Covert sensitisation in conversion practices

1. Introduction

Version followed: the psychotherapist's own work with clients affected by covert sensitisation used as a sexual orientation or gender identity change effort, as framed by the APA 2009 Task Force report and the APA 2021 resolutions, the UK Memorandum of Understanding on Conversion Therapy (Version 2, Revision A, 2019) and the UN Independent Expert's 2020 report (A/HRC/44/53); history after Davison et al. (2024/2025) and Spandler and Carr (2022).

Covert sensitisation is a behaviour-therapy technique described in the mid-1960s by the psychologist Joseph Cautela: an aversion procedure in which an unwanted behaviour is linked, in imagination rather than physically, with an unpleasant consequence [source: Gale Encyclopedia of Psychology entry, encyclopedia.com]. It was developed and studied for alcohol and drug use, smoking, overeating, gambling and some sexual behaviours [source: Gale Encyclopedias of Psychology and Mental Health, encyclopedia.com]. The precise first-publication year (often given as 1967) is [uncertain: not verified]. This guide concerns its misuse: applying imagined aversion to same-sex attraction or to gender identity, as one form of what the UK Memorandum calls conversion therapy, an approach that assumes one orientation or identity is inherently preferable and tries to change or suppress it [source: UK MoU v2].

The claimed mechanism of change was conditioning: repeated imagined pairing was meant to make same-sex attraction itself aversive. Professional and international bodies state that this does not change sexual orientation. The APA's 2021 resolution states there is "no evidence of sexual orientation change" and that former participants view such efforts as harmful [source: APA press release, 2 March 2021]. The APA 2009 Task Force found that enduring change in orientation is uncommon and that early aversive methods were documented to cause harm, including loss of sexual feeling, depression, anxiety and suicidality [source: APA 2009 Task Force report, pp. 2-3]. The UK Memorandum's signatories call conversion therapy "unethical and potentially harmful" [source: UK MoU v2, para. 3]. The UN Independent Expert concluded that no such approach "can claim 'conversion' as an outcome" and that the practices are degrading, inhuman and cruel in essence [source: A/HRC/44/53, paras 65, 70].

For the psychotherapist, the change that matters here is different: recovery from shame, conditioned distress and trauma linked to a person's own attractions or identity, and safe integration of sexuality, gender, faith and family. This guide covers that work only. Covert conditioning as a current, legitimate behavioural technique (for example in addiction treatment) is covered in Domain II 052; it must never be aimed at sexual orientation or gender identity [synthesis].

2. Framework

Session number and length follow the client's needs and the setting; the phases below are a practice structure [synthesis] built on the affirmative framework the APA 2009 Task Force describes: acceptance and support, comprehensive assessment, active coping, social support, and identity exploration and development, with no predetermined outcome for how the client identifies [source: APA 2009 Task Force report, p. 4].

Historical phases of the practice (outline).

Mid-1960s: Cautela describes covert sensitisation as an imagined form of aversion therapy [source: Gale Encyclopedia of Psychology].
Late 1950s to early 1970s: aversion therapy for homosexuality in NHS hospitals in England (for example Crumpsall in Manchester, the Maudsley, Banstead, Glenside), mainly with electric shock or nausea-inducing drugs; Feldman and MacCulloch are named by historians as the most prominent practitioners [source: Davison et al. 2024/2025; Spandler and Carr 2022]. Historians report that many "voluntary" patients were under coercion and that use was phased out in Britain after 1973 [source: Davison et al.; Spandler and Carr].
Covert sensitisation applied to same-sex attraction: one 1973 US study in the Journal of Abnormal Psychology combined contingent shock with covert sensitisation for men referred for "sexual deviation", including homosexual men [uncertain: secondary, unverified]. The wider extent of covert-only use against same-sex attraction is [uncertain: not verified].
1973 onwards: a 1973 survey found 13% of British behaviour therapists would treat a homosexual person to change orientation even against that person's wishes [source: Spandler and Carr 2022]. APA discouraged change efforts in 1997 and 2009 and opposed them in 2021 [source: APA press release 2021].
Today: change efforts continue, mostly outside health care; in one US study 81% of those who had experienced conversion therapy received it from a religious leader and 31% from a health care provider [source: Williams Institute summary of Blosnich et al. 2020]. Imagery-based "urge" work aimed at same-sex attraction in some religious or "unwanted attraction" counselling is reported informally [uncertain: not verified].

