Conversion Therapy, Reparative Therapy, SOCE: Proposed New Jersey Legislation Prohibiting Efforts to Change Same-Sex Attraction Experienced by Minors

On June 13, 2013, a New Jersey Assembly committee heard testimony about the bill A3371 (An act concerning the protection of minors from attempts to change sexual orientation). The bill was released from committee, and if passed will prohibit licensed mental health professionals of all disciplines from carrying out treatment of minors with the intention of altering a child’s behavior and experience of attraction to members of his or her own sex. The bill can be read at http://legiscan.com/NJ/text/A3371, and a description of the hearing can be seen at http://s.nj.com/udvnK11. Testimony was heard from a range of witnesses, with support for the bill coming from individuals with relevant personal histories, psychologist, psychiatrists, and representatives of gay and Lesbian organizations. Some of those who testified against the bill also told personal stories, including some self-described ex-gays, one mental health professional who described some of his own methods of doing the treatment, and a pastor of the Assemblies of God who argued that the bill would infringe on religious liberties by removing a clergy member’s option of referring a child or adolescent for this treatment. Several of the witnesses referenced research on children and adolescents with minority sexual orientations, and they particularly pointed to the 2009 report of the American Psychological Association that recommended against use of “conversion” therapies (www.apa.org/pi/lgbt/resources/therapeutic-response.pdf).

I myself testified in support of the bill, and this was my statement:

 Good Morning,

I’d like to start my testimony by saying thank you to Chairman Conway and Assemblyman Tim Eustace for sponsoring this bill, and the rest of the committee for bringing this important matter to a hearing.

I am Dr. Jean Mercer, and I am a developmental psychologist, a retired professor of psychology, and an expert on unconventional psychotherapies for children. I have published several books and a dozen articles in professional journals that discuss the problems of using unconventional, non-evidence-based mental health interventions for children and adolescents.

            I support  the bill to prohibit the use of so-called “conversion therapies” for minors.  I would point out that these treatments lack the support of systematic outcome research. They have not been shown to be either effective or safe. They are implausible in that they disagree with established principles and research evidence about human development. These are problems with respect to the use of such treatments for adults, but are especially important when minors are concerned.

            The use of “conversion therapies_,” or sexual orientation change efforts (SOCE), with children and adolescents pose[s] particular ethical problems. Minors cannot effectively refuse or resist treatments wanted by their parents or other authorities, so the fiduciary responsibility of those who make decisions for the treatment of children and adolescents is great.  Adults making such decisions need accurate information, and in some cases need the help of the state to  assist in making the best decisions. An example is the requirement of the state that dairies test their herds for tuberculosis and thus assure parents that no milk they choose to buy will transmit this disease. If a dairy claimed that its cows where tuberculosis-free when this was not the case, parents would not be able to make informed choices about purchasing milk, and this is why New Jersey and other states have acted to make sure that parental decisions are healthy ones.

            Parents have the right to make decisions about their children’s medical and psychological treatment, but they can exercise this right only when they also enjoy the right of accurate information about the choices they make. Unfortunately, proponents of “conversion therapies” have not provided accurate information. They have claimed that their treatments effectively change minors’ sexual and/or gender orientation, when there is in fact no systematic evidence to show that such treatments for minors are either effective or safe, and when in fact a number of adverse events have been reported in connection with the treatments. Because publications supporting “conversion therapies” have been fraught with inaccuracies and omissions, the rights of both parents and children to give their informed consent to an intervention have been interfered with. Informed consent can be given only when a guardian has been given accurate information about the demonstrated effectiveness of a treatment, about risks connected with the treatment, and about alternative treatments that may be preferred for various reasons. When there is no evidence that a treatment has been shown to be effective for people like the proposed client, guardians must also be informed of this fact. If these types of information are not provided, parental rights to make appropriate decisions are violated, as are the rights of minors to understand and agree with their treatment.

            If  “conversion therapies” had been shown to be necessary, safe, and effective, discomfort associated with them might be acceptable, as we accept a certain amount of discomfort with medical treatments. Because they have not, we must consider whether in fact these treatments are abusive. When they include holding therapy or aversive methods, it is clear that the line defining abuse is quickly crossed if the treatment is ineffective. When no physical methods are used, “conversion therapies” nevertheless meet criteria for emotional abuse by employing rejection, a refusal to acknowledge the minor’s worth or needs, and terrorizing, including verbal assault, bullying, and creating an atmosphere of fear by threats of present or eternal punishment. These treatments also resemble the “intrusive parenting” that has been shown to have detrimental psychological effects. 

            I believe that passage of this bill will help to safeguard rights of both parents and children to be safe from the effects of deceptive commercial speech and to make decisions based on accurate information. Thank you.

In listening to other people’s testimony, both pro and con, I was struck by a number of issues that were occasionally queried by committee members but never completely answered or resolved. I hope that when the bill comes to be discussed in the Assembly, some of these matters will receive attention.

