Conversion Therapy Carl G

PERSPECTIVE Changing Medical Practice, Not Patients

Changing Medical Practice, Not Patients Changing Medical Practice, Not Patients — Putting an End to Conversion Therapy Carl G. Streed, Jr., M.D., M.P.H., J. Seth Anderson, M.A., Chris Babits, Ph.D., and Michael A. Ferguson, Ph.D.

oy Erased and The Miseducation Psychiatric Association (APA) used conversion therapy for minors (see Bof Cameron Post, two movies this cultural moment to reaffirm map).1 Adults may voluntarily par- released in 2018, raised aware- its opposition to conversion ther- ticipate in conversion therapy in ness of efforts to change people’s apy, a stance it has maintained all states and jurisdictions. sexual orientation, also known as since 1998. Despite such long- Conversion therapy is rooted conversion therapy. These films standing opposition among pro- in the notion that any nonhetero- portray the trauma inflicted by fessional medical organizations, sexual sexual orientation is a pa- such efforts and the patently however, in the United States, thology in need of a “cure.” Al- false science underpinning this only 18 states, Puerto Rico, and though the science of sexuality debunked practice. The American Washington, D.C., have banned has since the mid-19th century

Washington New Hampshire Montana Vermont Maine North Dakota Minnesota Oregon Idaho Wisconsin South Dakota Massachusetts New York Wyoming Michigan Rhode Island Connecticut Iowa Pennsylvania Nevada Nebraska New Jersey Ohio Delaware Illinois Indiana Utah West Washington, D.C. California Colorado Virginia Maryland Kansas Missouri Virginia Kentucky

Tennessee North Carolina Oklahoma South Arizona New Mexico Arkansas Carolina Georgia Missis- Alabama Law banning conversion sippi therapy for minors Texas (18 states, 1 territory, Louisiana and Washington, D.C.) No law banning conversion therapy Florida for minors (32 states, 4 territories)

Alaska Hawaii U.S. Territories Commonwealth of the Northern American Samoa Mariana Islands Guam Puerto Rico U.S. Virgin Islands

State-Level Bans on Conversion Therapy for Minors. From Equality maps: conversion therapy laws.1

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recognized the existence of homo- cultural assimilation so they can young adults and found that par- sexual or same-sex attraction, live as cisgender (non-transgender) ticipants whose parents and other most doctors perceived such at- heterosexuals.2 caregivers had encouraged them traction as abnormal and believed Starting in the middle of the to attend conversion therapy had that it could be resolved with 20th century, some researchers higher rates of depression, suicid- surgery. At the turn of the 20th and psychologists challenged the al thoughts, and suicide attempts century, medical doctors, psychia- idea that homosexuality was an and lower educational attainment trists, psychotherapists, and sex- illness. In 1948, Alfred Kinsey’s and income than those who ologists continued to develop Sexual Behavior in the Human Male weren’t exposed to such efforts to theories regarding causes of and revealed that 37% of American change their sexual orientation.4 potential cures for sexual and men had participated in same-sex Conversion therapy has been gender variations. However, in the sexual activity to the point of or- challenged in court and found to pre–World War II era, no single gasm. Reports from other profes- be a fraud perpetrated on LGBTQ orthodox explanation emerged. sionals in various fields soon fol- people and their families. In the The APA listed homosexuality lowed. In 1951, ethologist Frank groundbreaking 2015 case brought as a mental illness in the first Beach and anthropologist Clellan by the Southern Poverty Law Cen- edition of the Diagnostic and Statis- Ford reported the acceptance of ter, Ferguson v. JONAH, a New Jer- tical Manual of Mental Disorders in homosexuality in a range of cul- sey state court ruled that homo- 1952. After World War II, theo- tures; psychologist Evelyn Hooker sexuality is not a mental illness ries blaming excessive parenting — specifically an overbearing mother — for causing male homo- Conversion therapy has been challenged sexuality became medically and culturally popular, as did theories in court and found to be a fraud perpetrated about the contribution of past on LGBTQ people and their families. sexual abuse. At the time, many medical professionals believed that such factors thwarted mat- began publishing research in the as a matter of law and found the uration to “normal” adult het- 1950s revealing a lack of discern- defendant, Jews Offering New Al- erosexuality. By the late 1960s, ible mental differences between ternatives for Healing (JONAH), clinicians were using behavior- homosexual and heterosexual men; liable for consumer fraud. In June modification therapy to try to re- and in 1961, psychiatrist Thomas 2019, the Jewish Institute for inforce heterosexual behavior in Szasz published The Myth of Men- Global Awareness (JIFGA), a non- manipulative ways, including the tal Illness, in which he refuted the profit organization established by use of commercial sex workers, premise that homosexuality was JONAH’s cofounders, was found orgasmic reconditioning, and a mental illness.3 In the decades to have violated the 2015 injunc- an emphasis on marriage to an that followed, variations in sexual tion and settlement agreement opposite-sex partner. Psychologists orientation and gender identity when it continued to offer con- and other professionals also used were found to be part of the nor- version therapy in violation of various forms of aversion therapy, mal range of human development. New Jersey’s consumer-fraud law. including electroshock, chemical, Studies of adults who under- JONAH and JIFGA operated in and deprivation therapy, to cause went conversion therapy earlier in Jersey City, New Jersey, and had a “heterosexual adjustment.” Evi- life document a range of health clients from New York City and dence that electroshock and chem- risks. The most recent and most surrounding areas — disproving ical therapies are still used for compelling evidence comes from the notion that conversion-therapy this purpose is scarce, but inter- the Family Acceptance Project, an practices operate only in politi- ventions such as behavioral and initiative that works to prevent cally and religiously conservative talk therapies continue to be physical and mental health risks regions. touted to lesbian, gay, bisexual, for LGBTQ young people. In 2018, Professional associations, such transgender, and queer (LGBTQ) the organization conducted a cross- as the American Medical Associa- people as providing a pathway to sectional study of 245 LGBTQ tion, have also publicly denounced