Phases of the psychotherapist's work [synthesis unless tagged].

Phase A, recognition and assessment. Goal: learn whether the client was subjected to, is currently in, or is drawn to change efforts, and what form they took; screen risk. Move on when you have a working picture of history, current exposure and risk.
Phase B, safety and safeguarding. Goal: suicide-risk assessment and safety plan; safeguarding for any minor; stopping ongoing exposure where the client wishes. Move on when acute risk is managed and the client is not under current coercion.
Phase C, stabilisation and psychoeducation. Goal: accurate information on orientation, gender identity and change efforts; grounding skills for intrusive, conditioned distress. Move on when the client can talk about the history without being overwhelmed.
Phase D, processing and repair. Goal: trauma-focused processing, shame and self-stigma work, religious and family integration, sexual-health and relationship work as needed. Move on when symptoms ease and the client's chosen identity and values feel livable.
Phase E, integration, advocacy and follow-up. Goal: community connection, optional complaint or legal routes, relapse-prevention for shame spirals, follow-up. Ending is guided by the client's goals.

Format: individual therapy is the base; family sessions, couple work and peer or survivor groups are added as indicated [synthesis]. Session number and length follow the client's needs and the setting [synthesis].

3. Guiding principles

No change goal for orientation or gender identity. You never attempt to change or suppress either; signatories to the UK MoU commit to this [source: UK MoU v2]. In practice: decline any treatment plan aimed at it, and say so plainly.
Non-directive, no agenda. Practitioners may help people who are distressed about their sexuality or gender identity to explore it and reach greater self-acceptance, provided they have no agenda favouring one identity [source: UK MoU v2]. In practice: follow the client's exploration; do not push towards any label.
Orientation and identity are not disorders. The MoU states that neither is in itself an indicator of mental disorder [source: UK MoU v2]; APA describes transgender and nonbinary identities as normal variations [source: APA press release 2021]. In practice: do not formulate attraction itself as the problem.
Identity, not orientation, is what may shift. The Task Force proposes that some clients reshape sexual orientation identity without change in orientation [source: APA 2009 Task Force report, p. 4]. In practice: help the client choose how to live and identify, not what to feel.
Respect faith. The Task Force recommends acceptance of the importance of faith alongside the science of sexual orientation [source: APA 2009 Task Force report, p. 5]. In practice: treat religion as a resource as well as a source of conflict.
Shame-based congruence is not wellbeing. The Task Force cautions that congruence built on stigma and shame is unlikely to support well-being [source: APA 2009 Task Force report, p. 4]. In practice: test whether a goal is freely chosen or driven by fear.
Least restrictive care and assent for youth. Services for young people should be in the least restrictive setting, with assent and developmentally appropriate informed consent [source: APA 2009 Task Force report, p. 5]. In practice: never accept a parent's change goal for a child.
Trauma-informed pacing. Aversive conditioning may have left conditioned fear, disgust or numbing around the client's own desires [synthesis, from harms listed in APA 2009 Task Force report, p. 3]. In practice: titrate, ground, and never re-expose the client to the original material.
Safety first. Change efforts are associated with roughly doubled suicidal ideation and attempts [source: Williams Institute summary of Blosnich et al. 2020]. In practice: ask about suicide early and repeatedly.
Clear technical boundaries. Covert conditioning may be used legitimately for client-chosen targets such as substance use (Domain II 052), but never for orientation or gender identity [synthesis]. In practice: review any imagery-based aversion plan for its target.
Collegial and institutional accountability. You never provide, supervise or refer to change efforts, and you act when a colleague or service uses them [synthesis]. In practice: know your regulator's and association's complaint routes.
No naming of survivors; even-handed facts. Write and speak about the history without moralising and without identifying anyone harmed [synthesis]. In practice: de-identify case material in supervision and teaching.
Dual roles. Where a pastor, mentor or family friend also acts as counsellor, the APA Ethics Code's Standard 3.05 on multiple relationships is relevant [source: APA Ethics Code]. In practice: avoid dual roles that compromise objectivity or invite pressure on the client.

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis]. None reproduces, adapts or teaches covert sensitisation or any change effort.

