Tuesday, January 29, 2013

Dr. David H. Barlow and Aversion Therapy for Gays

Should a professional society honor a highly accomplished investigator who conducted studies in the past that would now be considered unethical?

Distinguished professor and clinical psychologist Dr. David H. Barlow was recognized for his achievements by the Association for Psychological Science (APS) last year as the recipient of the 2012 James McKeen Cattell Fellow Award:
David H. Barlow has made enormous theoretical and empirical contributions in many areas of clinical psychology. He is best known for his efforts to develop psychological treatments for anxiety disorders. His early work on the treatment of agoraphobia laid the groundwork for exposure-based treatments that are today regarded as the gold standard. As we learned more about the relationship of agoraphobic avoidance to the occurrence of panic attacks, Barlow led the way in the development of treatments for the remediation of panic symptoms.

Much of Barlow’s research is based on the notion that anxiety is a disorder of emotion. He holds this to be the case regardless of the specific emotional disorder, and this has led him in the later years of his career toward the development and testing of a unified protocol for the transdiagnostic treatment of such disorders....

What you might not have known is that such disorders have included homosexuality and transsexualism. Barlow advocated and practiced aversion and conversion therapies to "cure" gay and transgendered people of their "deviant" sexuality.

While I do not wish to detract from Dr. Barlow's many positive accomplishments, I feel it is important to expose the questionable practices of the past and to hold people accountable for their actions. I looked far and wide to find a mea culpa from Dr. Barlow, much like Dr. Robert Spitzer's public apology for his published work on reparative therapy as a "cure" for homosexuality (Spitzer, 2003).1 But I did not find such a statement anywhere.

Should we question the judgment of APS in honoring Dr. Barlow with the Cattell Award? 2 Are they tacitly condoning exorcism in transsexuals (Barlow et al., 1977) and aversion therapy in gay men (Barlow et al., 1969; Hayes et al., 1983)? At the very least, APS did not publicly acknowledge or condemn these former practices, which remain secretly buried in the past.

I contacted two divergent experts to ask their opinions. Psychologist Dr. John Grohol, who founded the mental health networking and education site Psych Central, turned the question around:
"Should we honor professionals who may have made questionable judgments in their early career? I would ask a question in return -- Should we forever withhold such honors for the poor judgments one makes in one's early career?"
On the other hand, Professor Lynn Conway, the pioneering computer scientist, electrical engineer, and transgender activist, was surprised about the award. She felt an appropriate course of action is...
"... to expose these old miscreants and get their misdeeds on the record. That way they'll all have to run for cover in the years ahead..."

Let's examine some of these practices below so you can decide for yourself.


Exorcism for Transsexualism?

As some of you might have gathered, I came across this paper during my exorcism researchBarlow and colleagues (1977) didn't actually perform the exorcism themselves, but observed the resulting change in behavior "fortuitously" and used it as an example of how atypical gender identity could be modified, if not prevented all together:
Although the prevention of transsexualism is the ideal, work in this area has been fraught with ethical problems...
The authors reported the detailed case history of "John", a 21 year old patient who had a clear identity as female and wished to transition. Before doing so, John was persuaded to visit a Fundamentalist Christian doctor, who performed an exorcism:
The physician administered a total physical exam and said that he could live quite well as a woman, but the real problem was possession by evil spirits. After some discussion of this, John reported a session which lasted 2-3 hr and involved exhortations and prayers over John by the physician and laying on a hands on John's head and shoulders. During this period, John reported fainting several times and arising to the continuing of the prayers and exhortations, resulting in the exorcism of 22 evil spirits which the physician called by name as they left his body.  ... The physician noted ... that he showed John that his life was a fake and that Jesus could redeem him and that a standard prescription of Scripture readings caused the spirit of the woman in John to disappear.

Immediately after the session John announced he was a man, discarded his female clothes (hiding his breasts as best he could), and went to the barber shop to have his long hair cut into his current short, masculine style...

Rather than condemn the outlandish and unethical behavior of this physician, and counsel John (who had identified as Judy) on her previously excellent adjustment as female and readiness for surgery, they considered this a successful change in gender identity. An even more questionable event was a visit to a faith healer. After the laying on of hands, John reported that his breasts (size 36B) had disappeared immediately. Personally, I think a psychiatric assessment would have been in order.

