The Philadelphia Inquirer
this morning headlines a story “Parents challenge state ban on gay conversion
therapy” (Nov. 5, 2013; B1, B8). As many readers will know, in recent months New
Jersey and California both passed legislation prohibiting the use with minors of
conversion therapy, an intervention that purports to alter same-sex attraction
so that the treated person experiences heterosexual attraction and behaves
accordingly. Conversion therapy has been practiced both by a small number of
mental health professionals and by members of the clergy; the New Jersey
legislation applies only to licensed therapists.
The California law has been upheld in a federal
appeals court. There are presently two challenges to the New Jersey law, both
in federal courts. According to the Inquirer
article, one case has two licensed therapists among the plaintiffs. The second
involves parents who claim a violation of their constitutional rights by the
law that prevents them from seeking conversion therapy for their 15-year-old
son (by the way, it does not prevent them from “seeking treatment”, as the Inquirer says; they are free to seek
treatment that will help the son resist inappropriate impulses or will help him
come to terms with his developing sexuality). The parents argue that the law
violates their rights to free speech, freedom of religion, and equal protection
of the laws.
One of the lawyers representing these plaintiffs,
Demetrios Stratis, also argued that the law was based on faulty and incomplete
research, and pointed out that even the American Psychological Association
report, which opposed conversion therapy, agreed that the scientific basis was
weak. Stratis also stated his belief that reports of harm from the treatment
are inaccurate.
Is this correct? Was this law enacted without
sufficient scientific evidence to support it? As one who testified in favor of
the New Jersey law, I must say that the answer is probably “yes”-- but that the question is not nearly as simple
as it appears to be.
Much of the evidence I heard given was personal in
nature. Members of the LGBT community spoke of their terrible difficulties in
growing up as part of a rejected minority. A few spoke of undergoing conversion
therapy and of the distress they experienced. Members of fundamentalist
Christian groups spoke deploring the troubles and dangers of a life of same-sex
attraction, and argued that although the clergy might be able to do the
treatment, they needed real mental health professionals to handle tough cases.
A very small number of us addressed the nature and foundational beliefs of
conversion therapy. It would be quite inaccurate to say that the information
witnesses provided to the Assembly committee emphasized scientific evidence,
either about the nature of sexual orientation or of the effectiveness and
safety of conversion therapy. Although the committee presumably sought more
information elsewhere, the effect of testimony was probably to pit the strength of
one political group’s power against that of another.
Although I strongly support the New Jersey law, I
cannot claim that it is based on scientific evidence rather than political positions.
There is little scientific work examining the safety and effectiveness of conversion
therapy, and that fact raises one of the questions packed into the question
about the evidence for the law. Why is this the case? Why are we lacking an
evidence basis that would support arguments for or against conversion therapy?
A possible answer to this question-- and the answer that I think the plaintiffs in
these appeals want to imply-- is that
conversion therapy is an emerging psychotherapy.
This would mean that it is a treatment so new and so underutilized that it has
not yet been possible to collect the data that would allow us to evaluate it.
There are such therapies, and it would be quite inappropriate to claim that
laws should prohibit their use simply because of lack of evidence.
A second possible answer is that there is little
evidence about conversion therapy for two reasons. One is that practitioners of
the treatment do not believe such evidence is necessary and therefore have not
systematically collected outcome data. The other is that practitioners of
conventional treatments have regarded conversion therapy as not worth their
while to study. They have thought of it with a range of rejecting terms like
unconventional, complementary-and-alternative, fringe, New Age, or snake oil-- although they might not have spent much time
considering how or why conversion therapy should be classified in one of these
ways.
In my opinion, conversion therapy is best classified
as an alternative psychotherapy. I
offer this term to describe a treatment that has three characteristics: first,
it lacks a clear evidence basis; second, it has been demonstrated to do harm,
in which I would include unnecessary emotional pain or burdens for the client;
and third, it is implausible, or incongruent with established information about
personality, development, or mechanisms of emotional change. Unlike emerging
therapies, there may be very good reasons for prohibition of alternative
psychotherapies, especially prohibition of their use with minors.
Let’s look at conversion therapy and see how it fits
into the category of alternative psychotherapy. We have already established the
lack of a clear evidence basis supporting the effectiveness of the
treatment-- this in fact forms part of
the foundation of the legal appeals. In addition, testimony has established
harm to clients in the form of distress and emotional burdens which appear to
me to be beyond the level to be expected from a psychotherapy.
Our remaining question is about plausibility—the extent
to which a treatment agrees with or contradicts established information. We can
look at conversion therapy’s plausibility both in terms of its assumptions
about the causes of homosexual attraction and about the methods for changing
such attraction.
All the present evidence states that same-sex
orientation as part of personality (rather than as a situational factor, such
as a long prison term, or as culturally determined) is dependent on the
individual’s genetic make-up. This means
that the primary factor causing same-sex attraction is in every cell of the
body throughout life. This does not mean that the individual must act on the
attraction—obviously neither heterosexuals nor homosexuals act on every
attraction they feel! But it does mean that the orientation is an intrinsic
part of that person’s constitution.
Conversion therapy, incongruently, attributes
same-sex orientation of males to a failure of a loving attachment relationship
with a father. Such an assumption is implausible in the light of what is known
about causes of sexual orientation. Heterosexuals do not prefer the opposite
sex because they had good relationships with a same-sex parent, but because of
much more basic factors. Some readers may remember the blundering work of John
Money in the 1970s; he recommended that a baby boy whose penis had been badly
damaged in a circumcision accident should be castrated and raised as a girl. In
spite of hormone treatment and constant reinforcement by affectionate and
concerned parents, the boy later abandoned the hormone treatment, returned to
living as a male, fell in love with a woman, and married. The same considerations
apply to same-sex attractions.
Conversion therapy is also incongruent with
established knowledge about development in its use of the attachment concept. Rather
than following conventional theory and research about the natural history of
emotional attachment, conversion therapy has simply picked up the views of
another alternative psychotherapy, so-called Attachment Therapy. Attachment
Therapy, which is also potentially harmful and without supportive research
evidence, which assumes that emotional attachment is caused by experiences of
dependency and by prolonged eye contact, and which posits that where attachment
has failed it can be produced in older persons by experiences of physical
restraint and forced submission. Conversion therapy also uses methods that
attempt to re-enact through physical restraint the experiences that are
erroneously believed to be the causes of attachment-- at the same time that its practitioners
erroneously assume that attachment is related to same-sex or opposite-sex
attraction. (Bizarrely, this produces a
situation in which a young man lies in the arms of an older male therapist in
order to be persuaded not to be attracted to males.)
Conversion therapy is thus clearly implausible, as
well as being without an evidence basis and potentially harmful. It is an
alternative psychotherapy, and that is why conventional mental health
professionals do not study or practice it.
But should all alternative psychotherapies be
prohibited by law? This is tempting, but would seem to be a Draconian measure
that would violate the First and Fourteenth Amendments, if treatment of adults
were included. Minors, however, need and deserve the full protection of the law
against ineffective, unsafe treatments, whether medical or psychological. I
hope the appeals court in New Jersey will act to provide that protection
against conversion therapy.
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