Banning conversion and reparative therapies for youth: one step forward

President Barack Obama took a significant step on April 9 when he approved a statement supporting state-level bans on “conversion or reparative” therapies for LGBT youth.

One part of the statement merits special attention:

“The overwhelming scientific evidence demonstrates that conversion therapy, especially when it is practiced on young people, is neither medically nor ethically appropriate and can cause substantial harm.”

More than 20 years ago, the National Association of Social Workers (NASW) (of which I am the immediate past president) condemned such “treatments,” first in a statement issued in 1992 and updated in 2000.

The question now is how Obama’s condemnation can be transformed into policy decisions that effectively end such treatments.

The states are the nation’s laboratories for social policy, and 18 states are considering legislative bans of the kind the President is recommending. California, New Jersey and the District of Columbia have already enacted such bans.

In the face of recent federal legislative gridlock, action at the state level is a pragmatic approach. However, this runs the risk that – like the current situation with same-sex marriage – protections will end up differing depending on where people live.

A history of conversion therapy

Let’s review some history.

“Homosexuality” was a psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until removed in 1972 and in the International Classification of Diseases (ICD) until 1990.

In other words, before 1972, if homosexuality was a “sickness,” it required treatment. There are many treatments that were and are used. The most inclusive way of describing them (and the way I would have preferred the President to talk about them) is “sexual orientation change efforts” or SOCEs.

In the English-speaking world, psychoanalytic and behavioral treatments were offered to treat homosexuality. These included electric shocks administered to “extinguish” expressions of homosexual desire – something called “aversion therapy.”

The terms “conversion” and “reparative” therapy are often used interchangeably when discussing SOCEs. Historically the term “conversion therapy” implied converting desires, behavior, or identification from homosexual to heterosexual. “Reparative therapy” often referred to insight-oriented treatments aimed at addressing the underlying problems thought to be causes of homosexuality, which was by definition a psychological dysfunction.

Even though homosexuality is no longer defined as a disorder, “reparative” and “conversion” therapies continue to be embraced by religious organizations, like Exodus International, which seek to “repair” a state of sin.

A minority in the mental health community defend such practices as providing what the patient may want. As a discredited treatment, however, no guidelines for practice exist.

Contemporary accounts of these therapies as provided by mental health professionals mention that men are encouraged to become “more masculine” by playing contact sports or touching their private parts.

All are encouraged to identify past traumas, like “repressed” experiences of child abuse, especially sexual abuse, or other problems in the family as causes of their gay or lesbian identity. Therapists often pray over these patients in sessions.

A selfie by Leelah Alcorn, a transgender teen, who committed suicide in 2014 following conversion therapy, medication, and a period of isolation mandated by her parents.Tumblr, CC BY-SA

All SOCEs, past and present, reinforce negative feelings about the self, based most often in fear of family or religious condemnation. There is also evidence that some who were previously provided such treatments were harmed as well.

While some headlines suggested that the Obama administration’s statement is aimed at all such therapies, it is specific to banning such treatments for “youth” (legal minors).

It is usually parents or guardians who enroll their children and adolescents in these discredited therapies when a child is or is perceived to be gay, lesbian, bisexual, transgender, queer or gender non-conforming.

Because children and youth do not have self-determination about these treatments (parents or guardians must consent to this treatment), the proposed and enacted state bans address legal minors in particular.

Adults, on the other hand, are assumed to be electing such “treatments” freely. Homophobia in society, especially rejection by families and/or condemnation by some religious groups, surely influences such choices.

Limiting the use of ineffective “therapies”

These “therapies” are at odds with best practices in the medical and mental health professions.

In the last two decades, health, mental health and social services have moved toward the use of evidence-based practices and evidence-supported treatments. That is, they identify treatments that are effective in achieving outcomes, while also identifying practices that run the risk of harming those receiving them.

Experts have concluded that there is little to no evidence of the long-term effectiveness of SOCEs and much evidence of harm, especially for young people.

As the White House statement says,

“The medical and mental health communities have long made clear that they reject the practice of conversion therapy, aimed at ‘changing’ one’s sexual orientation' because they have been ‘shown in countless instances to have dangerous effects.'”

Reflecting a key tenet in evidence-based medicine, California in 2012 not only banned therapies that aimed to change the sexual orientations of gay and lesbian minors but initially also required that adults receiving such treatments be provided with disclaimers about its lack of effectiveness and possible adverse effects, although this provision was eventually removed in the final bill.

As a professional social worker and immediate past president of NASW, I wish the White House statement would have referenced the NASW stance on these therapies along with the other professional organizations mentioned.

The Substance Abuse and Mental Health Administration asserts that social workers provide the majority of mental health services in the United States. Therefore social workers' condemnation of these practices is surely relevant.

It’s also worth highlighting that the NASW’s position has been emulated by the International Federation of Social Workers. In 2014 they adopted their first official statement on Sexual Orientation and Gender Identity that included a condemnation of SOCEs.

Who pays for these treatments?

Like the President’s Executive Order on LGBT Workplace Discrimination that just went into full effect, there may be other administrative actions that can be taken by the President to limit the use of SOCE.

In a 2014 statement, NASW “condemns SOCE or so-called reparative therapy by any person identifying as a social worker or any agency that identifies as providing social work services. Public dollars should not be spent on programs that support SOCE.”

Are federal dollars being used in this way? Do any federally funded health insurance programs reimburse for these practices? What about the health insurance provided for federal employees?

It is important to view conversion therapies within the context of human rights for the LGBT community worldwide.

I know that LGBT people face even greater challenges in other parts of the world, such as criminalization and even death as documented in the first United Nations statement on the rights of LGBT people made in 2012 by the Pan American Health Organization within the World Health Organization (WHO).

The UN General Assembly has not yet been willing to bring discussion of the statement’s adoption to the floor. The United States should be actively working to move this issue forward.

Banning harmful mental health treatments is a positive step forward, but providing federal civil rights protections that would cover all 50 states is needed for a society in which LGBTQ people of all ages can flourish.

Jeane W. Anastas, Ph.D., LMSW, ACSW is affiliated with the National Association of Social Workers.