4.1 Historical literacy for yourself and your team

Purpose / when: before seeing affected clients, and when training colleagues; to recognise covert sensitisation as part of the aversion-therapy history and to tell it apart from legitimate covert conditioning (Domain II 052) [source: Davison et al.; Gale Encyclopedia of Psychology].
Steps: 1) Read the history of aversion therapy for homosexuality in your country (in the UK, NHS hospital use from the late 1950s to the early 1970s). 2) Learn the current professional positions (APA 2021, UK MoU, A/HRC/44/53). 3) Note that change efforts today come mostly from religious leaders and that imagery-based variants may not be labelled as "therapy". 4) Agree within your service that no imagery-based aversion plan may target orientation or gender identity.
Example language (illustrative): "Imagery-based aversion was once used to try to change who people were attracted to. It did not do that, and our service never uses it for that purpose."
Watch for: colleagues who treat the history as remote; it is within living memory, and survivors are still in services [source: Davison et al.]. Working when staff can name the history and the boundary.

4.2 Routine, non-leading screening for past change efforts

Purpose / when: at intake with any client, and especially LGBTQ+ clients, clients from high-control religious settings, and clients describing unexplained disgust or fear about their own desires.
Steps: 1) Ask in plain terms whether anyone (a therapist, religious leader, mentor, family member or programme) ever tried to change or stop their attractions or gender identity. 2) Include imagery or "urge" exercises explicitly, because clients may not call them therapy. 3) Accept "not sure" and return to it later. 4) Record the answer factually.
Example language (illustrative): "Some people were asked, by a counsellor or a church or a programme, to imagine unpleasant things whenever they noticed attraction. Has anything like that ever happened to you?"
Watch for: shame or silence; some clients still believe the effort was for their good. Working when the client can answer without feeling judged either way.

4.3 Careful history of the change effort

Purpose / when: once a client discloses past exposure; to understand setting, age, consent, coercion and lasting effects, without asking them to relive the content.
Steps: 1) Ask who provided it, where, at what age, for how long in general terms, and whether it felt voluntary. 2) Do not ask the client to describe the imagery used; ask instead what effects it left. 3) Ask about other forms of pressure that came with it (family, religious, legal). 4) Ask what they were told would happen and what actually happened. 5) Pause and ground if distress rises.
Example language (illustrative): "You don't need to tell me what you were asked to imagine. I'm more interested in what it left you with, and whether you felt free to say no."
Watch for: many "voluntary" patients were under coercion [source: Davison et al.]; record it as the client describes it. Working when the history is clear enough to plan care and the client feels in control of the telling.

4.4 Suicide-risk assessment and safety planning

Purpose / when: early with every affected client and at points of stress (disclosure, family rejection, faith crisis). Change efforts are associated with being nearly twice as likely to think about and attempt suicide [source: Williams Institute summary of Blosnich et al. 2020]; the APA notes more suicide attempts among young people who had change efforts [source: APA press release 2021].
Steps: 1) Ask directly about suicidal thoughts, intent, plans and past attempts, using your service's standard assessment. 2) Build a written safety plan: warning signs, coping steps, people and places, professional contacts, crisis lines. 3) Use lethal-means counselling (safe storage or removal) without discussing methods. 4) Agree review points.
Example language (illustrative): "People who went through change efforts often carry thoughts of not wanting to be alive. Have you had thoughts like that, now or in the past?"
Crisis resources: 988 Suicide and Crisis Lifeline (US); Samaritans 116 123 (UK and Ireland).
Watch for: spikes after family rejection, religious exclusion or anniversaries. Working when the client uses the plan and can name supports.

4.5 Assessment of trauma and conditioned after-effects

Purpose / when: after disclosure; the Task Force lists loss of sexual feeling, depression, anxiety and suicidality as documented effects of early aversive methods [source: APA 2009 Task Force report, p. 3]; the UN report adds shame, guilt, self-disgust, self-hatred and PTSD symptoms [source: A/HRC/44/53, paras 55-56].
Steps: 1) Screen for PTSD, depression and anxiety with validated measures your service licenses. 2) Ask specifically about intrusive unpleasant imagery or nausea or fear that arrives with attraction or intimacy. 3) Ask about sexual function and avoidance of intimacy. 4) Ask about substance use as coping. 5) Formulate these as effects of what was done, not as evidence of something wrong with the client.
Example language (illustrative): "When you notice attraction now, does anything unpleasant come with it, like images, sickness or fear, that you think started back then?"
Watch for: clients blaming themselves for the after-effects. Working when the client can see the link between the practice and the symptoms.

