Readings

Editor’s Note: Societal changes and expression of concern about Rekers and Lovaas’ (1974) Behavioral Treatment of Deviant

Sex-Role Behaviors in a Male Child

The Society for the Experimental Analysis of Behavior and Linda A. LeBlanc, Editor-in-Chief

Journal of Applied Behavior Analysis

In an early study in the Journal of Applied Behavior Analysis, Rekers and Lovaas (1974) evaluated the Behavioral Treatment of Deviant Sex-role Behaviors in a Male Child. They investigated the use of reinforcement and punishment to target non-gender-conforming behaviors of a 5-year- old male child. This study was considered by some to be controversial and concerning, even near the time of publication (Nordyke et al. 1977; Winkler, 1977). The concerns focused on the ethicality of selecting non-gender-conforming behavior as a target response and the use of punishment for this type of response, particularly at the behest of parents when the young child was not seemingly distressed. The study has subsequently been used as empirical support for conversion therapy creating concerns about misinterpretation of the original article and harm to the LGBTQ+ community. This editorial reviews the concerns originally presented by Nordyke et al. (1977) and Winkler (1977) and issues an official Expression of Concern about the various harms that have been associated with this paper. Key words: conversion therapy, ethics, gender non-conforming, LGBTQ+

The early volumes of Journal of Applied Behav- ior Analysis (JABA) included many articles that seem controversial in retrospect. For example, the terminology used to describe participants with intellectual and developmental disabilities (i.e., the current professionally accepted term), although considered appropriate at the time, is offensive in today’s society. Even the U.S. national organization for this population used the term “retarded citizens” at that time, but no longer does so. Similarly, terms such as “mentally retarded,” “retardate,” “deviant,” and “mentally handicapped” are no longer evident in the pages of JABA from recent decades. As soci- ety and its focus on inclusive and bias-free lan- guage evolved, so has our own terminology such that what was contextually acceptable at one point in time is no longer acceptable today. Early studies published in JABA also were also more

likely than recent studies to examine the effects of aversive consequences (Shawler et al., 2019). As our technology and scientific literature base evolved, so has our research and clinical practice such that recommended practice is the use of nonpunishment-based procedures when possible and operating according to the principle of “least intrusive intervention” (Vollmer et al., 2011). There is one clear instance in which an early

JABA study was considered controversial, and potentially unethical even at the time of publi- cation. Rekers and Lovaas (1974) used rein- forcement and punishment to reduce “feminine behaviors” in a 5-year-old male child. That is, the treatment was specifically designed to reduce gender nonconforming behaviors at the request of the parents. The mother was taught to reinforce masculine behaviors and to extin- guish feminine behaviors using social reinforce- ment in the clinic and the father spanked the child at home based on the results of the a token reinforcement procedure in the home (i.e., a certain colored card indicated that there

Address correspondence to: Linda LeBlanc, 1006 Dogwood Drive, Golden, CO 80401. Email: [email protected]

doi: 10.1002/jaba.768

Journal of Applied Behavior Analysis (Fall) 2020, 53, 1830–1836 NUMBER 4

© 2020 Society for the Experimental Analysis of Behavior (SEAB)

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had been feminine behaviors at clinic and the child would be spanked). Although this study, and the treatment research program on child- hood gender problems from which it came, were supported by United States Public Health Service Research Grant 21803 OlAl from the National Institute of Mental Health, other researchers at that time still questioned the eth- icality of selecting non-gender-conforming behavior as a target response for modification for a young boy. Nordyke et al. (1977) and Winkler (1977)

each published papers that outlined significant concerns with the rationale for targeting this par- ticular behavior, the degree to which the study attended to recent literature and social change, and the ethicality of the procedures used by Rekers and Lovaas (1974). Winkler (1977) pointed out that some researchers (Davison, 1976; Winett & Winkler, 1972) were already expressing concerns about the type of behavioral goals set in that same decade, though others, including the American Psychiatric Association (APA) and its framework for diagnosing mental disorders (APA, 1968), clearly felt that homosex- uality was pathological (Bieber, 1976; Rekers, 1977). The publication of these response papers within a few years of the original study provides evidence that some members of the sci- entific community were concerned about this issue at the time of publication. Nordyke et al. (1977) questioned both the

