Nicholas Cavnar said he tried everything he could think of in his 30-year quest to become heterosexual. He spent years in therapy, paying thousands of dollars for treatment designed to overcome his homosexuality. He faithfully attended meetings of Christian self-help groups for "strugglers." He married and fathered three children, a metamorphosis featured on the cover of a Catholic magazine.
Yet every day, the 54-year-old Washington publishing executive recalled, he had to suppress his deepest feelings about who he really was -- emotions he thought he had left behind at 20 when, to the delight of his devout family, he abruptly renounced his openly gay life in San Francisco.
Three years ago, Cavnar said, after soul-searching prompted by the Sept. 11 terrorist attacks, he decided his days of "white-knuckling it" were over. "I told my wife I couldn't not be gay anymore," recalled Cavnar. His biggest regret, he said, was the devastating impact ending their 26-year marriage had on the woman who had struggled with him.
Cavnar's odyssey -- from gay to ex-gay to ex-ex-gay -- is inextricably linked to his long involvement in reparative therapy, a controversial form of psychotherapy aimed at making gays straight.
While its supporters cite success stories from their clinical practices as well as a recent and much debated study showing that conversion therapy can work, the treatment is opposed by virtually every medical and mental health organization, including the American Medical Association, the U.S. Surgeon General and the American Psychiatric Association (APA), which removed homosexuality from its list of mental disorders in 1973.
Until the early 1990s the treatment, also known as reorientation therapy, was largely relegated to religious groups or to the fringes of mental health. Mainstream therapists have been taught to help patients distressed about their homosexuality work toward self-acceptance, to overcome the internalized homophobia thought to be the cause of much emotional turmoil.
Reparative therapists reject the views held by an overwhelming majority of mental health practitioners. They regard homosexuality as a pathological preference forged in the crucible of a troubled childhood and not, as most scientists believe, an inborn orientation significantly influenced by biological factors such as genetics and exposure to hormones in the womb.
"I don't think sexual orientation is genetically determined, but like a lot of preferences we have in life is a complicated and idiosyncratic mix of temperament and experience," said Warren Throckmorton, a supporter of reparative therapy who is an associate professor of psychology at Grove City College in Pennsylvania and former president of the American Mental Health Counselors Association. "The other reason I think change is possible is that I've worked with a lot of clients who've done it."
In the past decade, the growing influence of religious conservatives and the national debate over gay rights, especially gay marriage, has revived interest in the therapy, significantly raising its public profile, spawning new practitioners and igniting debate about a matter that had been considered settled, supporters and critics agree.
"Reparative therapy is the laetrile of mental health," said New York psychiatrist Jack Drescher, referring to the quack cancer cure banned in the United States in the 1970s.
To gay rights activist Wayne R. Besen, the author of "Anything But Straight," a 2003 book that tracks the history of ex-gay groups, the therapy is "a kinder, gentler form of homophobia. The argument has shifted from 'You're harming society' to 'You're harming yourselves.' "
Web sites with names like "inqueery" and "freetobeme" have sprung up, directing confused teenagers and frantic parents to reparative counselors. Parents and Friends of Ex-Gays and Gays (PFOX), a national group headquartered in Fairfax County, has sponsored highway billboards in Rockville and Richmond that state "Ex-Gays Prove That Change Is Possible."
PFOX, founded seven years ago to counter PFLAG -- Parents, Families and Friends of Lesbians and Gays -- was active in the recent battle over sex education in Montgomery County. Central to the dispute was the way homosexuality would be taught.
As a result of a lawsuit, PFOX has won a seat on the board that will help rewrite the health curriculum, and its officials say they plan to push for inclusion of reparative therapy.
Reparative therapists have their own organization, the 1,000-member California-based National Association for Research and Therapy of Homosexuality (NARTH), founded in 1992. Its leaders often appear at "Love Won Out" workshops that draw more than 1,000 participants and are sponsored by Focus on the Family, a group founded by conservative psychologist James Dobson, a staunch opponent of gay rights who has ties to the Bush administration.
Mental health experts are alarmed by the resurgence of a treatment they say has been discredited.
In the view of Drescher, chair of the APA's committee on gay, lesbian and bisexual issues, reparative therapy's ascendance resembles the resurrection of creationism, a religious belief at odds with science that has been rechristened with the more scientific-sounding name "intelligent design."
"Many people who try this treatment tend to be desperate, very unhappy and don't know other gay people," said Drescher, who has treated about a dozen men who previously underwent conversion therapy. (Men are far more likely than women to receive the treatment.)
"I see people who've been very hurt by this," said Drescher, who said some people do manage to temporarily change their behavior, often by becoming celibate, but not their sexual orientation. "They spend years trying to change and are told they aren't trying hard enough."