4.6 Safeguarding a child or young person exposed now

Purpose / when: whenever a minor is currently subjected to, or threatened with, change efforts. The UN Independent Expert states that subjecting children to these practices constitutes ill-treatment and may constitute torture [source: A/HRC/44/53, para. 71]. Exposure before age 10 was associated with severe psychological distress [source: A/HRC/44/53, para. 57].
Steps: 1) Assess immediate risk, including suicide risk. 2) Follow your local child-protection procedure and mandatory-reporting law; consult your safeguarding lead. 3) Seek the young person's views and assent; explain confidentiality limits in age-appropriate terms. 4) Engage parents where safe (4.13). 5) Document facts, dates and actions.
Example language (illustrative): "Your feelings are not something that needs fixing. Because I'm worried about what's being done to you, I need to talk with people whose job is to keep young people safe. I'll tell you what I'm doing."
Watch for: retaliation at home or in a religious community after disclosure. Working when the exposure stops and the young person has a trusted adult.

4.7 Responding to a client who asks to change orientation or gender identity

Purpose / when: when a client requests change, including requests for imagery or "urge" techniques. The MoU allows exploration and work toward self-acceptance without an agenda [source: UK MoU v2]; the Task Force frames the response as acceptance, support and identity exploration with no a priori outcome [source: APA 2009 Task Force report, p. 4].
Steps: 1) Thank the client for being open and explore what drives the request (faith, family, fear, internalised stigma, trauma). 2) State clearly that you will not attempt change, and why: the evidence and professional positions. 3) Offer what you can do: explore distress, values and options for living. 4) Agree goals the client chooses within that frame. 5) Do not refer onward to change efforts.
Example language (illustrative): "I won't try to change your attractions, because the evidence is that it doesn't work and often harms people. What I can do is help with the distress and the conflicts you're carrying, and help you work out how you want to live."
Watch for: the client feeling rejected; name that you are declining a method, not them. Working when the client stays in therapy with a goal they own.

4.8 Informed-consent conversation about the work

Purpose / when: at the start of therapy and whenever goals shift.
Steps: 1) Describe what therapy will and will not do. 2) Explain the affirmative, non-directive stance. 3) Explain confidentiality and safeguarding limits. 4) Invite questions about your own views and training. 5) Record agreement.
Example language (illustrative): "We can look at anything you want to look at: faith, family, attraction, identity. I won't steer you to an answer, and I won't try to change who you are."
Watch for: clients seeking hidden reassurance that change is possible. Working when consent is explicit and revisited.

4.9 Affirmative psychoeducation

Purpose / when: in Phase C, to correct misinformation absorbed during change efforts.
Steps: 1) Ask what the client was told about orientation or gender identity. 2) Share professional positions in plain terms: not disorders, change efforts do not work and carry harm [source: UK MoU v2; APA press release 2021]. 3) Distinguish orientation, identity and behaviour [source: APA 2009 Task Force report, p. 4]. 4) Offer reputable written sources. 5) Check understanding and emotional reaction.
Example language (illustrative): "What you were taught was that your feelings could be conditioned away. The professional bodies now say plainly that there's no evidence that happens."
Watch for: grief or anger at time lost. Working when the client can hold accurate information without collapsing into self-blame.

4.10 Grounding and stabilisation for conditioned distress

Purpose / when: when attraction, intimacy or reminders trigger intrusive aversive reactions.
Steps: 1) Teach the client to notice the reaction as a learned after-effect. 2) Use ordinary grounding skills (orienting to the room, paced breathing at a comfortable rhythm, sensory anchors) [synthesis]. 3) Build a short plan for triggers. 4) Practise in session at low intensity. 5) Never use imagery exposure to the original aversive content.
Example language (illustrative): "That surge is something that was trained into you. It isn't a message about who you are. Let's bring you back into the room first."
Watch for: dissociation or panic; slow down. Working when the client recovers faster after triggers.