rationale for treatment (e.g., relieving the child’s suffering from social isolation and scorn, preventing lifelong pathology, alleviating paren- tal concern), the procedures used, and the descriptions of the masculine and feminine sex- roles. Nordyke et al. suggested that the earlier study appeared “to be not only accepting but also supporting sex-role stereotyping, thereby failing to contribute to the solution of a larger social problem.” The authors suggested that concern about social isolation and scorn was a poor rationale for targeting the child’s behavior rather than societal change when they drew the

analogy that “feminists may be scorned and iso- lated by segments of society, and while they may not like the societal scorn, most have indi- cated a need for modification programs aimed not at themselves but at the very segments of society that set the occasions for their problems” (p. 554). Nordyke et al. expressed concern that Rekers and Lovaas (1974) admitted that “social and parental pressure led them to conduct sex- role therapy” (p. 553). For example, even Rekers and Lovaas indicate that “society probably could afford to become more tolerant with individuals with sex-role deviations,” however, they suggest that they targeted the boy’s behavior instead of societal responses because “it is potentially more difficult to modify society’s behaviors than Kraig’s [the participant’s pseudonym” (p. 174). Winkler (1977) expressed concern that the authors made no mention of contemporaneous changing of societal attitudes and psychiatric opinions about homosexuality and other sexual behavior, changing laws, and expanding gay rights movements. Nordyke et al. suggested that Rekers and Lovaas should have sought out other viewpoints such as “spokespersons for lesbian and homosexual organizations, representatives of AABT [the Association for the Advancement of Behavior Therapy] positions concerning homo- sexuality, children’s rights advocates, and others (p. 554)”.

Other studies published in JABA and other journals targeted homosexual responses in adults, but at the request of the distressed adult who gave consent for the use of the procedures (Abel et al., 1975; Barlow & Agras, 1973; Brownell et al., 1977) rather than a minor. Although the distress may unfortunately have been due to societal pressures and norms, none- theless it existed, and these individuals sought their own treatment. Both Winkler (1977) and Nordyke et al. (1977) expressed concern that in the case of the Rekers and Lovaas (1974) study, the child was not presenting with distress. The parents were presenting with alarm at the gender nonconforming behaviors and requesting the

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treatment with no apparent consideration for the rights of the minor. Nordyke et al. suggest that by taking only the parental point into con- sideration, “the therapist has become the par- ents’ agent, rather than the child’s, or society’s” (p. 554) with potential consequences for the field and society if behavior analysis is used to change behavior that is questioned only by other agents, such as parents or courts. Nordyke et al. (1977) also questioned the

treatment procedure in which the token (i.e., the immediate consequence for so called feminine or masculine play) resulted in punish- ment in the form of “timeout or a spanking by the father” (p. 555). Nordyke et al. suggested that the use of punishment in this instance was also questionable in regard to new areas of application of behavior change. Even as early as the 1960s and 1970s, the notion of “least intrusiveness” as a guidepost for treatment selection was evident. Nordyke et al. suggested that beginning with treatment procedures that involved punishment for these behaviors, including physical punishment from the father, was inappropriate according to this guideline. The publication of this study caused concern

to some in the behavior-analytic community immediately1 in the context of the 1970’s soci- ety even though it was federally funded and in alignment with the status of early versions of the Diagnostic and Statistical Manual which designated gender nonconformance and homo- sexuality as pathological (APA, 1968). From the retrospective viewpoint of almost 45 years later and today’s social context, that study seems almost inconceivable as a scientific endeavor. The societal change that has now occurred and is still underway with respect to civil rights of the LGBTQ+ community was already beginning at the time the original study was published. The discord between those

