Conversion therapy

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Conversion therapy is the pseudoscientific practice of attempting to change an individual's sexual orientation, gender identity, or gender expression to align with heterosexual and cisgender norms.^[1] Methods that have been used to this end include forms of brain surgery, surgical or hormonal castration, aversive treatments such as electric shocks, nausea-inducing drugs, hypnosis, counseling, spiritual interventions, visualization, psychoanalysis, and arousal reconditioning.

There is a scientific consensus that conversion therapy is ineffective at changing a person's sexual orientation or gender identity and that it frequently causes significant long-term psychological harm.^[2] The position of current evidence-based medicine and clinical guidance is that homosexuality, bisexuality and gender variance are natural and healthy aspects of human sexuality.^[2][3] Historically, conversion therapy was the treatment of choice for individuals who disclosed same-sex attractions or exhibited gender nonconformity, which were formerly assumed to be pathologies by the medical establishment.^[3] When performed today, conversion therapy may constitute fraud and when performed on minors, a form of child abuse; it has been described by experts as torture, cruel, inhuman, or degrading treatment, and contrary to human rights.

An increasing number of jurisdictions around the world have passed laws against conversion therapy.^[4]

Terminology

Medical professionals and activists consider "conversion therapy" a misnomer, as it does not constitute a legitimate form of therapy.^[5] Alternative terms include sexual orientation change efforts (SOCE)^[5] and gender identity change efforts (GICE)^[5]—together, sexual orientation and gender identity change efforts (SOGICE).^{[6][better source needed]} According to researcher Douglas C. Haldeman, SOCE and GICE should be considered together because both rest on the assumption "that gender-related behavior consistent with the individual's birth sex is normative and anything else is unacceptable and should be changed".^[7] "Reparative therapy" may refer to conversion therapy in general,^[5] or to a subset thereof.^[8]

Advocates of conversion therapy do not necessarily use the term either, instead using phrases such as "healing from sexual brokenness"^[9][10] and "struggling with same-sex attraction".^[11]

History

Sexual orientation change efforts (SOCE)

The term homosexual was coined by German-speaking Hungarian writer Karl Maria Kertbeny and was in circulation by the 1880s.^[12][4] Into the middle of the twentieth century, competing views of homosexuality were advanced by psychoanalysis versus academic sexology. Sigmund Freud, the founder of psychoanalysis, viewed homosexuality as a form of arrested development. Later psychoanalysts followed Sandor Rado, who argued that homosexuality was a "phobic avoidance of heterosexuality caused by inadequate early parenting".^[4] This line of thinking was popular in psychiatric models of homosexuality based on the prison population or homosexuals seeking treatment. In contrast, sexology researchers such as Alfred Kinsey argued that homosexuality was a normal variation in human development. In 1970, gay activists confronted the American Psychiatric Association, persuading the association to reconsider whether homosexuality should be listed as a disorder. The APA delisted homosexuality in 1973, which contributed to shifts in public opinion on homosexuality.^[4]

Despite their lack of scientific backing, some socially or religiously conservative activists continued to argue that if one person's sexuality could be changed, homosexuality was not a fixed class such as race. Borrowing from discredited psychoanalytic ideas about the cause of homosexuality, some of these individuals offered conversion therapy.^[4] In 2001, conversion therapy attracted attention when Robert L. Spitzer published a non-peer-reviewed study asserting that some homosexuals could change their sexual orientation. Many researchers made methodological criticisms of the study, which Spitzer later repudiated.^[4]

Gender identity change efforts (GICE)

Gender Identity Change Efforts (GICE) refer to practices of healthcare providers and religious counselors with the goal of attempting to alter a person's gender identity or expression to conform to social norms. Examples include aversion therapy, cognitive restructuring, and psychoanalytic and talk therapies.^[13] Western medical-model narratives have historically institutionalized transphobia: systemically favoring a binary gender model and pathologizing gender diversity and non-conformity.^[14] This aided the development and proliferation of GICE.^[15] A "psychotherapeutic” approach viewing gender incongruence as a mental health disorder or a state of confusion was used for decades, has not been shown to be effective, and was superseded by an evidence-based gender-affirming approach.^[16]

Early interventions were rooted in psychoanalytic hypotheses.^[17] Robert Stoller advanced the theory that gender-nonconforming behavior and expression in children assigned male at birth (AMAB) was caused by being overly close to their mother. Richard Green continued his research; his methods for altering behavior included having the father spend more time with the child and mother less, expecting both to exhibit stereotypical gender roles, and having them praise their child's masculine behaviors, and shame their feminine and gender-nonconforming ones. These interventions resulted in depression in the children and feelings of betrayal from parents that the treatments failed.^[17]