4.11 Referral or provision of evidence-based trauma-focused therapy

Purpose / when: in Phase D, when PTSD symptoms or intrusive conditioned reactions persist after stabilisation.
Steps: 1) Offer or refer to a recognised trauma-focused therapy delivered by a clinician competent in affirmative care [synthesis]. 2) Brief the receiving clinician (with consent) that the trauma involved aversive conditioning of the client's own attractions. 3) Agree that processing will focus on the client's experience of what was done to them, never on recreating the aversive material. 4) Keep suicide risk under review.
Example language (illustrative): "There are well-tested ways to help memories like these lose their grip. The aim is that your attractions stop setting off the alarm that was installed in you."
Watch for: therapists who frame attraction as the "trigger" to be extinguished; that repeats the original harm [synthesis]. Working when intrusions and avoidance lessen.

4.12 Shame, self-stigma and minority-stress work

Purpose / when: throughout Phase D; the Task Force names reducing self-stigma as a goal and warns that stereotyped interventions may increase self-stigma and minority stress [source: APA 2009 Task Force report, pp. 4-5].
Steps: 1) Map the messages the client absorbed (from the practice, family, faith, culture). 2) Separate those messages from the client's own values. 3) Use compassion-focused or cognitive work on self-criticism [synthesis]. 4) Build positive identity experiences at the client's pace.
Example language (illustrative): "Whose voice is it that says this part of you is disgusting? Was it ever yours?"
Watch for: shame returning under stress. Working when self-talk softens and the client can name pride or ease alongside pain.

4.13 Family work and parent guidance

Purpose / when: when families were involved in arranging change efforts, or when a young person is at risk. The Task Force reports that family interventions reducing rejection and increasing acceptance are helpful, and that clinicians can give parents accurate information and anticipatory guidance [source: APA 2009 Task Force report, p. 5].
Steps: 1) Meet parents separately first to hear their fears and beliefs. 2) Give accurate information without contempt for their values. 3) Identify specific rejecting behaviours and accepting alternatives [synthesis]. 4) Bring the family together when the client wants it and it is safe. 5) For adult survivors whose parents arranged treatment, support whatever repair or distance the client chooses.
Example language (illustrative): "You wanted to protect your child. The evidence now is that what protects them is acceptance, not change efforts."
Watch for: parents seeking a covert route to change. Working when rejecting behaviour falls and the young person reports feeling safer at home.

4.14 Religious and spiritual integration

Purpose / when: when distress centres on conflict between faith and orientation or gender identity. The Task Force supports religious coping and integration of religious and sexual identities [source: APA 2009 Task Force report, p. 5]. The DSM-5-TR "Religious or Spiritual Problem" may be recorded as Z65.8 [source: ICD-10-CM Z65.8 (Unbound Medicine)].
Steps: 1) Use the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions to understand the client's tradition. 2) Explore which beliefs, communities and practices are sources of meaning and which of harm. 3) Map options (staying, changing congregation, changing role, leaving, reinterpreting) without choosing for the client. 4) With consent, connect the client with affirming clergy or faith groups within their tradition. 5) Note dual-role risks when a religious leader acts as counsellor (APA Ethics Code Standard 3.05).
Example language (illustrative): "Your faith matters to you, and so does being honest about who you are. Let's look at what each means to you before deciding anything."
Watch for: you imposing a secular answer, or the client feeling they must choose immediately. Working when the client describes a livable relationship with faith, whatever form it takes.

4.15 Sexual-health and relationship support

Purpose / when: when the client reports loss of sexual feeling, avoidance of intimacy or relationship strain; loss of sexual feeling is a documented effect of aversive methods [source: APA 2009 Task Force report, p. 3].
Steps: 1) Assess sexual and relational difficulties with sensitivity. 2) Refer for medical review of any physical concern. 3) Refer to an affirming psychosexual or relationship therapist (in the UK, organisations such as the College of Sexual and Relationship Therapists and Relate are MoU signatories [source: UK MoU v2]). 4) Coordinate care with consent.
Example language (illustrative): "It makes sense that closeness feels loaded after what you went through. There are therapists who specialise in helping with exactly that."
Watch for: partners' confusion or blame; offer couple sessions if wanted. Working when intimacy feels safer.