changes and the Rekers and Lovaas (1974) study was concerning to some contemporane- ous researchers and is of grave concern to soci- ety today. In addition, the expectations for considerations of personal rights of participants and use of less intrusive procedures as initial treatment options were also heavily discussed in the scientific community at that time. The Bel- mont Report had not yet been published at that time and the Human Subjects Institutional Review Board (HSIRB) infrastructure that we know today was not yet established. Today, the HSIRB requirements for treatment research with children specifies that there should be pro- cedures for child assent (when obtainable) as well as parental permission. The Rekers and Lovaas study would seemingly never be approved in recent decades, much less receive federal grant funding or be published. Multiple readers of JABA have reached out to

the present Editor-in-Chief of JABA to make the Society for the Experimental Analysis of Behavior (SEAB) board aware of multiple harms that have been associated with the Rekers and Lovaas (1974) article. These communications led SEAB to undergo a detailed examination of all available information and publications rele- vant to the paper or the subsequent uses of the paper in alignment with the Committee on Publication Ethics (COPE) guidelines (COPE, 2019). The actions of Retraction and Expression of Concern were carefully reviewed to determine whether the original study met the established criteria for those actions. The criteria for retraction are primarily based on clear and defensible evidence of scientific misconduct, fal- sification or fabrication of data, or clear ethics violation. By today’s standards and in light of our current scientific knowledge, the study would be considered unethical and would not be published in JABA. However, the available evidence does not make it clear that the original study was unethical by the standards of that day. While the evidential criteria were not met for retraction, SEAB and the Editor of JABA

1 Although the publication dates for both papers are 1977, Nordyke et al. was originally submitted in August, 1975, while Winkler was submitted April, 1975.

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made the decision to issue an official Expression of Concern (COPE, 2019) along with this edi- torial to clearly outline the concerns about the Rekers and Lovaas (1974) paper and the various harms potentially or actually resulting from it. This decision by a long-standing scientific organization was reached to minimize adverse effects associated with the use of outdated litera- ture that was concerning to some even at the time of publication. From this point forward, the original article will be electronically linked to the original response papers, to this editorial, and the accompanying publisher’s (i.e., Wiley Periodicals, LLC) Expression of Concern so that the original article cannot be accessed without awareness of the other publications that respond to the original study. The first clearly evident harm was to the par-

ticipant and family. A 2012 CNN story by Anderson Cooper exposed various background details about the family and participant as well as the significant personal harm experienced by the participant of that study, who eventually died by suicide (CNN, 2012; National Center for Lesbian Rights, 2020). The tragic details are available to those who wish to know them and will not be repeated here. While the sui- cide cannot be causally linked to participation in the study decades earlier, it is clear from the family’s report that the experience of participat- ing in this study was very negatively impactful for them. This harm, regrettably, cannot be undone and the fact that this study was con- ducted and published in a different societal context cannot be erased. Instead, it behooves us to remember the past, behave differently in the future, and speak out strongly to prevent similar psychological harm to others. The second evident harm is that this study

has been and may still be being inappropriately used as evidence for the effectiveness of conver- sion therapy (i.e., aversive conditioning of same- sex stimuli to reverse sexual preference) resulting in continued harm to the LGBTQ+ commu- nity. The use of this study as support for

conversion therapy seems to be related to the first author’s (i.e., Reker) personal actions and advocacy against the LGBTQ+ community. The claim is unfounded from a scientific per- spective (i.e., the study did not target responses to sexual stimuli, the participant’s sexual orienta- tion remained same sex into adulthood and until his suicide) as well as reprehensible from a human rights perspective. Following a scandal regarding his travels with a hired male compan- ion (Bailey, 2010; Bullock & Thorpe, 2010), the first author resigned from the anti-LGBTQ+ organization National Association for Research and Therapy of Homosexuality (NARTH), for which he had formerly served as officer and sci- entific advisor. His expertise and professional reputation were discredited, eliminating his abil- ity to testify in cases related to the civil liberties of the LGBTQ+ community as he had done in the past. As of the beginning of 2020, 19 states have