In the 1970s, UCLA psychologist Richard Green recruited Ole Ivar Lovaas to adapt the techniques of ABA therapy to attempt to prevent children from becoming transsexual.^[18] Deemed the "Feminine Boy Project", the treatments used operant conditioning to reward gender-conforming behaviors, and punish gender non-conforming behaviors.^[18] They recruited George Rekers as a behavioral therapist for the project.^[18] The project published several studies focusing on one subject and claiming that the child had been "cured" after 60 treatment sessions.^{[18][19][20][21][22]} However, decades later at the age of 38, the subject died of suicide, with the family blaming psychological trauma from the program.^[23][24]

Kenneth Zucker at CAMH adopted Richard Green's methods, but narrowed the scope to attempting to prevent the child from identifying as transgender. His model used the same interventions as Green with the addition of psychodynamic therapy.^[17] In January 2015, members of Rainbow Health Ontario, a provincial health promotion and navigation organization, approached CAMH expressing their concerns regarding Zucker's clinic.^[25] Rainbow Health Ontario submitted a review of academic literature and clinical practices for transgender youth, and expressed concern that the gender identity clinic was not following accepted practices.^[26] Others linked the Gender Identity Clinic's practices to suicide of transgender youth caused by conversion therapy, and referenced the high-profile case of Leelah Alcorn, a transgender teen from Ohio.^[25] In November 2015, an external review of the clinic was published.^[27] The review noted numerous strengths of the clinic, but also described it as an insular entity with an approach dissimilar from other clinics and described it as being out of step with current best practices, including WPATH SOC Version 7.^[27] After the review, CAMH shut down the clinic and fired Zucker. Kwame McKenzie, medical director of CAMH's child, youth, and family services, said "We want to apologize for the fact that not all of the practices in our childhood gender identity clinic are in step with the latest thinking" and that Zucker is, "no longer at CAMH."^[28]

Gender exploratory therapy

GET is a form of conversion therapy^{[16][29][30][31][32]} characterized by requiring mandatory extended talk therapy attempting to find pathological roots for gender dysphoria while simultaneously delaying social and medical transition indefinitely.^{[16][30][31][33][34]} Practitioners often view medical transition as a last resort and propose their patient's dysphoria is caused by factors such as homophobia, social contagion, sexual trauma, and autism.^[30][32] Bioethicist Florence Ashley found it had strong conceptual and narrative similarities with previous conversion practices such as "reparative" and "reintegrative" therapy, noting they portrayed themselves as exploring the underlying psychological causes of same-sex attraction rather than directly aiming at altering it.^[33] Some practitioners avoid using their patients's chosen names and pronouns while questioning their identification.^[34] There are no known empirical studies examining psychosocial or medical outcomes following GET.^[34][35] Concerns have been raised that by not providing an estimated length of time for the therapy, the delays in medical interventions may compound mental suffering in trans youth.^[30][34] The gender-affirming model of care promotes gender identity exploration without favoring any particular identity, and individualized care.^[34] GET proponents deny this,^[36] framing gender-affirming care as pushed by activists,^[33] and claiming the media is colluding with LGBTQ activists to silence them.^[37]

Multiple groups exist worldwide to promote GET and have been successful in influencing legal discussions and clinical guidance in some regions.^[31] The Gender Exploratory Therapy Association (GETA) asserts that "psychological approaches should be the first-line treatment for all cases of gender dysphoria", that medical interventions for transgender youth are "experimental and should be avoided if possible", and that social transition as "risky".^[36] All of GETA's leaders are members of Genspect, a "gender-critical" group that promotes GET and argues that gender-affirming care should not be available to those under 25.^[36] GETA also shares a large overlap with the Society for Evidence-Based Gender Medicine (SEGM), which promotes GET as first-line treatment for those under 25.^[37] GETA co-founder Lisa Marchiano stated U.S. President Joe Biden's executive order safeguarding trans youth from conversion therapy would have a "chilling effect" on GET practices.^[36][38] GETA also opposed Biden's Title IX changes protecting trans students from discrimination, stating allowing trans youth in restrooms would harm the mental health of their peers.^[38] The American College of Pediatricians, a small group aligned with the Christian Right and not to be confused with the American Academy of Pediatrics, has cited numerous studies from SEGM to claim GET is necessary to restore transgender people's "biological integrity".^[37]