Catherine Wulfensmith, 46, a family therapist in Monrovia, Calif., said she attempted suicide several times after reparative therapy failed to alter her attraction to women. "I bought it hook, line and sinker," she said. "If you don't change, what are you left with?"
Reparative therapy typically involves once- or twice-weekly psychotherapy sessions lasting a minimum of two years; it may be covered by insurance if it is listed as being for a "sexual disorder not otherwise specified." Patients are encouraged to delve into their childhood relationships, especially with the same-sex parent; to cultivate straight friends and "gender-appropriate" activities such as sports or sewing; and to avoid anything, or anyone, gay. Prayer is often recommended.
NARTH co-founder Joseph Nicolosi, a clinical psychologist in Encino, Calif., who coined the term reparative therapy and is one of its leading practitioners, emphatically rejects the view that it is ineffective and potentially damaging. He points to a study published in 2003 by Columbia University psychiatrist Robert L. Spitzer which found that therapy seemed to work for some highly motivated patients.
"It can only be damaging if the agenda of the therapist supersedes that of the patient," said Nicolosi, who added that it should never be forced on unwilling participants.
Although no rigorous outcome studies have been published, Nicolosi estimates that one-third of patients treated at the Thomas Aquinas Psychological Clinic, of which he is founding director, experience "significant improvement -- they understand their homosexuality and have some sense of control" but may still have gay sex. Another third, he said, are "cured": They don't have gay sex and the intensity and frequency of their same-sex desires is diminished, but not necessarily gone. The other third fail to change.
Hector Roybal, a 52-year-old financial consultant in Los Angeles, spent four years in intensive treatment with Nicolosi, who considers him to be cured. Roybal concurs, but said he still sometimes struggles with sexual feelings for men, although he has remained faithful to his wife, the only woman to whom he says he feels physically attracted.
"I saw myself as someone who had a problem with homosexuality but was meant to be straight," said Roybal, who, like Nicolosi, is a conservative Catholic. "This is about making a choice."
Although reparative therapists sometimes differ about the causes of homosexuality, they are united in saying it is not inborn and it is never normal.
Nicolosi maintains it is the result of a defective bond with the same-sex parent. Boys who feel rejected by their fathers develop a "defensive detachment" -- they reject them and identify with their mothers and other females. Because opposites attract, he theorizes, they are sexually drawn to men, even though what they are searching for is their lost masculinity. Once they find it, he said, their attraction to women will follow, although lifetime vigilance is required to avoid slipping.
Even though reparative therapists say they support "free choice," they see nothing contradictory in their view that homosexuality is pathological. Nor do they regard as incongruent their refusal to work with a straight or bisexual client who thinks he or she might be gay. In their view, homosexuals are doomed to miserable, unhealthy lives.
"We say to patients, 'Your true self is heterosexual,' " Nicolosi said. He said he tells male patients, "Look at your body: It was designed to fit a woman, not a man."
Robert Spitzer sounds weary when discussing the study published two years ago in the Archives of Sexual Behavior that earned him the enmity of many of his colleagues and the admiration of reparative therapists.
Spitzer's study has special resonance: In 1973 he was the driving force behind the removal of homosexuality from psychiatry's diagnostic manual.
Thirty years later, he said, he decided to test the widespread hypothesis that reparative therapy never worked. "I like to challenge conventional notions," he explained.
Despite the active cooperation of NARTH and ex-gay religious groups, Spitzer said it took him more than 16 months to recruit 200 people who had undergone treatment. He conducted 45-minute telephone interviews and found that 66 percent of 143 men and 44 percent of 57 women, all of whom Spitzer described as "highly motivated" and almost all of whom were "extraordinarily religious," had achieved "good heterosexual function" lasting at least five years. They were in a committed relationship, had satisfying heterosexual sex at least monthly and said they were rarely or never bothered by homosexual feelings.
In an accompanying commentary, former APA president Lawrence Hartmann, a professor at Harvard Medical School, called Spitzer's study "too flawed to publish." Hartmann noted the study was retrospective, that it lacked controls or independent measurements, and was based entirely on self-reports by people who were motivated to say they had changed because of their affiliation with ex-gay or anti-gay groups.
While Nicolosi and others frequently cite the study as proof reparative therapy works, Spitzer said his results have been misrepresented. "It bothers me to be their knight in shining armor because on every social issue I totally disagree with the Christian right," he said.
"What they don't mention is that change is pretty rare," he added, noting that the subjects of his study were not representative of the general population because they were considerably more religious.
And Spitzer calls "totally absurd" the twin hypotheses that everyone is born straight and that homosexuality is a choice.
Drescher agrees. "There are probably a small number of people with some flexibility in their sexual identity who can change," he said. "Out of the hundreds of gay men I've treated, I've had one."