Deviant Sexual Behavior: Modification and Assessment
(This paper was published in the journal Behavior Therapy, V.6, Number 4, July 1975.)
If this book had been published five years ago, it might have been highly praised. Its subject, aversion therapy, was the treatment in vogue for people we called "deviants." At the time it was fashionable to argue the relative merits of electric shock and apomorphine injections. And at that time we were still capable of imagining that our clinical judgments were value-free, morally neutral. Five years ago I would have singled out for praise Bancroft's succinct style of writing, his clarity in reviewing past research, and his fair evaluation of treatment methods.
But five years have elapsed, a period during which new issues have been brought sharply into focus; in the present context, this book can only appear muddled and evasive. In the intervening years the American Psychiatric Association has removed homosexuality from its list of disorders. AABT has followed a similar course, and the most recent presidential address of this organization questions the values -- the personal and professional morality -- of those therapists who would attempt to change the sexual orientation of homosexual men and women.
Perhaps sensing that morality has become a critical issue, Bancroft begins with it. He carefully reviews the recent objections to the use of aversion therapy on homosexuals, and he focuses particularly on the objection that the behavior modifier is in collusion with societal pressures designed to maintain the status quo. But, unfortunately, his discussion of this point is partial, poorly reasoned and circular when it is not confused. For instance, when mentioning distressed homosexual men, Bancroft states, "It is of little help to such individuals to point out that social attitudes are gradually changing, however desirable change may be." Bancroft is expressing a kindly, benevolent attitude toward homosexual men, though insisting they be treated. Yet earlier in the book Bancroft has taken a different stand regarding lesbians. After pointing out (though not explaining) that there are almost no studies about changing the sexual orientation of the lesbian, Bancroft then says, "This is perhaps as it should be and it is hoped that in the future there are will be less need for the modification of deviant sexual behavior in the male also."
Concealed beneath these seemingly innocent statements are a host of peculiar assumptions. Is Bancroft merely reporting a double standard in societal attitudes toward male and female homosexuals, or is he actively endorsing it? More importantly, is Bancroft suggesting that the behavior therapist is, willy-nilly an agent of society? If the therapist is not simply a guardian of public morality, then why would he use aversive techniques?
Bancroft confuses us constantly. Should we try to "help" patients referred to us by the courts, when submitting to aversive techniques has been made a condition of parole for the prisoner? No, he says, because "In this latter case the therapist is primarily acting as an agent in society." But, paradoxically, Bancroft later writes, while discussing motivation, "The homosexual may recognize all too clearly the advantages of being heterosexual at an intellectual level whereas in contrast he may have already experienced the emotional rewards of a homosexual relationship" (emphasis mine). I confess that I am baffled. If a homosexual has experienced a rewarding emotional relationship, why should he want to change the sexual orientation that enabled him to enjoy that rewards? Why, for that matter, would the therapist want to effect such a change? Surely the behavior therapist that modifies a successful sexual orientation in the patient is doing so not for the patient's good, but as an "agent of society." Bancroft tells his readers about a 48-year-old schoolmaster who was attracted to his male students, though the schoolmaster never acted on this attraction. Naturally, he was worried he might be discovered harboring these desires. A small dose of benperidol eliminated his homosexual interest -- and he stopped masturbating. "Although he then felt relatively sexless, he found life much less troublesome and had not lost anything that was previously rewarding" (emphasis mine). Is asexuality an appropriate goal of treatment? Bancroft's bland assumption that sexuality is not "rewarding" is an astonishing notion, as is the implicit assumption that the patient's alternatives were child molesting, heterosexual marriage, or sexual abstinence. A more useful procedure might have been to follow Serber's lead and trained his patient for appropriate adult sexual behavior with another man.
Despite his evasive and contradictory remarks, it seems inescapable that the author sees the role of the behavior therapist as a social engineer of conventional morality. And indeed he does states this position clearly at one point: "In the absence of unequivocal scientific criteria of morbidity, behavior may be deemed pathological because it violates social norms" (emphasis mine). The naivete and inherent mischief of this remarkable statement requires no comment beyond reminding the reader that every sensible philosopher of science, pre-eminently Karl Popper, has logically demonstrated that no accumulation of scientific facts will every yield a moral position. Even if we have the most "unequivocal scientific criteria of morbidity," we would not be one shot further along toward deciding whether to treat a condition that "violates social norms."
The same contradictory statements are made in other areas as well. The author says much about the advantages of a behavioral approach over the medical model. "A further reason for concentrating on the behavioral approach is that it allows want to escape from the medical model,” and, "in addition behaviorists have been more ready than their psychotherapist colleagues to recognize the part that society plays in labeling behavior as either deviant or symptomatic." Moreover, in his chapter on treating homosexuals, Bancroft again rejects the medical model because rejecting it counted as any tendency of either party to consider the problem and "illnesses" which should necessarily be "treated" and underlying the degree of choice that the patient has. But Bancroft is only playing with words; he repeatedly refers to the "clinical problem" of homosexuality. On a conceptual level, "clinical problem" is equivalent to "emotional illness." Bancroft has not abandoned a normative approach to homosexuality. His point of view is to a large extent based upon psychoanalytic writers such as Beiber's "make-believe" research, and particularly Rado, who rejected Freud's theory of bisexuality. Bancroft even explains motivation of homosexuals in psychoanalytic terms. This is a most curious way of rejecting the medical model! And what of "the degree of choice the patient has area?" The author outlines three choices a patient might have: to respond heterosexually; to reduce homosexual interest; or to reduce the problems in maintaining a homosexual or other deviant adaptation. Bancroft discusses at length the first two options, but then says, "If it is … the improvement of deviant adaptation, discussion of the appropriate help is beyond the scope of this book." So much for choices.
