The Growing Regulation of Conversion Therapy

On April 8, 2015, the Obama administration called for an end to conversion therapies that seek to change a person's sexual orientation or gender identity. The White House issued a statement saying, “As part of our dedication to protecting America's youth, this Administration supports efforts to ban the use of conversion therapy for minors.”1 This unprecedented announcement occurs at a time when California, New Jersey, Oregon, Illinois, Vermont, Washington, D.C., and the Canadian province of Ontario, have banned such therapies undertaken by licensed professionals for minors. In addition, 17 states have seen bills introduced into their legislatures also seeking to ban these therapies. Unlicensed practitioners of conversion therapy have been successfully sued in New Jersey using consumer fraud legislation; however, most states do not regulate “therapy” provided by unlicensed practitioners.

This growing trend toward banning conversion therapies creates novel challenges for licensing boards and ethics committees, most of which are unfamiliar with the issues raised by complaints against conversion therapists. In an effort to close that knowledge gap, this paper outlines the state of current research and ethical considerations surrounding conversion therapy.

Karl Maria Kertbeny, a Hungarian writer, and Richard von Krafft-Ebing, a psychiatrist, first used the terms “homosexual” and “homosexuality” in the 19th century, though they disagreed on the term's moral implications.2,3 Their early differences presages an ongoing argument that continued into the middle of the 20th century, where two major competing theoretical views of homosexuality predominated: that of psychoanalysis, a field dominated by psychiatric physicians, and that of academic sexology research.

Sigmund Freud, the father of psychoanalysis, offered a view of homosexuality as a developmental arrest, a form of “immaturity,” in which normal sexual instincts of childhood persist into adulthood.4 However, psychoanalysts after Freud, until the last decade of the twentieth century,5,6 based their views on the work of Sandor Rado, who believed there was no such thing as normal bisexuality.7 Rado defined adult homosexuality as a phobic avoidance of heterosexuality caused by inadequate early parenting.

His views were highly influential in the pathological models of psychiatrists of the mid-20th century who theorized about homosexuality from a self-selected group of patients seeking treatment and from prison populations.8,9 

Sexology researchers of the mid-twentieth century tried to make sense of human sexual behavior by studying general populations. They did field research, recruiting large numbers of non-patient subjects for study. The work of Alfred Kinsey and Evelyn Hooker lent support to a growing scientific view that homosexuality, like heterosexuality, is a normal variation of human sexual expression.10,11,12 American psychiatry at that time, under the sway of psychoanalytic theory, mostly ignored this research and its normalizing conclusions.

In 1970, sexology research was brought forcefully to the attention of the American Psychiatric Association (APA). Organized gay and lesbian activists, convinced that psychiatry's pathologizing attitudes about homosexuality were a major contributor to social stigma, disrupted the 1970 and 1971 annual APA meetings. As a result, APA embarked upon a process of studying the scientific question of whether homosexuality should be considered a psychiatric disorder. After an extensive review of the literature, the APA's Board of Trustees voted to remove homosexuality from the DSM-II in December 1973.13,14 

The removal of the diagnosis from the DSM contributed to changes in cultural attitudes about homosexuality in the U.S. and other countries. Those who accepted scientific authority on such matters gradually came to accept the view that homosexuality is a normal variant of human sexual expression. Similar shifts gradually took place in the international mental health community as well. In 1990, the World Health Organization removed homosexuality from the International Classification of Diseases (ICD-10).15 

Despite these changes in scientific thinking in the last two decades, social and religious conservatives have advanced their own illness/behavior model of homosexuality.16 These individuals believe that if homosexual behavior can be changed in just one person, homosexuality cannot possibly be an inborn trait, like race.17 They maintain that homosexuality is not inborn and that variations of long disproven psychoanalytic theories of homosexuality's etiology can serve as a basis for offering conversion therapies.16,17,18,19 

The position that a homosexual orientation can change received a great deal of media attention in 2001 when Robert L. Spitzer, MD, presented his study of 200 individuals who claimed to have undergone such changes.20,21 According to Spitzer, a majority of the study's subjects reported some change from a “predominantly or exclusively” homosexual orientation to a “predominantly or exclusively” heterosexual orientation. Many scholars made methodological criticisms of the study, which was published without conventional peer review.20 Instead, reviewer commentaries — most of them negative and urging the journal not to publish — accompanied the study's publication. In 2012, Spitzer repudiated his own study, writing, “There was no way to judge the credibility of subject reports of change in sexual orientation.”22 

Assessments of the peer-reviewed literature from multiple professional organizations, including the American Psychiatric Association, the American Psychological Association, and the American Academy of Child and Adolescent Psychiatrists, have found no evidence that conversion therapy treatments result in changes in sexual orientation.23,24,25 There is no formal training available on how to conduct conversion therapy. Moreover, the evidence, suggests these treatments are harmful.26,27,28,29 

In the past, professional organizations regarded conversion therapies as private agreements between individual patients and therapists. Many believed that efforts to eradicate homosexuality were a reasonable and harmless undertaking.16 In recent years, however, complaints about poor outcomes have led to greater scrutiny. An emerging clinical focus developed on individuals who — after attempting and failing conversion therapy — later adopted a gay or lesbian identity. Referring to themselves as “ex-gay survivors,” these individuals have begun organizing themselves.30 An accumulation of patient reports paints a disturbing picture: therapists may be doing psychological damage to patients who fail to change and eventually come out as gay or lesbian — and to their families, as well. Ethical violations in these treatments include:

• Telling patients that homosexuality is a mental disorder because of practitioner beliefs when there is no evidence that this is the case.