Very worth reading in regard to this paper is the text on Rogue Theories of Transsexualism written by Professor Conway. She says that "By seeing a collection of such theories side-by-side, we grasp the strangeness of them all."


Aversion Therapy to Cure Sexual Deviance

Even more outrageous were the papers on aversion therapy. As a prelude to the actual practices described by Barlow et al. (1969), I will use American Horror Story: Asylum as a near-exemplar.



The year is 1964. Lana Winters is a reporter investigating the unethical practices at Briarcliff Manor, a mental institution for the criminally insane. She's caught snooping around and is committed against her will to keep her quiet, with the ostensible reason being that she is gay. She is forced to have shock treatment. Sympathetic psychiatrist Dr. Oliver Thredson tries to persuade her to undergo aversion therapy, which is presented as more "humane." She eventually agrees because she thinks it'll get released her from Briarcliff once Thredson pronounces her "cured."

Under the direction of Dr. Thredson, Winters views a slide show of erotic pictures of women. She has an iv drip going into her left arm. She starts to get physically ill while viewing the slides and then throws up into a metal bucket.




Winters: "What is this stuff?"

Thredson: "Apomorphine. Standard drug for this kind of cutting edge aversion therapy. They use it at Harvard, Brigham Young, Cornell. The theory is that we're training your body to be physically repelled by certain.....triggers."

Next slide: a picture of her girlfriend smoking a cigarette in bed. He cranks up the apomorphine until she vomits again.


Experimental control of sexual deviation through manipulation of the noxious scene in covert sensitization

Come on, you're saying, it couldn't have been that bad in real life. Plus the paper was published in 1969, that's ancient history by now. But if you were one of the men interviewed for this story on When gays were 'cured', you might think otherwise.

Barlow et al. (1969) didn't actually administer apomorphine, but they did try to make same sex attraction as physically repulsive as possible. The study was a case report of two patients treated with aversion therapy. One especially offensive aspect of the paper is that a pedophile and a gay man were treated as equivalently deviant. The description of the gay subject was particularly condescending:
The S2 was a 32-yr.-old married male who reported a 14-yr. history of homosexual experiences averaging about three contacts per week, usually in public toilets. He recently had fallen in love with a "boyfriend," which was threatening his marriage and which motivated him to seek treatment. Sexual relations with his wife, although prevalent early in the marriage, had been virtually nonexistent for the previous 3 yr.
The protocol paired descriptions of sexually arousing scenes with nauseating scenes.  I'll quote the noxious script in its entirety to allow the full impact to wash over you:
In each session Ss were given relaxation instructions and presented with eight scenes. In four scenes S was described approaching the small girl (male), feeling nauseous and vomiting. For example, in one of the homosexual scenes, S2 was described approaching his boyfriend's apartment.

"As you get closer to the door you notice a queasy feeling in the pit of the stomach. You open the door and see Bill lying on the bed naked and you can sense that puke is filling up your stomach and forcing its way up to your throat. You walk over to Bill and you can see him clearly, as you reach out for him you can taste the puke, bitter and sticky and acidy on your tongue, you start gagging and retching and chunks of vomit are coming out of your mouth and nose, dropping onto your shirt and all over Bill's skin."

The description of the nauseous scene was usually expanded and lasted from 30 to 60 sec. In the remaining four scenes S would be described approaching the small girl (male) and beginning to feel nauseous. At that point he would turn, start walking away from the scene, and immediately feel relieved and relaxed.

They concluded that an intensely disgusting and obnoxious scenario could serve as a substitute for apomorphine and shocks in aversion therapy designed to straighten out gay men.

A follow-up experiment with four gay male subjects manipulated the instructions given during phases of covert sensitization (pairing of sexually arousing scenes with vomiting scripts) and extinction (no pairing). To assess the effects of treatment on arousal patterns, penile circumference was measured while the subjects viewed slides of nude men (Barlow et al., 1972).


1973 and Beyond

The American Psychiatric Association removed homosexuality from its list of mental illnesses in 1973. (see DSM-II Homosexuality Revision). Should we forgive Barlow for work conducted before then? He was still a strong advocate of aversion therapy around this time (Barlow, 1973):
"[other authors] speak of the necessity of increasing more appropriate and assertive heterosocial behaviors in the treatment of sexual deviation. Despite these views, aversion therapy aimed at eliminating sexual deviation is increasingly advocated as the treatment of choice (Barlow, 1972), due in part to the growing application of the experimental behavioral sciences to the clinic and in part to the relative success of this technique..."

