the study. If the therapist had been conducting the study, then we would be having a different discussion about how best to obtain a sample.

Past interviews. I don’t think I’ve seen these other videos of Spitzer talking about his study previously (with the exception of the I Do Exist DVD from Throckmorton). Is it wrong or unethical to show those videos? I think it wise that if the videos are shown to acknowledge that the researcher has had a change of heart toward his initial interpretation of the findings.

Closing declarations. This was probably the most interesting part of the interview for me. I’m not sure what to make of Spitzer’s claims toward the end of the interview. These include that those who advance ex-gay therapy are “full of hatred of homosexuality”; that any attempt to change is “misguided”; that orientation “cannot be changed”; and that efforts to change will be “disappointing” and “can be harmful.” Where to begin?

There are no doubt people who hold a great deal of hatred toward homosexuals, but is it true that those who provide such therapy are full of this hatred? I know that that is the developing narrative, but is it true? Is the offering of such therapy (or assistance in the form of ministry) an act of hatred toward homosexuals? Although I do not provide reparative therapy, I know some people who do, and I am quite familiar with the various Christian ministries that exist, and I find this kind of declaration fails to grasp the motivations some people have who pursue such therapy (as well as the motivations of those who provide such therapy). Without some evidence to support the charge, it comes off as rather unscientific as stated.

The claim toward the end of the interview that sexual orientation “cannot be changed” is particularly interesting given Spitzer’s change of heart regarding the methods of his own study. It is one thing to admit growing doubts about whether the design was adequate to support the initial conclusion that in some cases sexual orientation can change, but it is quite another thing to declare that orientation cannot change. Presumably this is coming from the same study that was not of adequate design to support the claim of change. If a researcher concludes that the design is poor, and it cannot prove success, then that study cannot disprove success or prove failure.

Memorial Day

One of the benefits to living in Virginia Beach has been getting to know so many military families. We have several bases here and in the surrounding area; there are over 20 active military installations in Virginia. Here in the Tidewater area, these include the Army represented (e.g., Fort Eustis, Fort Story), the Coast Guard, and the Navy (e.g., Little Creek Naval Amphibious Base, Oceana Naval Air Station).  That brings many military folks into our daily life. Whether we are talking about our neighborhood, our church, our place of employment, and so on, we have many active and retired military here in our community.

So Memorial Day takes on a new meaning. We have lived here for over 14 years, and I’ve never lived in an area that had so many military personnel present. And it matters. Memorial Day is not just another day off of work. It is not just a day to get the pool going or to break out the grill. Rather, it is a time to reflect on the meaningful service and sacrifice of the many folks in this area. We can discuss and debate particular policies (and neighbors/coworkers/etc. do), but what cannot be debated is the level of commitment it takes to serve the country in this unique capacity.

So Thank You for your service. Today we remember those who have made the ultimate sacrifice in service of our country.

On Legislating around the Complexities of Clinical Practice

There has been a lot in the news recently about whether California will ban the practice of reorientation therapy with teens and have specific wording as part of informed consent for adults who seek such services. The California senate committee has passed Bill 1172 to the full senate for a vote. I was interviewed about this today for a story that may run over the weekend, and let me share a few thoughts.

In terms of practicing cognitive complexity, let’s take a look at this from the perspective of those who are advancing Bill 1172. It appears to be out of a genuine regard to protect young people who are believed to be at risk for a type of therapy that proponents of the Bill believe is ineffective and inherently harmful.

On the other side are those who disagree with the Bill for several reasons. The main concerns that come to my mind are these:

1. Venue. I tend to agree with the various CA mental health organizations that have either opposed the Bill or expressed concern that legislating around the complexities of clinical practice in this area is not a good idea. Although it isn’t the first case of making a technique or practice illegal, it is not a common practice at all. Opponents also point out that mental health professionals have regulating bodies that oversee clinical practice, license practitioners, and follow up on ethical complaints. Further, several mental health professions also convene working groups and task forces to review the extant literature and provide updates on research in this area, trying to make that information available to practitioners and the public alike.

2. Science around SOCE for teens. There is not much by way of well-designed research on adolescents who pursue sexual orientation change efforts (SOCE). I don’t think the 2009 APA task force report on appropriate therapeutic responses to sexual orientation was able to identify one such study (if memory serves); instead, the task force cited published articles with case examples of clinicians who worked with adolescents navigating sexual and religious identity conflicts. The science that seems to be cited is that of adults who participated in SOCE and then extrapolated to the adolescent.

3. Science around SOCE for adults. This brings up the research on SOCE for adults that has been reviewed by a number of professionals and organizations. The Bill references a number of mental health organizations. One concern is that the Bill uses stronger language than the organizations, in at least a few cases. For example, the Bill indicates that SOCE are ineffectual, while the APA task force tends to talk about not have sufficient evidence to support claims of change, that change is “uncommon”, and that newer studies are not sufficient in quality to answer whether or not SOCE does or does not change orientation. I would note that there are those who disagree with these conclusions, but even if you agreed with these conclusions, this language and these nuances are simply not seen in the Bill.