4.16 Distinguishing legitimate covert conditioning in your own practice

Purpose / when: whenever you or colleagues use covert conditioning techniques for client-chosen targets (see Domain II 052).
Steps: 1) Confirm the target is a behaviour the client freely wants to change (for example substance use) and not attraction, orientation or gender identity. 2) Check that paraphilia or sexual-behaviour work never extends to consensual same-sex attraction or gender expression [synthesis]. 3) Document the target and consent. 4) Discuss borderline cases in supervision.
Example language (illustrative, to a colleague): "Before we use this, can we write down exactly what the target is? It must not touch who the client is attracted to."
Watch for: vague targets such as "unwanted urges" that include same-sex attraction. Working when every plan has a specific, appropriate target.

4.17 Duties when a colleague or institution uses it

Purpose / when: when you learn that a colleague, supervisee, service or affiliated programme is using covert sensitisation or any change effort on orientation or gender identity.
Steps: 1) Make sure any client involved is safe and offered alternative care. 2) Raise it with the colleague or service where safe and appropriate [synthesis]. 3) Report through your professional body or licensing board as its procedures set out; in the UK, the MoU signatory bodies have committed to oppose conversion therapy [source: UK MoU v2]. 4) In the US, use your state licensing board and association ethics routes [synthesis]. 5) For minors, follow child-protection procedures (4.6). 6) Keep factual records.
Example language (illustrative): "I'm not able to be part of a plan aimed at changing a client's orientation. I'd like us to stop it and offer the client affirmative care instead."
Watch for: pressure to stay silent in faith-based or small services. Working when the practice stops and affected clients are supported.

4.18 Supporting complaints, records and legal routes

Purpose / when: when a survivor wants to complain, seek records or explore legal action.
Steps: 1) Explore what the client hopes for (acknowledgement, apology, accountability, compensation). 2) Explain your role: support, not legal advice. 3) Help the client find the right body (regulator, professional association, hospital trust, consumer-protection or legal advice service) [synthesis]. 4) Help them prepare for re-activation of symptoms. 5) Write factual reports only within your competence and with consent.
Example language (illustrative): "You can decide whether to take this further. If you do, we'll plan how to look after yourself while it happens."
Watch for: retraumatisation through the process; pace it. Working when the client feels the choice is theirs.

4.19 Peer support and community connection

Purpose / when: Phases D-E, to counter isolation; social support is part of the Task Force framework [source: APA 2009 Task Force report, p. 4].
Steps: 1) Explore what community the client has and wants. 2) Identify LGBTQ+ community groups, affirming faith groups and survivor networks as they publish themselves [synthesis]. 3) Check safety and fit before recommending. 4) Review how connection is going.
Example language (illustrative): "Would it help to meet people who've been through something similar and come out the other side?"
Watch for: groups that mix support with renewed pressure to change. Working when the client reports belonging.

4.20 Repair when care caused harm

Purpose / when: when a client was harmed by a previous therapist, or by your own service, including historic NHS treatment [source: Davison et al.].
Steps: 1) Acknowledge the harm without defensiveness. 2) Where the harm came from your service, follow its duty-of-candour or apology procedures [synthesis]. 3) Invite the client to say what repair would look like. 4) Restore trust through consistency and transparency. 5) Offer a different clinician if wanted.
Example language (illustrative): "What was done to you in the name of treatment was wrong. I'm sorry it happened, and I want this to be a different experience."
Watch for: the client testing whether you, too, secretly want them to change. Working when the client can disagree with you safely.

4.21 Advocacy and service development

Purpose / when: Phase E and in your wider role.
Steps: 1) Review your service's policies against the MoU commitments to training and policy review [source: UK MoU v2]. 2) Push for CPD on work with gender and sexually diverse clients [source: UK MoU v2]. 3) Support survivors' wishes for acknowledgement of historic harm, as historians propose for the UK [source: Davison et al.]. 4) Contribute de-identified learning to training.
Example language (illustrative, to a manager): "Our intake form doesn't ask about past change efforts. Can we add a question and train staff to follow it up?"
Watch for: tokenism. Working when policy and practice change.

5. Handling problems

The problems below are the psychotherapist's own synthesis [synthesis] unless tagged.