Dr. Grohol made the following observation:
"At the time, [homosexuality] was a recognized mental disorder, so it may have been a reasonable area in which to conduct research. While it's both difficult and repugnant to utter those words today, it highlights one of the drawbacks of the DSM classification system -- it's a malleable, social-constructed manual as much as it is based in hard, scientific data."

Barlow continued to publish accounts of homosexual conversion treatments after 1973 involving exposure to male and female nudes (and porn) while penile circumference was measured (Herman et al., 1974; Barlow et al., 1975).  The latest one I could find was from 1983, which treated one exhibitionist, two pedophiles, and one gay man with covert sensitization (Hayes et al., 1983). The technique paired arousing scenes with aversive scenes designed to disgust or humiliate the participant. The authors issued a caveat, yet accepted the gay man into this treatment program and continued to use the term "deviant" (just to be consistent with the criminals):
Subject 2, an unemployed 39-yr-old single white male, sought treatment to decrease homosexual behavior and to increase heterosexual arousal (thus, he is not sexually deviant by current classification).* 
. . .

Despite the strong recommendations by some (e.g. Begelman, 1975) not to treat homosexuals for their homosexuality, this individual had clearly stated his preferences and was accepted into treatment.

*The use of terms like ‘deviant arousal’ is problematic with this subject, but they are used for the sake of consistency. ‘Undesired arousal’ is more accurate and better reflects our attitudes towards this case.

Did any of these behavior therapy techniques work? There's no evidence that they did. Studies were poorly controlled and overly reliant on self-report, follow-ups were brief, and participants were inadequately characterized (Serovich et al., 2008). Moreover, there is ample evidence that the treatments were harmful (King & Bartlett, 1999). Some patients became severely depressed and suicidal.

Not all behavior therapists were in favor of pathologizing homosexuality in the early-mid 1970s. Dr. Gerald C. Davison, President of the Association for Advancement of Behavior Therapy (AABT) from 1973-1974, gave an impassioned speech at the annual meeting where he argued against the use of conversion therapies for gays and lesbians (Sept. 2003 AABT Newsletter, PDF).3


In their review on British psychiatry and homosexuality, King and Bartlett (1999) suggested that mental health professionals should be aware of past mistakes, including ones they themselves may have committed:
Although many professionals may have been well intentioned in helping a disadvantaged group of patients towards what they regarded as a better adjustment to life, very few seem to have later questioned the wisdom of their work. In the past 20 years, one psychiatrist has written of the excesses of the profession (Bancroft, 1975, 1995). Bancroft claimed that he would not now provide aversion therapy because of its limited effectiveness and because of different social attitudes towards homosexuality (Bancroft, 1991, 1995). Others who published in the British psychiatric press, such as Nathaniel McConaghy in Australia, continued to defend their methods into the 1980s.  ...  Professionals who published extensively on this topic, such as Bancroft, McCulloch, McConaghy, McDougall, Storr and Glasser, remain in prominent positions as commentators or as principals or chairs in institutions around the world.

It is my view that many more of these distinguished professionals should publicly reconsider their earlier work, as did Spitzer and Bancroft. To be forgiven, they must acknowledge their wrongdoing.

I e-mailed to Dr. Barlow to ask if he had any comments about his early work in light of contemporary views of homosexuality, or whether he had issued such a statement in the past. I haven't heard back, but I will post such remarks (with permission) if I receive them.

Ironically, Barlow ended his 2012 acceptance speech with the following important yet vague words:
"Time marches on. Ideas change — hopefully for the better."


Footnotes

1 From Spitzer reassesses his 2003 study of reparative therapy of homosexuality in the Archives of Sexual Behavior (the same journal that published his original study):
I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some “highly motivated” individuals.
2 However, APS is certainly not unique in honoring Dr. Barlow, who is the author of over 500 articles.

