Conversion therapy – there’s still a need for better evidence.￼
A notable feature of the debate about conversion therapy is the degree to which it borrows from, implicitly or explicitly, the language of evidence-based practice. There are other criteria of course: the value-based judgement that all attempts to change sexual orientation or gender identity are wrong, or the pragmatic argument about unintended consequences that might come from poorly drafted legislation. Nonetheless it remains reasonable to ask how good the research evidence is, evaluated independently of these other arguments, in providing grounds for proposed legislation to make it illegal.
An immediate problem is posed by the broadness of the definition usually employed. For example recent government documents describe conversion therapy as…“techniques intended to change someone’s sexual orientation or gender identity. These techniques can take many forms and commonly range from pseudo-psychological treatments to spiritual counselling”. What this means is that the form, content or style of any intervention being evaluated is often unclear, or that widely differing interventions are conflated in a single intervention category.
Another barrier to interpreting research findings is the lack of attention given by many commentaries to the question of consent. For example the nature of consent is not reported in the UK survey of experience conversion therapy: the results show that more people were offered than received therapy, but not how many had consented to or even actively requested it. In a US study of the experiences of men who have sex with men, 40% of respondents who had experienced therapy said the decision to initiate therapy had been “mostly” or “completely” theirs. One might expect that unwanted or coerced intervention would be more likely to have negative outcomes, but the necessary analyses don’t seem to have been undertaken.
Apart from this (rather obvious) observation that coerced intervention may be the more harmful, there is another complication that arises. People who request therapy may be seeking help with a range of relationship problems that are conflated with their sexual orientation or gender identity, making it difficult to tease out the effect of the “conversion” element. The recent publication of Patricia Highsmith’s journals and diaries provides an example if a rather atypical one.
Reported outcomes typically describe one of two domains: change in sexual orientation or gender identity rarely occurs; negative effects for example on mood and sense of self-worth are commoner than in those who have not received therapy. The evidence is by no means clear that such negative effects are universal and by comparison, benefits have been rarely sought or reported.
One exception is a study of LGBQ individuals affiliated with the Church of Jesus Christ of Latter-day Saints, 720 of whom provided unstructured comments on their experiences in addition to completing structured assessments. The authors note, of these comments “Many found therapy to be a helpful, even life-saving experience. To be able to talk to a knowledgeable professional about a very private concern was salutary. Others reported improved relationships with family or other close associates. Of particular interest was the large number of individuals who reported decreased levels of depression and anxiety and improved feelings of self-worth…For some participants, psychotherapy was clearly unrewarding. As a general rule, however, experiences of harm or iatrogenic distress were much less frequent than reports of benefit.”
Qualitative studies suggest that benefit accrues from aspects of therapy such as discussions about the meaning of the immutable nature of sexual orientation or gender identity or about how to manage any resultant dissonance that arises in the family or religious groups. One interpretation of how attempts at conversion might contribute is that they can act as a sort of behavioural experiment the results of which will depend upon how they are handled. Sensitive discussion can help, while insensitive, coercive or rejecting responses will not. For example, one study of people who had experience of conversion therapy found that those who had subsequently left the religious community for whatever reason were more negative about the effects of therapy than those who had not. One consequence of the definitional problem (see above) is how difficult it is to find much in the research literature that notes whether conversion therapy came with a certain package of other responses or not.
One piece of evidence I have been unable to dig up is what happens next in countries where legislation has already been passed. Has it led to prosecutions? What is the effect on religious communities? In most of the relevant states evangelical Christian groups predominate and it is hard to find anything about other religions. What happens in the madrasa or orthodox Jewish groups? I think we simply don’t know.
In summary – nobody surely would disagree that imposed or coercive attempts to change somebody’s sexual orientation or gender identity are abusive and should not be allowed. However, the proposed UK legislation initially promised to impose a blanket ban on any form of conversion therapy. Even consented or requested therapy, competently delivered as part of a wider discussion of the issues, would be criminalised.
This takes us away from a popular caricature of conversion to a more complicated picture of a type of talking therapy that might be actively sought, with more mixed motivations and with attempts to use effects of the process as the basis for wider exploration. Should that really be criminalised? Such an approach might be argued about on the basis of values rather than evidence, but it is difficult to read the research literature and find unequivocal justification for it.
As things stand, the government has backed off (again) and now says it will not legislate on consented therapy involving adults. It is difficult to believe, of this government, that the decision is one of principle – more likely a response to legal advice about difficulties of drafting the law. Only time will tell what the eventual bill contains. Meanwhile some careful planning of prospective research would be a good idea.
- Steven Meanley, PhD, MPH, Sabina A Haberlen, PhD, Chukwuemeka N Okafor, PhD, MPH, Andre Brown, PhD, MPH, Mark Brennan-Ing, PhD, Deanna Ware, MPH, James E Egan, PhD, MPH, Linda A Teplin, PhD, Robert K Bolan, MD, Mackey R Friedman, PhD, MPH, Michael W Plankey, PhD, Lifetime Exposure to Conversion Therapy and Psychosocial Health Among Midlife and Older Adult Men Who Have Sex With Men, The Gerontologist, Volume 60, Issue 7, October 2020, Pages 1291–1302, https://doi.org/10.1093/geront/gnaa069
- American Psychological Association, Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Retrieved from http://www. apa.org/pi/lgbc/publications/therapeutic-resp.html 9 May 2022
- Kate Bradshaw, John P. Dehlin, Katherine A. Crowell, Renee V. Galliher & William S. Bradshaw (2015) Sexual Orientation Change Efforts Through Psychotherapy for LGBQ Individuals Affiliated With the Church of Jesus Christ of Latter-day Saints, Journal of Sex & Marital Therapy, 41:4, 391-412, DOI: 10.1080/0092623X.2014.915907