Client insists on change and wants imagery techniques. Hold the boundary (4.7) and stay curious about the request. Explore costs and hopes. If the client leaves to seek change elsewhere, give crisis resources, leave the door open and document your reasons. Never refer to a change provider.
Client defends the practitioner who treated them. Do not argue; ask what the relationship meant and what it cost. Loyalty and harm can coexist.
Overwhelm during history-taking. Stop detail, ground (4.10), return to effects rather than content. Never ask for the imagery used.
Re-activation by attraction, sex or intimacy. Normalise it as a conditioned after-effect; add grounding and trauma-focused work (4.11); refer for psychosexual support (4.15).
Suicidal crisis. Follow your service's risk procedure and the safety plan; 988 (US), Samaritans 116 123 (UK and Ireland). Do not discuss methods. Review after family or religious ruptures.
Ruptures over your identity or beliefs. Clients may suspect a hidden agenda in either direction. Invite the concern openly, explain your non-directive stance [source: UK MoU v2], and repair.
Non-attendance or stalling. Shame often drives avoidance. Reach out once with a low-pressure message; shorten or slow sessions; check for ongoing pressure at home or in a congregation.
Family or community pressure continues. Assess safety; plan for disclosure risks; involve safeguarding for minors (4.6); consider housing and practical support for adults.
Religious client fears losing faith or community. Avoid forcing a choice (4.14); connect with affirming members of their own tradition where wanted.
A minor's parents demand change therapy. Decline; explain the evidence and your duties [source: APA 2009 Task Force report, p. 5]; offer family work; follow child-protection procedures if harm is occurring.
A colleague's covert conditioning plan has a vague target. Ask for the target to be specified and recorded (4.16); escalate if it includes orientation or gender identity (4.17).
Contested evidence cited by the client. Some commentators dispute the suicide-risk findings [uncertain: not verified]. State what professional bodies conclude (APA 2021; A/HRC/44/53) and keep the focus on the client's own experience.
Legal uncertainty in the US. On 31 March 2026 the US Supreme Court ruled 8–1 in Chiles v. Salazar that Colorado's conversion-therapy law, as applied to a counsellor's talk therapy, regulates speech based on viewpoint; it reversed the lower courts, which had not applied sufficiently rigorous First Amendment scrutiny, and sent the case back (SCOTUSblog; NPR). Its effect on other states' laws is [uncertain]. Your professional ethics and your body's position still apply; check current guidance from your licensing board and association.
Your own reactions. Anger, guilt about the profession's history, or rescuing urges are common; take them to supervision.

Harm account

What was actually done

From the late 1950s to the early 1970s, aversion therapy aimed at homosexuality was given in NHS hospitals in England (for example Crumpsall, the Maudsley, St George's, Banstead, Glenside), mainly with electric shock or nausea-inducing drugs; historians name Feldman and MacCulloch as its most prominent practitioners and report that many "voluntary" patients were under coercion [source: Davison et al. 2024/2025; Spandler and Carr 2022]. Women were also treated [source: Spandler and Carr 2022]. Covert sensitisation, described by Cautela in the mid-1960s, transferred the aversive element into imagination [source: Gale Encyclopedia of Psychology]; at least one 1973 US study combined it with contingent shock for men including homosexual men [uncertain: secondary, unverified]. The UN Independent Expert's 2020 report documents aversive change practices, including shocks and nausea-inducing drugs while erotic material is shown, in many countries [source: A/HRC/44/53, para. 43]. Change efforts continue today, most often from religious leaders [source: Williams Institute summary of Blosnich et al. 2020].

What it looked like to the client. In covert sensitisation nothing physical is done to the person: the clinician guides them to picture themselves vividly in a situation linked to the targeted behaviour and then to imagine a sickening, frightening or humiliating consequence, such as nausea, vomiting, vermin or social embarrassment; the imagery is practised in sessions and as homework between them [source: Gale Encyclopedia of Psychology]. Aimed at same-sex attraction, this meant a client was taught to connect their own attractions with disgust, fear and shame, largely in private and over a long period [synthesis from the general description]. Physical aversion given in the same era to lesbian and bisexual women in NHS hospitals paired sexual images of women with shocks or nausea-inducing drugs over courses of weeks, and left some women feeling ill at the sight of women without changing their attraction [source: Spandler and Carr 2022]. Warning signs today: a "therapy" or "ministry" that asks a client to imagine disgust or punishment when they feel same-sex attraction or gender-related feelings; homework to rehearse such images; and a client who reports nausea, panic or self-disgust at their own attractions after such work [synthesis].