4. Beyond attractions/desires. The other issue that has been brought up by some of the CA mental health organizations that oppose the Bill in its present form has to do with how broad it is. I believe their concern had to do with a possible unintended consequence if clinicians were not to work with teens to explore a range of sexual and gender identity issues for fear of legal ramifications associated with Bill 1172. I would also note that the Bill covers therapies to change attractions, desires, and behavior. That is rather remarkable and extends far beyond therapies that purport to change orientation. Is anyone really wanting to get behind a legal measure that restricts a clinician from helping someone change their behavior?

5. Issues with informed consent. I wrote an article published in 1998 that argued that those who provide reorientation therapy should obtain advanced informed consent for their services. Informed consent refers to the kind of information the average person would need in order to make a meaningful, informed decision about services. Advanced or expanded informed consent provides even more details about services, potential benefits, risk of harm, and so on. What I did not like about the Bill is that the language overreaches in it’s claim of SOCE being ineffective and the extent of potential harms associated with it. These seem to me to be important considerations that need to be tied to well-designed research studies. The existing research (with the use of convenience samples and seeking out those who were not pleased with services) is fraught with too many methodological problems to be the last word on risks associated with this type of therapy. I am not saying that there are not risks. But I am saying that important questions about the interventions, expectations, and competence of the clinician should also be better understood.

I would also like to see an advanced inform consent form co-authored by people who represent the different stakeholders in these discussions. Is the research far enough along that we could see an informed consent form where people who might otherwise disagree on a number of issues can at least agree on what the public needs to know to make truly informed decisions about services?

6. Trends in providing services to minors. One last thought is that Bill 1172 appears to run contrary to current trends in terms of access to services by minors. I do not want to make too much of this because there are legitimate concerns here about potential harm to minors through misinformation about unrealistic expectations, stigma, and so on. But the trend is toward putting mental health and related health care decisions into the hands of adolescents rather than restricting access (think reproductive health, parental notification laws, issues with consent, etc.). This discussion moves in the other direction – toward restricting access even if an adolescent where to assent to treatment.

I want to reiterate that I recognize the concern that minors may be at greater risk in some ways. Of course a competent clinician knows that he or she has to obtain assent from any minor who seeks any kind of mental health services, even in cases where the parent have provided consent. If the minor does not assent to services, the services should not be provided. I also recognize that some minors may give assent because of pressure they feel from their parents – and this is a genuine concern.

Although I do not provide reorientation therapy, I would say that in my experience not that many teens request reorientation therapy. The interest in it tends to come more from the parents, so the idea that there could be  pressure from parents is definitely something that should be addressed with all involved.  I think the best way to handle the potential for undue pressure is to do a good and thorough assessment of goals, expectations, motivations, and so on. I am really open to ideas on this one, but it is worth more reflection.

I am sure that there are other arguments both for and against the Bill. These are just a few thoughts. And I don’t intend to come across as a defender of reorientation therapy for minors. I have mixed feelings about reorientation therapy. It is not something I provide. My preference is to explore sexual identity questions and to navigate conflicts between religious and sexual identity concerns (following the SIT Framework). But I have defended the rights of clients to pursue such therapy if they are given sufficient advanced informed consent. I hadn’t thought about it that much for teens in part because I have not seen that many teens asking for it.

In any case, I hope these reflections show that this is at least a  complicated issue. My main concern is that legal answers such as the one proposed rarely reflect the complexity inherent in providing clinical services.

UPDATE: CBN News ran a story on the CA Bill.

UPDATE: The CA Senate approved Bill 1172. (5.30.12)

Responding to Gender Atypical Behavior in Childhood

There is another story making the rounds on the internet. Baptist minister Sean Harris offered a “special dispensation” to parents of gender nonconforming children. Here is a portion of the transcript from Good As You:

So your little son starts to act a little girlish when he is four years old and instead of squashing that like a cockroach and saying, “Man up, son, get that dress off you and get outside and dig a ditch, because that is what boys do,” you get out the camera and you start taking pictures of Johnny acting like a female and then you upload it to YouTube and everybody laughs about it and the next thing you know, this dude, this kid is acting out childhood fantasies that should have been squashed. Can I make it any clearer? Dads, the second you see your son dropping the limp wrist, you walk over there and crack that wrist. Man up. Give him a good punch. Ok? You are not going to act like that. You were made by God to be a male and you are going to be a male.

He has since that time offered a clarification that he misspoke and overstated what he was trying to convey. Thankfully, many Christians have rejected these suggestions and challenged his statements.

Harris raises a controversial topic that is actually difficult for many parents: How should Christian parents respond when their child demonstrates gender nonconforming (or what is sometimes referred to as gender “atypical”) behaviors?

This is an area that I was asked to cover when I wrote Homosexuality and the Christian: A Guide for Parents, Pastors and Friends. I won’t be able to do the topic justice here, but you can take a look at Chapter 5 of that resource. As I mention there, gender nonconformity in childhood is often reported by adults who identify as transgender and by adults who identify as gay or lesbian. It is not uncommon for Christian parents to express concern about homosexuality (parents are not typically aware of Gender Identity Disorder) if their child is demonstrating gender atypical behaviors.