1.      Minors versus adults.  When research about one group of people is to be generalized to another group, it’s necessary to take into account how similar the groups are. There is very little research about attempts to change the sexual orientation of children and adolescents. The research that exists is primarily focused on adults, and not only men, but white men, and not only white men, but to a considerable extent white men of fundamentalist Christian beliefs. Claims that the treatments are safe and effective for these individuals, who have chosen to be treated, are difficult to apply to a mixed group of younger persons who in many cases appear to have been coerced into treatment. I have been unable to find any report of systematic outcome research on the use of these therapies with children and adolescents on Academic Search Complete, PsycInfo,or Medline.

2.      The suicide issue. Witnesses testifying on both sides referred to an increased rate of  suicide , suicide attempts or suicidal ideation among different groups of people. Witnesses in favor of the bill attributed this increase to attempts to change sexual orientation; witnesses opposed to the bill attributed it to the fact of having a minority sexual orientation. One committee member asked what group this relative increase used as a standard of comparison, but no clear answer was given.

 The bill itself cites an article by  Ryan, C.,Huebner, D., Diaz, R.M., and Sanchez, J. (2009. Family rejection as a predictor of negative health outcomes in white and Latino Lesbian, gay, and bisexual young adults. Pediatrics, 123, 346). The Ryan et al paper reports 8.4 times as many suicide attempts  (not completed suicides) among sexual minority young adults ages 21-25 whose reported that their families rejected them than among a similar group who reported that their families were accepting of their orientation.  The participants were recruited from community sites and clubs that serve LGB young adults, so the comparison was not to a sexual majority group.

An article by Mark Hatzenbuehler (The social environment and suicide attempts in Lesbian, gay, and bisexual youth. [2011]. Pediatrics, 127, 896) stated that  sexual minority youth were more likely to report that they had attempted suicide during the previous year if they lived in negative, nonsupportive environments. In this study, about 20% of sexual minority youth (11^th graders) reported that they had at least one suicide attempt during that time, as compared to only 4% for heterosexual youth.  

If either side is to argue their position about this bill on the basis of suicide statistics, it is important to be clear on whether the reference is to completed suicide, self- reported attempted suicide, self-reported suicidal thoughts, or medically-reported suicide attempts. Although all of these are of concern, if we are to avoid the apples-and-oranges problem, clarity is needed.  

3.      Reversed burden of proof.  Witnesses opposing the bill argued that there was no evidence that the “conversion” treatment was not safe or effective--  indeed, claimed that the absence of research evidence meant that the bill was at least premature. However, this argument reveals a common problem of critical thinking, the demand that an opponent show that something is not correct. Rules of critical thinking place the burden of proof on the claimant who holds that something is true. It is for proponents of “conversion” therapy to demonstrate that the treatment is a safe and effective way of changing sexual orientation, and to do this by the rules governing outcome studies of conventional treatments, including the existence of an independent replication of results. Thinking about how they could do this raises an interesting question: would they also claim that they could treat a heterosexual person in such a way as to convert the person’s orientation and cause attraction to people of the same sex?

4.      What do “conversion” therapists actually do? Much of yesterday’s discussion focused on why anyone would, should, or should not want to change a young person’s sexual orientation. Little attention was paid to what the therapists actually do, and whether or not such actions are appropriate at all, whether or not they are effective. One Christopher Doyle, a mental health professional who does “conversion” therapy, stated that it was just talk therapy and therefore could not hurt.

This statement raises two issues: first, is it “just talk therapy”? And, second, if it were “just talk therapy”, could it be harmful?

Richard Cohen’s 2007 book Coming Out Straight describes a form of “conversion” therapy and discusses the rationale behind it. Cohen’s methods may not be those of every “conversion” therapist, but clearly they are the methods used by some and they are not “just talk therapy”. Cohen speaks rapturously of the version of Holding Therapy presented by the American psychiatrist Martha Welch, who believes that physical restraint of one person by another, accompanied by a wide range of emotional communications while the restraint continues for an hour or more, causes emotional attachment to take place. Cohen, like many other half-educated mental health professionals, assumes that most emotional disorders (among which he includes homosexuality) are caused by problems of attachment, and therefore can be treated by methods that he assumes affect attachment. In addition to Holding Therapy, Cohen also considered it helpful to employ a range of “new age” methods, including psychodrama, inner-child healing, bioenergetics, and other techniques that are both implausible and lacking in an evidence basis.

These are not “just talk therapy”, but it is presumably possible for some “conversion” therapists to confine their interventions to talk. If they do, is it true that no harm can be done? Scott Lilienfeld, in a well-known 2007 paper, argued that there are methods that should be considered potentially harmful treatments (Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70). He included as examples of treatments that have done direct harm such “just talk” methods as critical incident stress debriefing. In addition to direct harm from “just talk”, it’s important to consider the possible impacts of “talk” that focuses on unchangeable characteristics (as sexual orientation most probably is) rather than on discomforts like depression or social or family concerns, which in fact can respond to intervention. Harm can be done by “just talk” that ignores the client’s actual emotional needs and focuses elsewhere as the therapist’s agenda dictates.

A3321 obviously requires a good deal more discussion before it is put to a vote, and I hope the discussion will deal with some of the issues I have just noted. In my opinion, however, legislation to prevent a variety of inappropriate treatments for children and adolescents is long overdue. It is a mistake to accept the assurances of all the “helping professions” that they will regulate their own members, as they have clearly not done so.