Gay conversion therapy

The new Bill entitled the Affirmation of Sexual Orientation, Gender Identity and Gender Expression Act, which has been tabled in Parliament for its first reading, has been the source of much controversy over the past few weeks. Ironically and perhaps tellingly, all this hullabaloo erupted more than a month after the period for public consultation ended on January 15 and was in direct reaction to the publication of a position paper by an expert commission appointed by the Church in Malta.

From a psychiatrist’s point of view, the paper has two major shortcomings: it equates the conversion of an individual’s sexual orientation to a change in one’s sexual behaviour and, more importantly, appears to suggest that conversion (or reparative) therapy may work in the so-called “grey areas of complex sexual orientations encountered in clinical practice”.

According to the Royal College of Psychiatrists (2012 “Despite almost a century of psychoanalytic and psychological speculation, there is no substantive evidence to support the suggestion that the nature of parenting or early childhood experiences play any role in the formation of a person’s fundamental heterosexual or homosexual orientation (Bell and Weinberg, 1978). It would appear that sexual orientation is biological in nature, determined by a complex interplay of genetic factors (Mustanski et al, 2005) and the early uterine environment (Blanchard et al. 2006). Sexual orientation is therefore not a choice, though sexual behaviour clearly is.”

In its report, the expert commission claims that: “If the Bill is converted into law, it will become a crime to assist persons with a paraphilic condition, such as paedophilia, were such condition to be manifested in same sex behaviour.” It also states that “a homosexual person who seeks help from a therapist or a mentor because he or she wants to live a chaste life in accordance with his or her religious values (or vows) would be putting the latter in a position of risk of breaking the law.”

In both cases, the commission fails to make the distinction between sexual orientation and behaviour and appears to champion the use of conversion therapy as ideal in such situations. However, it is widely known and accepted that therapy aimed at suppressing or eliminating undesired sexual behaviour is quite different from therapy that intends to suppress or eliminate or change one’s sexual orientation, preference or inclination.

The former has a scientifically sound basis, the latter is not backed by a single shred of scientific evidence. For instance, there are no studies that demonstrate evidence that paedophilia can be cured but there is plenty of evidence that a number of therapies such as cognitive behaviour therapy and sex drive reduction can be successfully adopted to help paedophiles refrain from acting on their desires.

Most mental health professionals and bodies have concluded that there is no scientific or rational reason for conversion therapy

Very clearly, contrary to the expert commission’s views, the Bill does not seek to criminalise the use of such treatment by professionals for gay paedophiles. Similarly, professional help aimed at assisting a priest to refrain from sexual behaviour, whether homosexual or not, would not consist in conversion therapy and will certainly not be made a criminal offence.

Perhaps the most contentious part of the expert commission’s report is the apparent suggestion that conversion therapy may work in “grey areas of complex sexual orientations encountered in clinical practice” such as for instance when one’s perceived sexual orientation is not his or her real sexual orientation but is the result of trauma or early injuries (e.g. child sexual or emotional abuse) or when “a married bisexual person voluntarily seeks help to curb on his or her homosexual inclinations because he or she wants to save their marriage”.

Furthermore, in a clarification issued on February 22, the Curia said that whilst conversion therapy against one’s own free and informed consent is to be prohibited, “any adult person would be free to have whatever psychological services and other therapeutic services one may desire or require in relation to one’s sexual orientation, identity and gender”.

Unfortunately, this so-called clarification only serves to reaffirm the Church’s position that conversion therapy is an option when it is desired or requested by an adult. In doing so, the Church is guilty of a serious failure to address the known science of human sexuality and is clearly either ignoring or misrepresenting scientific research on this matter.

The history of conversion therapy can be traced back to the early Freudian period. Sigmund Freud was skeptical that conversion therapy could be used to eliminate homosexuality and observed that “in general to undertake to convert a fully developed homosexual into a heterosexual does not offer much more prospect of success than the reverse”.

In the following decades, mental health professionals experimented with extreme measures ranging from institutionalisation to castration and aversive conditioning techniques including electroconvulsive therapy and nausea-inducing dugsduring a demonstration of homosexual erotic images.

All these measures were based on the scientifically discredited premise that homosexuality is a biological defect or disorder that needed to be cured. According to Haldeman (1991), an examination of the literature shows that not only were such conversion therapies unethical and professionally irresponsible but they additionally constituted inadequate and questionable science. In addition, Haldeman argued that the studies that purport to back up conversion therapy have one thing in common, they are consistently flawed by homophobic researcher bias, poor or inexistent follow-up data, inappropriate classification of subjects (such as “converting” bisexuals who are not primarily homosexual in the first place), and confusion of heterosexual competence with a shift in sexual orientation.

In general, treatments to change sexual orientation that were prevalent up to the 1970s were very damaging to those patients who underwent them and affected no change in their sexual orientation.

As held by the Royal College of Psychiatrists, the best evidence for efficacy of any treatment comes from randomised clinical trials. Yet, to date, no such trial has been carried out in this area. Recent studies that were conducted in this field did not attempt to assess the patients before receiving therapy and relied heavily on the subjective accounts of the subjects.

Even so, their findings can hardly be considered as promising for those advocating the use of such therapy. For instance, a study conducted by Spitzer (2003) found that change was possible for a small minority (13%) of LGB people, most of who could be regarded as bisexual at the outset of therapy. Another study carried out by Shidlow & Schroeder (2002) concluded that conversion therapy had little effect as well as considerable harm on the subjects.

In 2009, the American Psychological Association (APA) issued a report concluding that: “The reported risks of the practices include: depression, guilt, helplessness, hopelessness, shame, social withdrawal, suicidality, substance abuse, stress, disappointment, self-blame, decreased self-esteem and authenticity to others, increased self-hatred, hostility and blame toward parents, feelings of anger and betrayal, loss of friends and potential romantic partners, problems in sexual and emotional intimacy, sexual dysfunction, high-risk sexual behaviors, a feeling of being dehumanized and untrue to self, a loss of faith, and a sense of having wasted time and resources.”

The American Psychiatric Association also says that: “The potential risks of reparative therapy are great, including depression, anxiety and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred.”

Faced with such evidence, it is no surprise that most mental health professionals and bodies including the APA and the Royal College of Psychiatrists have concluded that there is no scientific or rational reason for conversion therapy and that both the ethical and scientific perspectives offer ample and sound justification for abandoning conversion techniques. It is therefore most unfortunate that the Church’s expert commission ignored the broad scientific consensus that exists in this field against the use of such therapy. For make no mistake: in advocating the use of conversion therapy by consenting adults the Church may unwittingly be leading some of its followers in harm’s way.

Claire Axiak is a psychiatrist and psychotherapist at Mental Health Services.