Current Policy and Ethical Issues
Psychotherapy Bulletin Editors’ Note: Meet our new Contributing Editor in Ethics, Dr. Apryl Alexander. Dr. Alexander received a BS in Psychology from Virginia Tech and a MS in Clinical Psychology from Radford University. She received both her MS and PsyD in Clinical Psychology from the Florida Institute of Technology, with specializations in forensic psychology and child/family therapy. Dr. Alexander completed a pre-doctoral internship at Patton State Hospital, a fellowship at Minnesota State Operated Forensic Services, and spent three years at Auburn University before joining the Graduate School of Professional Psychology at the University of Denver. Her current research and clinical work involves the assessment and treatment of adjudicated juveniles, victimization in adolescents and emerging adults, and trauma- and culturally-informed practice.
On April 25, 2017, Senate Bill 928 (2017)—Therapeutic Fraud Prevention Act of 2017 was introduced to Congress. The act would “prohibit, as an unfair or deceptive act or practice, commercial sexual orientation conversion therapy, and for other purposes.” Conversion therapy, also known as reparative therapy, is a term for approaches aimed at changing lesbian, gay, and bisexual (LGB) people to a heterosexual orientation (Yarhouse & Burkett, 2002) or at diminishing same-sex behavior and/or attractions. Senate Bill 928 provides a broader definition of conversion therapy (to include gender identity) as:
any practice or treatment by any person that seeks to change another individual’s sexual orientation or gender identity, including efforts to change behaviors or gender expressions, or to eliminate or reduce sexual or romantic attractions or feelings toward individuals of the same gender, if such person receives monetary compensation in exchange for such practices or treatments.
Additionally, this year several states introduced bills which would prohibit licensed mental health professionals from using conversion therapy with minors. New Mexico became the most recent state to pass such legislation (April 7, 2017) and 17 other states filed bills in this year. To date, several states (California, Illinois, New Jersey, New York, Oregon, Vermont, and the District of Columbia) have passed similar laws banning conversion therapy with minors.
Conversion therapy is based on the belief that an LGB sexual orientation is a mental illness or sinful (Haldeman, 2002). The American Psychiatric Association (APA) removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973—over 40 years ago. Further, in 2000, the American Psychological Association affirmed that “same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality regardless of sexual orientation identity” (American Psychological Association, 2009).
Risks Associated With Conversion Therapy
Despite the acknowledgment that homosexuality is not a mental illness, conversion therapy is still being practiced. Individuals with varying levels of mental health training—psychologists, psychiatrists, social workers, pastoral counselors, religious leaders, and laypersons with no formal training (Yarhouse & Burkett, 2002; Yarhouse, Burkett, & Kreeft, 2002)—engage in conversion therapy. Patients report the following techniques: various talk-based therapies, electric shock, orgasmic reconditioning aversive conditioning, isolation with someone of the opposite sex, exorcism, covert sensitization, marriage, and gender modification therapy (Tozer & McClanahan, 1999). For children and adolescents, conversion therapy attempts to change a child’s behavior, dress, and mannerisms to be more consistent with those stereotypically expected of their assigned sex at birth (Substance Abuse and Mental Health Services Administration [SAMHSA], 2015).
Many professional organizations are in consensus that conversion therapy may be harmful to clients (American Psychiatric Association, 2000; American Psychological Association, 1998; GLMA, 2013; National Association of Social Workers, 2000). Conversion therapy fails to meet criteria for an empirically-supported treatment. Researchers have reported that conversion therapy practices are ineffective in decreasing the likelihood of a future same-gender sexual orientation (Zucker & Bradley, 1995). In fact, research suggests that conversion therapy is associated with many negative outcomes for LGB clients, including increased level of depressive symptoms, frequent suicidal ideation and attempts, social isolation and anger toward family members, and decreased levels of self-worth (Haldeman, 2002; Serovich et al., 2008). Although we understand that adolescence is a time of sexual fluidity and curiosity, these harmful practices are being used with adolescents who might be perceived as non-heterosexual or gender nonconforming (American Psychological Association, 2009b; SAMHSA, 2015). LGB adolescents are especially vulnerable and at risk for negative outcomes of conversion therapy such as family rejection, depression, health risks, homelessness, and death by suicide (American Psychological Association, 2009b; SAMHSA, 2015).
Responses From the Professional Community
The APA’s 1998 Resolution on Appropriate Therapeutic Responses to Sexual Orientation describes the lack of efficacy conversion therapy. In 2000, the American Psychiatric Association adopted an official position statement opposing the practice of conversion therapy or any therapy that is based on the belief that LGB sexual orientation is a mental illness. The American Association of Marriage and Family Therapy and American Counseling Association also followed suit with statements (American Association for Marriage and Family Therapy, 2009; American Counseling Association, 2013). The Substance Abuse and Mental Health Services Administration (SAMHSA), with the support of APA, called for an end to the practice of conversion therapy for children and youth in 2015 (SAMHSA, 2015).