• Breaches of confidentiality, i.e., counselors in religious schools informing administration officials about a patient's sexual behavior discussed in therapy, sometimes leading to expulsion.

• Improper pressure placed on patients, i.e., threatening to end treatment if the patients do not submit to the therapist's authority.

• Abandoning patients who eventually decide to come out as gay or lesbian, i.e., unwillingness to refer a patient to a gay or lesbian affirmative therapist when conversion therapy fails.

• Indiscriminate use of treatment, i.e., regardless of the probability of success, conversion therapists will recommend their treatments to anyone.

• When patients are not able to change their sexual orientation, conversion therapists often blame the patient, rather than the therapy.29,31 This can lead to shameful internalizations that may induce or worsen depression.

These troubling ethical practices have raised alarm in major mental health professions, particularly because of the harm to patients. Further, all of these factors raise another ethical issue: Even if the questionable claims of conversion therapy's effectiveness are valid, should the conversion of some “homosexuals” to heterosexuality condone the iatrogenic harm done to other patients who later come out as gay or lesbian?16 In other words, should it not matter how many gay or lesbian people are hurt in the process of creating a few heterosexuals?

Harm can occur when patients blame themselves for their failure to change, questioning their faith or level of motivation. This may lead to depression, anxiety, and suicidal ideation. Some individuals are encouraged to marry during a course of conversion therapy and may have spouses and children by the time they accept that change has not happened. These families may break apart. In cases where religious beliefs discourage divorce, mixed orientation couples often stay living together in tragic circumstances. Also, years of trying fruitlessly to change one's sexual orientation can delay the decision to come out as gay or lesbian. When the individual does come out, the experience of conversion therapy, which can be likened to a concentrated dose of anti-homosexual stereotyping, may create intimacy and sexual problems. Haldeman refers to this as a “spoiled” gay identity.28 

Furthermore, while it is difficult to capture empirically the rates of depression, suicide, and other negative health outcomes caused by conversion therapy, there is strong evidence showing that social and family rejection of gay or lesbian identity are strongly correlated with negative health outcomes. Ryan and others show that lesbian, gay, and bisexual young adults who reported high levels of family rejection were 8.4 times more likely to have attempted suicide, 5.9 times more likely to report depression, and 3.4 times more likely to have tried illegal drugs when compared to individuals who did not feel rejected. Instead of protecting individuals who experience this rejection, conversion therapy can potentially increase this risk by deepening the rejection of the patient's identity.32 

Conversion therapists have at times defended their actions by claiming their clients should be able to choose to take part in these therapies. We disagree and suggest that a parallel proscribed behavior that regulatory bodies can consider while assessing how to respond to these complaints is sexual contact between therapists and patients. Sexual contact, even when consensual, has been shown to be very detrimental to the patient and has no place in the clinical setting.

As of this writing, five states (California, New Jersey, Oregon, Illinois, Vermont), the District of Columbia and the Canadian province of Ontario have passed legislation outlawing the practice of conversion therapy by licensed mental health professionals for patients less than 18 years of age (Table 1). In addition, New Mexico has passed legislation forming a state task force to study the practice of conversion therapy and bring recommendations back to the legislature.

Nineteen additional states have introduced legislation outlawing conversion therapy for minors for the current legislative session. In February 2016, New York Governor Cuomo issued an executive order that barred New York insurers from paying for conversion therapy to minors, prohibited New York Medicaid from covering conversion therapy, and forbid the New York State Office of Mental Health facilities from providing conversion therapy to minors. Overall, this level of legislative action points to the importance of state licensing boards familiarizing themselves with what constitutes conversion therapy in order to adjudicate possible complaints.

As of this writing, to our knowledge, there have been no formal actions by a regulatory body against a provider for engaging in conversion therapy. However, major mental health organizations have rejected conversion therapy as a treatment modality given that there is no rigorous scientific evidence to support the claim that sexual orientation can be changed and there is evidence that these treatments can cause harm to patients. Furthermore, there is likely to be more legislation banning the practice in the coming years. Regulatory bodies must take these issues into consideration when evaluating claims regarding these treatments.

While existing legislation only bans conversion therapy for minors, regulatory bodies should develop guidelines to deal with complaints from adults who have been harmed by conversion therapies.

As it is likely that more states will be banning conversion therapies for minors, regulatory bodies should create easily accessible mechanisms for the public to register complaints about them.

Regulatory bodies whose members do not have expert knowledge about conversion therapies should seek out expert consultation when managing complaints about them.

Regulatory bodies should develop appropriate guidelines on how to sanction licensed practitioners of conversion therapies.