3 Meanwhile, Barlow (who was AABT President from 1978-1979) published the "Heterosocial Skills Behavior Checklist for Males" in 1977 (Barlow et al., 1977). It was used to evaluate the behavior of sexual deviants (in this case, "five homosexuals, two transsexuals, one pedophiliac, one sadist, and one rapist"). One nugget of wisdom: when interacting with a member of the opposite sex, it is inappropriate to "giggle or laugh in a high-pitched manner, staccato and uncontrolled."


References

Barlow DH (1973). Increasing heterosexual responsiveness in the treatment of sexual deviation: A review of the clinical and experimental evidence. Behavior Therapy 4:655-671.

Barlow DH, Abel GG, & Blanchard EB (1977). Gender identity change in a transsexual: an exorcism. Archives of sexual behavior, 6 (5), 387-95. PMID: 921523

Barlow DH, Agras WS, & Leitenberg H (1972). The contribution of therapeutic instruction of covert sensitization. Behaviour research and therapy, 10 (4), 411-5. PMID: 4637499

Barlow DH, Agras WS, Abel GG, Blanchard EB, Young LD. (1975). Biofeedback and reinforcement to increase heterosexual arousal in homosexuals. Behav Res Ther. 13:45-50.

Barlow DH, Leitenberg H, & Agras WS (1969). Experimental control of sexual deviation through manipulation of the noxious scene in covert sensitization. Journal of abnormal psychology, 74 (5), 597-601. PMID: 5349402

Hayes SC, Brownell KD, & Barlow DH (1983). Heterosocial-skills training and covert sensitization. Effects on social skills and sexual arousal in sexual deviants. Behaviour research and therapy, 21 (4), 383-92, PMID: 6138027

Herman SH, Barlow DH, Agras WS. (1974). An experimental analysis of exposure to "explicit" heterosexual stimuli as an effective variable in changing arousal patterns of homosexuals. Behav Res Ther. 12:335-45.

King M, Bartlett A. (1999). British psychiatry and homosexuality. Br J Psychiatry 175:106-13.

Serovich JM, Craft SM, Toviessi P, Gangamma R, McDowell T, Grafsky EL. (2008). A systematic review of the research base on sexual reorientation therapies. J Marital Fam Ther. 34:227-38.

Spitzer RL. (2003). Can some gay men and lesbians change their sexual orientation? 200 participants reporting a change from homosexual to heterosexual orientation. Arch Sex Behav. 32:403-17.

Spitzer RL. (2012). Spitzer reassesses his 2003 study of reparative therapy of homosexuality. Arch Sex Behav. 41:757.


 
Dr. David H. Barlow - APS 24th Annual Convention (2012)

"Time marches on. Ideas change — hopefully for the better."
-David H. Barlow

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8 Comments:

At January 30, 2013 7:29 AM, Blogger Juan said...

Very interesting question. I endorse your view "that many more of these distinguished professionals should publicly reconsider their earlier work". I see your comment as an example of an application of psychological historical research.

 
At January 30, 2013 10:51 AM, Anonymous David Kydd said...

A public service and an entirely appropriate inquiry, NeuroCritiquer. The Brit govt performed chemical castration on the father of computer science and AI, Alan Turing, in the 1950s, yet publicly apologized in 2009. Both the APS and the APA should publicly apologize for all members who in the past performed experiments and therapy deemed harmful in retrospect. Individuals like Barlow should come clean, too. Everyone knows that life is full of well-intended risks ... and mistakes. When errors harm others, we apologize. That's the humane way!

Hence John Grohol's obfuscating reply to you shirks ethical responsibility. Nobody's asking to "forever withhold honors." In contrast, the way forward is to celebrate Barlow's positive achievements while firmly apologizing for his mischief. It's quite obvious.

Grohol also expresses a widely held assumption, and excuse: "... one of the drawbacks of the DSM classification system -- it's a malleable, social-constructed manual as much as it is based in hard, scientific data." Laws, customs, and manners are malleable, socially constructed products, too. This in no way means they're "drawbacks" -- they are simply facts of humankind. Hard, mute data must always be interpreted by soft, verbal humanity. As custodians of social institutions, we accept responsibility to Apologize when we step on others' feet. Academics in general and scientists in particular should be role models here, not foot-draggers.

Given our continuing inequitable treatment of the LGBT community, plus the upcoming Supreme Court decision to grant or withhold from them a right that everyone else enjoys (marriage), now would be a glorious moment for the APS, APA, and David Barlow to speak up. Namaste!