How it caused harm

It did not change orientation: the APA states there is "no evidence of sexual orientation change" [source: APA press release 2021]; the Task Force found enduring change uncommon [source: APA 2009 Task Force report, p. 2]. Early aversive methods were documented to cause loss of sexual feeling, depression, anxiety and suicidality, and high dropout may reflect perceived harm [source: APA 2009 Task Force report, p. 3]. Survivors of change practices report shame, guilt, self-disgust, worthlessness, self-hatred, PTSD symptoms, suicidal ideation and attempts [source: A/HRC/44/53, paras 55-56]. People who underwent conversion therapy were nearly twice as likely to think about and attempt suicide [source: Williams Institute summary of Blosnich et al. 2020]. Historians record lasting trauma for many British survivors, though experiences varied, and some women described being put off same-sex partners without any change in attraction [source: Davison et al.; Spandler and Carr 2022]. The IRCT's Independent Forensic Expert Group called offering these practices "a form of deception, false advertising and fraud" and considers them cruel, inhuman or degrading treatment when forced, possibly torture [source: A/HRC/44/53, paras 21, 62].

Recognising it today

Any plan pairing a client's same-sex attraction or gender identity with imagined unpleasant outcomes, however named ("urge management", "unwanted attraction" work, "sexual brokenness" programmes) [uncertain: not verified as to current labels].
Covert conditioning plans with vague targets such as "unwanted urges" that include consensual same-sex attraction [synthesis].
Religious or mentoring settings offering structured change work; most change efforts are provided by religious leaders [source: Williams Institute summary of Blosnich et al. 2020].
Clients reporting nausea, fear or disgust tied to their own attractions after past counselling [synthesis].
Legal position (dated, may change): the UN Independent Expert noted national bans in Ecuador and Malta and sub-national bans elsewhere as of 2020, and urged all states to ban the practices [source: A/HRC/44/53, paras 75-76, 87]. The UK Government Equalities Office's 2021 evidence assessment (published 29 October 2021) lists a 2020 German federal law banning conversion therapy for minors, and for adults where it is undergone by force, fraud or pressure, and sub-national bans in Canada and Spain [source: GEO 2021, Appendix 3]. Later national laws reported for other countries (for example Canada, France and Spain) and medical-only bans are [uncertain: not verified; check official sources]. On 31 March 2026 the US Supreme Court ruled 8–1 in Chiles v. Salazar that Colorado's conversion-therapy law, as applied to a counsellor's talk therapy, regulates speech based on viewpoint; it reversed the lower courts, which had not applied sufficiently rigorous First Amendment scrutiny, and sent the case back (SCOTUSblog; NPR). Its effect on other states' laws is [uncertain]. In the wider history, the Associated Press reported that a New Jersey jury found JONAH liable for consumer fraud in June 2015 (see 076), and Religion News Service reported Exodus International's June 2013 closure and its president's apology (see 074).

What to do instead and how to help those harmed

Supported alternative care: an affirmative, client-centred approach of acceptance and support, assessment, active coping, social support and identity exploration and development without a predetermined outcome [source: APA 2009 Task Force report, p. 4]; exploration and self-acceptance work without an agenda [source: UK MoU v2]; APA's Guidelines for Psychological Practice with Sexual Minority Persons (2021) [source: APA press release 2021].
For survivors: suicide-risk assessment and safety planning (4.4), trauma-focused therapy (4.11), shame work (4.12), psychosexual support (4.15), peer connection (4.19), repair (4.20). Crisis lines: 988 (US); Samaritans 116 123 (UK and Ireland).
For families: accurate information and work to reduce rejection [source: APA 2009 Task Force report, p. 5] (4.13).
For religious clients: integration of faith and identity (4.14); Z65.8 where a religious or spiritual problem is the focus [source: ICD-10-CM Z65.8 (Unbound Medicine)].
Reporting and legal routes: child-protection procedures for minors (4.6); professional body or licensing-board complaints for practitioners (4.17); legal and consumer-protection advice for survivors (4.18) [synthesis].
Survivor organisations: connect clients with survivor and LGBTQ+ community groups as they describe themselves; check fit and safety first [synthesis].

Sources

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