passed laws fully banning conversion therapy (Movement Advancement Project, 2020), par- ticularly for minors who may be forced into the pseudoscientific procedures by their parents (Southern Poverty Law Center, 2016). How- ever, in other states, studies such as Rekers and Lovaas (1974) may be inappropriately used to support continued implementation of conver- sion therapy. Multiple professional associations such as the APA (Anton, 2010), the American Psychiatric Association (Byne et al., 2012) and the American Medical Association (AMA, 2019) have published statements condemning the use of conversion therapy as non- scientifically supported. Although SEAB is not a professional association that could publish a position statement on behalf of the discipline of behavior analysis, as a scientific organization, SEAB strongly condemns conversion therapy and is fully in opposition of pseudoscience in all forms. However, practitioners and organiza- tions endorsing conversion therapy continue to cite the Rekers and Lovaas (1974) paper as evi- dence for conversion therapy, in the absence of

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acknowledgement of the Winkler (1977) and Nordyke et al. (1977) responses. Thus, the pro- fessional critiques of the ethical issues are hid- den in favor of a single example published over 45 years ago that was not actually an example of conversion therapy. The linking of the early articles and the publication of this editorial are designed to prevent selective access to the liter- ature as a means to support this practice. The third source of harm is to applied behav-

ior analysts as a whole due to the false impres- sion that may be created that this article, or the use of conversion therapy is in any way represen- tative of the field. As scientists and practitioners, we should be constantly mindful of the mission, purpose, and values of our field which focus on using science to achieve social good. Wolf (1978) encouraged us to fully embrace the notion of the social validity of our interventions with respect to the importance of our behavioral tar- gets, the acceptability of our treatment proce- dures, and the extent to which our achieved outcomes result in meaningful positive changes for those we serve. Both Sidman (1989) and Skinner (1948) expounded upon the dangers of coercion in every facet of society. They encour- aged behavior analysts to use the science of human behavior to minimize coercion in every circumstance. This commitment to our disci- pline’s mission is still evident in recent writings focused on compassionate care (Taylor et al., 2019) and understanding behavior in the con- text of the circumstances in which it occurs (Friman, in press). Those who are in a position to educate others are encouraged to use this edi- torial and this topic to educate your students about the ethics of the original study and the scholars who spoke out about the paper in the 1970s serving as voices for social justice. As pro- fessionals, we cannot let our science or practice be divorced from the values that created them. As professors and mentors to the next generation of scientists and practitioners, we must imbue their professional training with the mission and values upon which our field was founded.

Another concern is the connection between the early paper, the authors, conversion therapy and the unfortunate impression that behavioral treatments focus on the use of aversive proce- dures and are associated with conversion ther- apy. Multiple members of the SEAB board have encountered families with a child with feeding problems, intellectual disabilities, or autism spectrum disorder that delayed or wor- ried about starting evidence-based behavioral treatment services because of encountering information that erroneously links this treat- ment to conversion therapy and the perceived use of aversives in behavioral therapy. Mistaken impressions that delay or prevent families from accessing effective treatments harm those fami- lies as well as the reputation of our field. Every behavior analyst reading JABA should

be aware that individuals may have encountered a mistaken impression of our field based on their exposure to the Rekers and Lovaas (1974) paper. Those individuals might think of our field as solely linked to autism and be unaware that applied behavior analysis has created and is still creating positive impacts in areas from disease prevention (LeBlanc et al., 2020; Lombard et al., 1991) and safety (Lehman & Geller, 1990; Maxfield et al., 2019) to treatment of substance abuse and unemployment (Silverman et al., 2008; Silverman et al., 2019). They may think that applied behavior analysis is synonymous with the use of aversives without realizing that there is an enormous expanse of behavioral literature focused on refining proce- dures to provide a plethora of positive and effec- tive treatment alternatives. We behavior analysts must be sensitive to the concerns that are pres- ented by others and recognize that at least some of the concerns may be directly or indirectly linked to the paper by Rekers and Lovaas. We recommend that concerned readers use this edi- torial and Expression of Concern, and guidance from the Behavior Analyst Certification Board® Professional and Ethical Compliance Code for Behavior Analysts (BACB, 2014) as professional

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motivation to represent our field with dignity, integrity, compassion, and respect for human rights.

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