Motivations

A frequent motivation for adults who pursue conversion therapy is their religious beliefs, especially evangelical Christianity and Orthodox Judaism, that disapprove of same-sex relations. These adults prioritize maintaining a good relationship with their family and religious community.^[39] Adolescents who are pressured by their families into undergoing conversion therapy also typically come from a conservative religious background.^[39] Youth from families with low socioeconomic status are also more likely to undergo conversion therapy.^[40]

Theories and techniques

As societal attitudes toward homosexuality have become more tolerant over time, the most harsh conversion therapy methods such as aversion have been reduced. Secular conversion therapy is offered less often due to reduced medical pathologization of homosexuality, and religious practitioners have become more dominant.^[41]

Aversion therapy and behaviorism

Aversion therapy used on homosexuals included electric shock and nausea-inducing drugs during presentation of same-sex erotic images. Cessation of the aversive stimuli was typically accompanied by the presentation of opposite-sex erotic images, with the objective of strengthening heterosexual feelings.^[42] Another method used was the covert sensitization method, which involves instructing patients to imagine vomiting or receiving electric shocks, writing that only single case studies have been conducted, and that their results cannot be generalized. Haldeman writes that behavioral conditioning studies tend to decrease homosexual feelings, but do not increase heterosexual feelings, citing Rangaswami's "Difficulties in arousing and increasing heterosexual responsiveness in a homosexual: A case report", published in 1982, as typical in this respect.^[43]

Other methods of aversion therapy in addition to electric shock included ice baths, freezing, burning via metal coils, and hard labor. The intent was for the subject to associate homosexual feelings with pain and thus result in them being reduced. These methods have been concluded to be ineffective.^[44]

Aversion therapy was developed in Czechoslovakia between 1950 and 1962 and in the British Commonwealth from 1961 into the mid-1970s. In the context of the Cold War, Western psychologists ignored the poor results of their Czechoslovak counterparts, who had concluded that aversion therapy was not effective by 1961 and recommended decriminalization of homosexuality instead.^[45] Some men in the United Kingdom were offered the choice between prison and undergoing aversion therapy. It was also offered to a few British women, but was never the standard treatment for either homosexual men or women.^[46]

In the 1970s, behaviorist Hans Eysenck was one of the main advocates of counterconditioning with malaise-inducing drugs and electric shock for homosexuals. He wrote that this type of therapy was successful in nearly 50% of cases. However, his studies were disputed.^[47] Behavior therapists, including Eysenck, used aversive methods. This led to a protest against Eysenck by gay activist Peter Tatchell in a London Medical Group Symposium in 1972. Tatchell said that the therapy promoted by Eysenck was a form of torture.^[47] Tatchell denounced Eysenck's form of behavioral therapy as inducing depression and suicide among gay men who were subjected to it.^[48]

Brain surgery

In the 1940s and 1950s, U.S. neurologist Walter Freeman popularized the ice-pick lobotomy as a treatment for homosexuality. He personally performed as many as 3,439^[49] lobotomy surgeries in 23 states, of which 2,500 used his ice-pick procedure,^[50] despite the fact that he had no formal surgical training.^[51]

In West Germany, a type of brain surgery usually involving destruction of the ventromedial nucleus of the hypothalamus was done to some homosexual men. The practice was criticized by sexologist Volkmar Sigusch.^[52]

Castration and transplantation

Friedrich-Paul von Groszheim (1908–2006) was spared from a concentration camp after agreeing to castration under pressure in 1938.

In early twentieth century Germany experiments were carried out in which homosexual men were subjected to unilateral orchiectomy and testicles of heterosexual men were transplanted. These operations were a complete failure.^[53]

Surgical castration of homosexual men was widespread in Europe in the first half of the twentieth century and was also practiced in the United States.^[54] SS leader Heinrich Himmler ordered homosexual men to be sent to concentration camps because he did not consider a time-limited prison sentence was sufficient to eliminate homosexuality.^[55] Although theoretically voluntary, some homosexuals were subject to severe pressure and coercion to agree to castration. There was no age limit; some boys as young as 16 were castrated. Those who agreed to castration after a Paragraph 175 conviction were exempted from being transferred to a concentration camp after completing their legal sentence.^[56] Some concentration camp prisoners were also subjected to castration.^[57] An estimated 400 to 800 men were castrated.^[58]

Endocrinologist Carl Vaernet attempted to change homosexual concentration camp prisoners' sexual orientations by implanting a pellet that released testosterone. Most of the victims, non-consenting prisoners at Buchenwald, died shortly thereafter.^[59][60]