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conversion therapy and docu- therapy participant. Patients in- offer supportive therapies and mented the substantial harm as- volved in conversion therapy may provide accurate information and sociated with it. In addition to not volunteer relevant informa- resources for all LGBTQ patients the APA, the American Psycho- tion to a health care provider and and their families. We believe it logical Association, the American may go out of their way to con- is vital for clinicians to under- Academy of Pediatrics, and other ceal their participation. Although stand both the scientific and the professional organizations have people of many ages and gender ethical hazards of conversion ther- endorsed a primer on sexual orien- identities undergo conversion apy and appropriate responses for tation and young people, stating therapy, the most common par- survivors and at-risk patients and that “the idea that homosexuality ticipants are young men from con- to help create supportive environ- is a mental disorder or that the servative religious backgrounds ments for all LGBTQ persons. emergence of same-sex attraction with families that reject their Disclosure forms provided by the authors and orientation among some ad- LGBTQ-identified children. Many are available at NEJM.org. olescents is in any way abnormal survivors of conversion therapy From the Section of General Internal Medi- or mentally unhealthy has no sup- will need treatment for post-trau- cine, Boston Medical Center and the Bos- port among any mainstream matic stress disorder and post- ton University School of Medicine (C.G.S.), the Department of History, Boston Univer- health and mental health profes- religious trauma. sity (J.S.A.), and Beth Israel Deaconess sional organizations.” The World Beyond ending harmful prac- Medical Center, Harvard Medical School Psychiatric Association has de- tices,1 supporting the acceptance (M.A.F.) — all in Boston; and the Depart- ment of History, University of Texas at Aus- clared that interventions such as and inclusion of people of all gen- tin, Austin (C.B.). conversion therapy are “wholly under identities, gender expressions, ethical.” The American College and sexual orientations is critical. 1. Equality maps: conversion therapy laws. Boulder, CO: Movement Advancement Proj- of Physicians has pointed to re- Clinicians can complete continu- ect, 2019 (http://www.lgbtmap.org/equality search showing that “the prac- ing education on issues that are -maps/ conversion_therapy). tice may actually cause emotional relevant to LGBTQ patients, in- 2. Terry J. An American obsession: science, medicine, and homosexuality in modern so- or physical harm to LGBT indi- cluding on the ramifications of ciety. Chicago: University of Chicago Press, viduals, particularly adolescents conversion therapy. Only Wash- 1999. or young persons.” Former high- ington, D.C., currently requires 3. Bayer R. Homosexuality and American psychiatry: the politics of diagnosis. Prince profile proponents of conversion continuing education on such top- ton, NJ: Princeton University Press, 1987. therapy, including Alan Cham- ics for licensed physicians. 4. Ryan C, Toomey RB, Diaz RM, Russell bers, John Paulk, John Smid, and According to a draft of the ST. Parent-initiated sexual orientation change efforts with LGBT adolescents: implications David Matheson, have also de- U.S. Joint Statement on Conver- for young adult mental health and adjust- nounced the practice. And yet a sion Therapy, a consensus statement. J Homosex 2018 November 7 (Epub recent report estimates that 20,000 ment being prepared by more ahead of print). 5. Mallory C, Brown TNT, Conron KJ. Con- LGBTQ adolescents will undergo than a dozen health care organi- version therapy and LGBT youth. Los Ange- conversion therapy with a licensed zations, medical officials should les: the Williams Institute, January 2018 health care professional by the take into account developmental (https://williamsinstitute.law .ucla .edu/ wp 5 -content/ uploads/ Conversion - Therapy - LGBT time they reach 18 years of age. considerations for each stage of -Youth-Jan-2018.pdf). Clinicians can be alert to the the lifespan when caring for pa- DOI: 10.1056/NEJMp1903161

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