 
At January 30, 2013 12:17 PM, Blogger Roger Bigod said...

Frontal lobotomy is on the same list of wildly misguided therapy. But aversion therapy affected public attitudes more, because it looks punitive, even sadistic. Perhaps Barlow drew the wrong lesson from A Clockwork Orange.

Thanks for the tip about giggles. I'll try to watch it.

 
At January 30, 2013 10:15 PM, Blogger The Neurocritic said...

Juan - Thanks! I tried to be thorough...


David Kydd - Thanks for your comment. I'm not a member of APS, but I'd complain if I were. I thought I must be missing something... like was there an acknowledgment somewhere? Did everyone already know about the aversion therapy so it was old news?

I don't think John Grohol intended to be an apologist. He was trying to put these past practices into the historical context of the 1960s-70s. Not that's any excuse for what happened (which I see as quite offensive, of course).


Roger Bigod - Other things to avoid:

- a voice that's higher in pitch than female companion's voice.

- inflections are frequent and are made primarily by change in pitch rather than change in volume, particularly quick changes in pitch should be noted.

- excessive emphasis on words rendering a special dramatic effect.

Mustn't be overly dramatic...

 
At February 01, 2013 12:20 PM, Blogger Roger Bigod said...

One interpretation of "aversion therapy" is that it's inducing a PTSD. Although the content of the stimuli is physical disgust, the setting is that the subject is effectively trapped. Because it's repeated, there's anticipatory anxiety. This is supposed to be an important feature of childhood PTSD. This could be checked with fMRI to see if the activation is in insula only (disgust), or amygdala as well (anxiety, PTSD).

Ironically, a common response is identification with the patient and disgust directed at at the therapy, and the therapist.

I can play devil's advocate and argue that inducing PTSD in a rapist or pedophile may be beneficial to the subject and potential victims. That's the rationale for "treating" Little Alex in A Clockwork Orange. But the "therapists" didn't bother with other approaches -- facilitating arousal to legal sexual stimuli, encouraging empathy for victims, strengthening executive mentation to deal with temptation.
It comes across as poorly rationalized sadism.

 
At February 01, 2013 10:32 PM, Blogger The Neurocritic said...

Roger - Interesting idea about aversion therapy and PTSD. Since you mentioned A Clockwork Orange, I checked when Burgess wrote the book (1962) and at first thought he was ahead of his time with the fictional Ludovico Technique. Then I found this bizarre article [PDF] from 1956 that treated a case of fetishism (for attacking baby carriages and handbags) with apomorphine aversion therapy.

At any rate, that opened a window onto a much larger literature than I expected on such treatments. It makes for unpleasant reading.

 
At February 03, 2013 1:33 PM, Blogger Roger Bigod said...

Interesting paper. There's no indication that the treatment raised his general level of anxiety. And from the wikipedia article, aversion therapy doesn't appear to cause that problem for most uses, so my speculation about PTSD may have been overly influenced by Little Alex.

The situation is different for sexual matters, in particular homosexual orientation. There were some bad outcomes.

The paraphilia paper reminded me of a public event I hadn't considered in while.
After a weekly meeting of chess players in a public hall, we were standing around chatting. A friend nudged me and told me to watch a guy a few yards away. All I noticed was that his face was a little flushed and there were occasional facial tics. Suddenly he dove for the feet of a guy in front of him and started licking his shoes (nice wing-tips), making porcine snuffling noises. Everyone was paralyzed for a few seconds, including he poor guy whose shoes were the object of attention. Then two friends of the fetishist grabbed him from each side and pulled him away.
He stood up looking dazed at first. When he pulled himself together, a look of intense shame and defeat came over him and he ran from the room. The tics and primitive sounds made he wonder about some sort of seizure activity, although it was triggered by a fetish for male executive footware.

 
At June 20, 2013 1:50 PM, Anonymous Jerry G said...

I am not sure whether this will be read by anyone, but I am interested by the comments made by Roger Bigod about PTSD and aversion therapy. I had electric shock AT in England in 1972 that led eventually after a mental breakdown in 2010 to me being diagnosed as having PTSD as a result of the AT. I have also been diagnosed with depression and dissociation. I am still in therapy for PTSD.

 

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