An unknown number of men were castrated in West Germany and chemical castration was used in other Western countries, notably against Alan Turing in the United Kingdom.^[61]

Ex-gay/ex-trans ministries

OneByOne booth at a Love Won Out conference

Ex-gay ministries are religious groups that attempt to use religion to eliminate or change somebody's sexual orientation.^{[62][63][64][65]} The ex-gay umbrella organization Exodus International in the United States ceased activities in June 2013, and the three member board issued a statement which repudiated its aims and apologized for the harm their pursuit has caused to LGBT people.^[66][67] Ex-trans organizations often overlap and portray being trans as inherently sinful or against God's design, or pathologize gender variance as due to trauma, social contagion, or "gender ideology."^[68][69]

Hypnosis

Hypnosis was used in conversion therapy since the 19th century by Richard von Krafft-Ebing and Albert von Schrenck-Notzing. In 1967, Canadian psychiatrist Peter Roper published a case study of treating 15 homosexuals (some of which would probably be considered bisexuals by modern standards) with hypnosis. Allegedly, 8 showed "marked improvement" (they reportedly lost sexual attraction towards the same sex altogether), 4 mild improvements (decrease of "homosexual tendencies"), and 3 no improvement after hypnotic treatment; he concluded that "hypnosis may well produce more satisfactory results than those obtainable by other means", depending on the hypnotic susceptibility of the subjects.^{[70][better source needed]}

Psychoanalysis

Main page: Social:Psychoanalysis

Haldeman writes that psychoanalytic treatment of homosexuality is exemplified by the work of Irving Bieber et al. in Homosexuality: A Psychoanalytic Study of Male Homosexuals. They advocated long-term therapy aimed at resolving the unconscious childhood conflicts that they considered responsible for homosexuality. Haldeman notes that Bieber's methodology has been criticized because it relied upon a clinical sample, the description of the outcomes was based upon subjective therapist impression, and follow-up data were poorly presented. Bieber reported a 27% success rate from long-term therapy, but only 18% of the patients in whom Bieber considered the treatment successful had been exclusively homosexual to begin with, while 50% had been bisexual. In Haldeman's view, this makes even Bieber's unimpressive claims of success misleading.^[71]

Haldeman discusses other psychoanalytic studies of attempts to change homosexuality. Curran and Parr's "Homosexuality: An analysis of 100 male cases", published in 1957, reported no significant increase in heterosexual behavior. Mayerson and Lief's "Psychotherapy of homosexuals: A follow-up study of nineteen cases", published in 1965, reported that half of its 19 subjects were exclusively heterosexual in behavior four and a half years after treatment, but its outcomes were based on patient self-report and had no external validation. In Haldeman's view, those participants in the study who reported change were bisexual at the outset, and its authors wrongly interpreted capacity for heterosexual sex as change of sexual orientation.^[72]

Reparative therapy

The term "reparative therapy" has been used as a synonym for conversion therapy generally, but according to Jack Drescher it properly refers to a specific kind of therapy^{[clarification needed]} associated with the psychologists Elizabeth Moberly and Joseph Nicolosi.^[8] The term reparative refers to Nicolosi's postulate that same-sex attraction is a person's unconscious attempt to "self-repair" feelings of inferiority.^[73][74]

Marriage therapy

Previous editions of the World Health Organization's ICD included "sexual relationship disorder", in which a person's sexual orientation or gender identity makes it difficult to form or maintain a relationship with a sexual partner. The belief that their sexual orientation has caused problems in their relationship may lead some people to turn to a marriage therapist for help to change their sexual orientation.^[75] Sexual orientation disorder was removed from the most recent ICD, ICD-11, after the Working Group on Sexual Disorders and Sexual Health determined that its inclusion was unjustified.^[76]

Effects

There is a scientific consensus that conversion therapy is ineffective at changing a person's sexual orientation.^[2] Advocates of conversion therapy rely heavily on testimonials and retrospective self-reports as evidence of effectiveness. Studies purporting to validate the effectiveness of efforts to change sexual orientation or gender identity have been criticized for methodological flaws.^[77] After conversion therapy has failed to change someone's sexual orientation or gender identity, participants often feel increased shame that they already felt over their sexual orientation or gender identity.^[39]

Conversion therapy can cause significant, long-term psychological harm.^[2] This includes significantly higher rates of depression, substance abuse, and other mental health issues in individuals who have undergone conversion therapy than their peers who did not,^[78][79] including a suicide attempt rate nearly twice that of those who did not.^[80] Modern-day practitioners of conversion therapy—primarily from a conservative religious viewpoint—disagree with current evidence-based medicine and clinical guidance that does not view homosexuality and gender variance as unnatural or unhealthy.^[2][3]