As you can imagine, this is very controversial in the field of psychology. I am not aware of any research suggesting that a parent can intervene to prevent homosexuality. It might be argued that since we do not know the causes of homosexuality (we tend to discuss Nature vs. Nurture but it is likely some combination that is weighted differently for different people), the environment could be addressed in some way, but it is unclear the extent to which that would be preventative as such.

There is some data that supports the view that parents can intervene to help reduce symptoms of Gender Identity Disorder (GID) in childhood (see the work of Dr. Ken Zucker on this). At the same time, the field has been trending toward a different strategy altogether when there has been a diagnosis of GID (i.e., use of hormone blockers to delay puberty until the child – then a teen – around 16 or so can make a decision about gender identity).  This approach is also controversial.   There are still those who intervene through therapy and coaching parents in how to redirect their child away from gender atypical behaviors (again, Dr. Ken Zucker being perhaps the most well-known example). But that approach looks nothing like what Harris was suggesting in his sermon.

If any good can come out of the statements by Harris, perhaps it is that parents will reject his suggestion (as they should) and look for helpful resources on whether or how they might respond to gender typical behaviors in childhood. There is still much that we do not know about gender atypical behavior, sexual identity, and gender identity, so there is a need for humility as we consider what is best for a child in these circumstances.

Anti-Christian Diatribe and the Need for Increased Cognitive Complexity

There has been a lot of discussion of Dan Savage’s recent diatribe on the Bible and on Christians at a national journalism conference, including discussions about insulting the estimated 100 or so teenagers who didn’t care to listen to him trash their faith in such a vulgar manner.

Predictably, people are reacting to his extremism. Before I get to that, let me say this: It is always interesting to hear someone who does not understand hermeneutics discuss the Bible. Not only does he make the mistake of claiming that Scripture is pro-slavery, but he proceeds to demonstrate his lack of understanding of the Holiness Code. It is obviously intuitively appealing to some of the students, as there is a fair amount of applause at different points. But throughout his rant there is a steady stream of teens leaving the session.

The timing is interesting; I actually just finished reading the biography of William Wilberforce (by Eric Metaxas), Amazing Grace: William Wilberforce and the Heroic Campaign to End Slavery. I’ll likely blog about the book because it is a helpful reminder of the role Christians played in creating a social conscience around those who were suffering and dying through slavery, which was clearly seen as an institutionalized evil by many evangelical Christians of that day. The book Amazing Grace is a good place to start for anyone who thinks Savage got any of this right about slavery. Also helpful might be Slaves, Women and Homosexuals by William Webb. I realize that neither of these resources is as colorful as Savage; but there is something to be said for historical accuracy.

What I want to focus on is not the claims themselves but the process that comes from any extremist rant or diatribe. It creates  further division and emotional polarization. By not entering into a thoughtful, informed exchange of ideas around biblical scholarship, theological ethics, or care and protection of others, these kinds of outbursts only create more polarization. They can reflect the speaker’s lack of cognitive complexity around values and will drive others (in the audience – live or via the web) toward less cognitive complexity and tolerance of differing values. (In fact, the web is a prime setting for fostering value polarization.)

I do think that if I put myself in the speaker’s shoes and try to give him the benefit of doubt, which is difficult, I suspect that his primary value has been around protecting vulnerable youth – sexual minorities who he sees as at great risk of hurting themselves – which he associates with religious doctrine. But I do not think that the enemy here is Christianity, even when we are talking about a doctrine that teaches an orthodox sexual ethic. Many Christians would stand in solidarity against violence toward anyone by virtue of that person bearing the image of God. This would obviously include young people who are sorting out sexual identity questions or who have embraced a gay identity. By attacking Christianity, the speaker fuels emotional polarization which leads to further entrenchment because it limits cognitive complexity. It moves people toward black and white thinking that does not lend itself to living in a diverse society.

The enemy, then, is not Christianity; nor is it the gay community. Nor is the answer necessarily to foster a gay Christian community as such. Rather, I would say that all of these can coexist, but it means identifying the real problem, which I think is found (from a psychological standpoint) in the  cognitive elements found in extremism, in how both “sides” in a debate can make certain values trump when they reflect their extreme views.

People who want to move forward in a world that reflects substantive diversity will be able to think in more complex ways, particularly around values and social issues. (Substantive diversity refers to really respecting genuine differences in values, hence the adjective “substantive”.)  That does not mean finding ways to have other people agree with you. That does not mean winning the public debate. That does not mean passing laws that enforce your preferred values. No, it is recognizing the diverse world in which we find ourselves and creating space for that diversity of thought and values. The capacity to see that, to demonstrate perspective-taking and to find pro-social ways of relating to one another, reflects this kind of cognitive complexity.

Examples of extremism and lack of cognitive complexity are ubiquitous and can be found around many emotionally-charged social and values issues. This is just one recent example. And it is tempting to point a finger at the “enemy” who is opposed to your preferred values. Again, there is a resource in the field of psychology that can assist. The way forward is found in increasing cognitive complexity.