Ethical guidelines call for scientific bases for professional judgments, benefit from harm, justice, and respect for people’s rights and dignity. In 2015, the American Counseling Association Chief Executive Officer Richard Yep stated, “Our code of ethics is really grounded on ‘do no harm.’ Our feeling is that people who are exposed to sexual orientation change efforts are exposed to all sorts of harm” (Grisham, 2015). The APA’s Ethical Principles of Psychologists and Code of Conduct (2016) provide guiding principles to professionals in the field of psychology. Below are the important and relevant General Principles which should guide decisions to not conduct conversion therapy with LGB persons:
Principle a beneficence and nonmaleficence
The General Principle reads, “Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally” (also see Standard 3.04 Avoiding Harm). The ultimate goal of psychologists and mental health professionals is to avoid or limit harm. Treatment should support and promote the health and well-being of those being served rather than further marginalize. Further, sexual minority youth are a vulnerable population who lack protections from involuntary and coercive treatment, as their caregivers have to make informed decisions about their mental health care. Caregivers should be provided with scientifically accurate information in order to make these decisions and reduce harm. Given the paucity of research supporting the efficacy of conversion therapy, the practice should be banned in order to abide by this general ethical principle.
Principle C integrity
The General Principle states, “Psychologists seek to promote accuracy, honesty and truthfulness in the science, teaching and practice of psychology.” The goal of conversion therapy is to alter or change a person’s sexual orientation to a heterosexual orientation. However, numerous studies have demonstrated this is ineffective. In addition, the General Principle of Integrity, Standard 5.01 Avoidance of False or Deceptive Statements notes, “Psychologists do not knowingly make public statements that are false, deceptive or fraudulent concerning their research, practice or other work activities or those of persons or organizations with which they are affiliated.” In 2012, the APA disseminated guidelines for working with LGB clients which encourages the use of accurate information on sexual orientation and sexuality (American Psychological Association, 2012). Additionally, Standard 8.10 addresses avoiding deceptive research, as research about LGB people has been historically misused and misrepresented (see Herek, 1995; Herek, Kimmel, Amaro, & Melton, 1991; Russell & Kelly, 2003).
Principle E respect for people’s rights and dignity
The General Principle reads,
Psychologists are aware of and respect cultural, individual and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.
Psychologists must be aware of the heterosexism and homophobia and the impact it has on LGB clients. The practice of conversion therapy posits that LGB individuals are mentally ill, inferior, or in need of repair or change, which—in addition to being incorrect—violates the dignity of LGB persons. This practice denies individuals with the acceptance, support, and nurturance that is essential to the therapeutic relationship.
Principle D justice
The General Principle states, “Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence and the limitations of their expertise do not lead to or condone unjust practices.” Psychologists may inhibit both explicit and implicit biases about LGB individuals. Again, conversion therapy is rooted in heteronormative and homophobic viewpoints about same-sex attraction. This Principle encourages psychologists to take precautions to reduce such biases, as not to cause harm or engage in incompetent practice. Standards 2.01 Boundaries of Competence and 3.01 Unfair Discrimination also address that psychologists should take precautions to ensure that their potential biases do not lead to unjust practices.
In addition to those guidelines, scholars have argued that conversion therapy is unethical because it is intended to change a marginalized group into members of the dominant group—essentially forcing LGBTQ individuals to conform to societal norms based on heterosexist and heteronormative assumptions that idealize and solely validate a heterosexual sexual orientation (Green, 2003; Jenkins & Johnston, 2004; McGeorge & Carlson, 2011; Oswald, Blume, & Marks, 2005; Serovich et al., 2008; Tozer & McClanahan, 1999).
As noted above, despite the lack of empirical evidence for conversion therapy and ethical guidelines informing professional judgment when considering such practice, mental health professionals continue to practice conversion therapy and views on conversion therapy are mixed. According to Tozer and Hayes (2004), many mental health professionals either provide conversion therapy or refer clients to clinicians who offer such services. For instance, McGeorge, Carlson, and Toomey (2015) surveyed 762 members of the American Association for Marriage and Family Therapy (AAMFT) about their beliefs regarding conversion therapy. Although approximately 73% of participants reported it is unethical to practice conversion therapy, 20% reported that it is ethical to practice conversion therapy and it is possible (if presented the opportunity) that these individuals could practice conversion therapy in the future. In fact, 3.5% of participants endorsed having practiced conversion therapy.
Where do we go from here? The field of psychology has progressed significantly in its treatment of LGB person since the removal of homosexuality from the DSM in 1973. In the APA’s 1975 resolution, it urged “all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientations” (Conger, 1975, p. 633). However, future strides need to be made to promote affirming therapeutic practices (i.e., practices that are culturally-informed, evidence-based approach and do not pathologize sexual orientation or gender identity) for LGB individuals. For instance, the APA recommends providing relevant material concerning LGBT issues, as well as training in affirmative, evidence-based and multiculturally informed interventions for sexual minorities, in undergraduate programs, graduate training programs, internship sites, and postdoctoral programs (APA, 2009). Continued work must include advocating for these individuals in times of public policy reform in order to facilitate broader social change. Although biases and misinformation about LGB individuals continue to exist, psychologists and leading mental health organizations must attempt correct these ideals about LGB persons with accurate scientific knowledge, and competent and sound professional practice.
Cite This Article
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