In 2020, ILGA world published a world survey and report Curbin Deception listing consequences and life-threatening effects by associating specific public testimonies with different types of methods used to practice conversion therapies.^[81]

A 2022 study estimated that conversion therapy of youth in the United States cost $650.16 million annually with an additional $9.5 billion in associated costs such as increased suicide and substance abuse.^[79] Youth who undergo conversion therapy from a religious provider have more negative mental health outcomes than those who had consulted a licensed healthcare provider.^[39]

Public opinion

A 2020 survey carried out on US adults found majority support for banning conversion therapy for minors.^[82]

A 2022 YouGov poll found majority support in England, Scotland, and Wales for a conversion therapy ban for both sexual orientation and gender identity, with opposition ranging from 13 to 15 percent.^[83]

Legal status

Map of jurisdictions that have bans on sexual orientation and gender identity change efforts with minors.

  Criminal prohibition against conversion therapy on the basis of sexual orientation and gender identity

  Only medical professionals are banned from performing conversion therapy

  Conversion therapy is banned only in some subnational jurisdictions

  Ban on conversion therapy pending or proposed

  No ban on conversion therapy

Some jurisdictions have criminal bans on the practice of conversion therapy, including Canada, Ecuador, France,^[84] Germany, Malta, Mexico and Spain.^[85] In other countries, including Albania, Brazil, Chile, Vietnam and Taiwan, medical professionals are barred from practicing conversion therapy.^[86]

In some states, lawsuits against conversion therapy providers for fraud have succeeded, but in other jurisdictions those claiming fraud must prove that the perpetrator was intentionally dishonest. Thus, a provider who genuinely believes conversion therapy is effective could not be convicted.^[87]

Conversion therapy on minors may amount to child abuse.^[88][89][90]

Human rights

In 2020 the International Rehabilitation Council for Torture Victims released an official statement that conversion therapy is torture.^[88] The same year, UN Independent Expert on sexual orientation and gender identity, Victor Madrigal-Borloz, said that conversion therapy practices are "inherently discriminatory, that they are cruel, inhuman and degrading treatment, and that depending on the severity or physical or mental pain and suffering inflicted to the victim, they may amount to torture". He recommended that it should be banned across the world.^[91] In 2021 Ilias Trispiotis and Craig Purshouse argue that conversion therapy violates the prohibition against degrading treatment under Article 3 of the European Convention on Human Rights, leading to a state obligation to prohibit it.^[86][92] In February 2023 Commissioner for Human Rights, Dunja Mijatović, qualified those practices as “irreconcilable with several guarantees under the European Convention on Human Rights" and having no place in a human rights-based society urging the Member States of the Council of Europe to ban them for both adults and minors,^[93] later in July 2023 she advocated for clear actions during a public hearing at the European Parliament studying different approaches to legally ban "conversion therapies" in the European Union.^[94]

In media

Efforts to change sexual orientation have been depicted and discussed in popular culture and various media. More recent examples include: Boy Erased, The Miseducation of Cameron Post, Book of Mormon musical, Ratched, and documentary features Pray Away, Homotherapy: A Religious Sickness.^[95][96]

Medical views

National health organizations around the world have uniformly denounced and criticized sexual orientation and gender identity change efforts.^[97][98][99] They state that there has been no scientific demonstration of "conversion therapy's" efficacy.^{[62][100][101][102]} They find that conversion therapy is ineffective, risky and can be harmful. Anecdotal claims of cures are counterbalanced by assertions of harm, and the American Psychiatric Association, for example, cautions ethical practitioners under the Hippocratic oath to do no harm and to refrain from attempts at conversion therapy.^[101] Furthermore, they state that conversion therapy is harmful and that it often exploits individual's guilt and anxiety, thereby damaging self-esteem and leading to depression and even suicide.^[103] There is also concern in the mental health community that the advancement of conversion therapy can cause social harm by disseminating inaccurate views about gender identity, sexual orientation, and the ability of LGBT people to lead happy, healthy lives.^[98] Various medical bodies prohibit their members from practicing conversion therapy.^[104]

See also

• Christianity and homosexuality
• Recovering from Religion
• Sexual orientation change efforts and the LDS Church

References

Bibliography

Further reading

• Haldeman, Douglas C. (2021) (in en). Sexual Orientation and Gender Identity Change Efforts: Evidence, Effects, and Ethics. Columbia University Press. ISBN 978-1-939594-36-5. 

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