Bancroft might have avoided these traps if he had bothered to learn more about the life experiences and personality characteristics of the "deviants" he treats. His knowledge is severely limited. He states that homosexuals classify women into two categories: women who are like one's mother or sister and tarts and prostitutes. "It is not uncommon for homosexuals to enjoy heterosexual relationships, but only with the second category of women." Also, "pedophilia, although most commonly homosexual, may also be heterosexual in the choice of partner involved." These are outrageous statements. Where do they come from? Certainly not from research. There is no discussion anywhere in the book about homosexual behavior or personality characteristics. Surely there is a large enough literature to be cited. Has it no relevance to therapists? Nowhere do we find data to indicate that some homosexuals suffer from pathology; nor can we discover the great quantity of data that says they do not. Homosexuals are treated as members of a uniform class and the wide variety of their behavior patterns is never taken up. In Bancroft's only example regarding fitting personality to treatment, he tells us from experience to be cautious in the use of electric shock with masochists. It turns them on! The paucity of facts and the unintended jocularity are equally distressing.
Early in the book the author comments that he will pay little attention to lesbians. "This reflects the fact that such behavior is seldom presented for treatment and hence there is little evidence to report." Finding only four lesbians treated in the behavior modification literature, he states, "It is therefore not possible, to draw any conclusions from the available evidence…." But the scanty numbers are in and of themselves data. Only four lesbians in the midst of hundreds of homosexual men is a fact that cries out for comment. Are lesbians less concerned about their sexual orientation than gay men? If they are, Bancroft should explain why, at least comment on the startling phenomenon. At the very least, he should change the title of the book to exclude lesbians.
Bancroft carefully details the results of behavior therapy, particularly aversive techniques. He figures and overall long-term "improvement" score of 40 percent. He finds that psychoanalytic studies claim an overall long-term rate of 39 percent. One would hope for some comment on this striking statistical similarity, but none is forthcoming.
Bancroft is that his best when he mentions the problems of sampling techniques, dependent variables, and the competition of treatment models. His evaluation of the results of treatment is pessimistic, though accurate. His discussion on sampling problems is quite interesting, but again we find the curious introduction of information without comment or interpretation. For example, he finds that in a sample of studies that 20 to 51 percent of the subjects either refused or dropped out of treatment. This tickles my curiosity. What is the difference between those subjects who participate in a painful treatment procedure, and those who refuse it? It also raises an ethical question for me. Are we designing techniques to aid people who need help, or are we merely finding people willing to undergo the treatment we want to deliver? If only a few homosexual men and almost no lesbians come to us for treatment, and of that number as many as 50 percent refuse our procedures, do we have the right, on the basis of such a small and special sample, to say anything of scientific worth about homosexuals in general?
The inconclusive results of aversive treatment for homosexual men appear to be directly related to the question of why so many men, and so few women, used to go into therapy to change their sexual orientation. One need not resort to subterranean libidos or archaic archetypes in order to suggest that a complaint from a client may in itself be a symbol. My experience is that men do not object to having homosexual sex, as long as they do not become homosexuals. The sexual experience is not feared, only the social role. Research by McDonald suggests that condemnation of homosexuals is related to a general desire to maintain a strict distinction between men and women. Homosexuals are condemned not for their sexual practice per se, but because, in social terms, they appear to have become more like women.
The homosexual man who accepts this general notion that homosexuality reduces male superiority may be the one who enters treatment, and the type of treatment could, ideally, be directly related to the degree of impairment of his self-image. If this hypothesis is accurate, it follows quite naturally that aversive techniques will not be effective for two reasons. First because the problem to be treated is a set of attitudes (lowered self-image and guilt), not overt behavior. Second, aversive techniques (punishment) can only reinforce feelings of guilt, not reduce them. It follows quite plainly from these speculations that lesbians would be less prone to seek help in changing their sexual orientation, for as women they feel no need to uphold a male dominated society. Their complaints will probably be as women, not as homosexuals.
As one point, Bancroft notes that we have never developed techniques for helping homosexuals deal with their sexual problems and relationships. He suggests we should. But in the current atmosphere I can't imagine a crazy quilt clinic for homosexuals were each person could "freely" choose the kind of therapy he wants. In one room covert sensitization has a man imagining putrid homosexual scenes; in another a physician is administering anectine to condition its violent effects to a slide of an attractive nude man; and in the third room another behavior modifier is using assertive training to help his client enjoy sex more fully as a homosexual. Indeed, only one client is needed. His treatment will depend upon which of the therapists is available at the moment.
This is not treatment, nor is it science.