Conversion Therapy: Evidence is Irrelevant

Pressure mounts upon equalities minister Kemi Badenoch to resign over the UK government’s failure to ban conversion therapies. Conversion therapies involve attempts to change the sexual orientation of subjects, primarily aimed at reducing homosexual desire and behaviour in favour of heterosexuality. In 2019, I wrote The Positivity Machine, an examination of how the standards of evidence in Evidence-Based Medicine left a chasm open for ‘evidence-based alternative medicine’, and gave the false appearance of a potentially strong evidence base for a range of alternative therapies. In that paper, I discussed conversion therapy at length, particularly in the context of calls in 2017 for the UK government to legislate against it.

There has been one notable advance since: in 2017, it was deemed the remit of the Secretary of State for Health to respond to the petition to ban conversion therapy, with a further statement issued by the Parliamentary Under Secretary of State for Public Health and Innovation. At the time, I noted that this allocation of ministerial responsibility was unacceptable. Conversion therapy is not a medical intervention. Since both homosexuality and ego-dystonic homosexuality were removed from the DSM (the bible of mental disorders), there is no disease or illness here to treat. The equalities minister seems a more relevant purview in which to situate this debate.

In 2017, it was a 30,000-person petition which forced the government to take notice of conversion therapy. Now, the backlash is underpinned by a 250,000-signee petition and the resignation of four members of the government’s LGBT Advisory Council, established in 2019 but largely sidelined since. Under Theresa May in 2018, the government commissioned research into conversion therapy. That research is yet to see daylight. But any research on conversion therapy must focus only on clarifying the prevalence of such practices and on facilitating the writing of a targeted and robust legislative instrument to ban it. There is no value to research intended to establish whether or not conversion therapy can work, as The Positivity Machine demonstrated:

In March 2017, over 30,000 British citizens signed a petition calling for conversion therapy for homosexuality to be banned in the UK.2 Conversion therapy has a torrid history. It is now associated with fundamentalist churches in America. However, in the UK in the 1950s and 1960s, LGBT people were pressured and in some cases legally compelled to undergo conversion therapy by teachers, medical practitioners and the courts. The most famous case is that of Alan Turing, the father of modern computer science and artificial intelligence research. Turing was convicted of gross indecency in 1952 after admitting to a homosexual relationship. The court ordered a hormonal conversion therapy, a course of one year of synthetic oestrogen injections which were effectively a chemical castration. Turing took his own life in 1954.

‘Conversion therapy’ or ‘reparative therapy’ covers a broad range of interventions. Therapies can target behaviour or desire, trying to decrease homosexual attraction and/or increase heterosexual attraction. Behavioural therapies can be targeted at reducing homosexual behaviour and attraction through negative association—electric shock therapy and aversion therapy, for instance, in which painful shocks, nausea-inducing drugs or revulsive imagery is repeatedly administered when homosexual desires are felt. Or therapies can simply remove the person’s ability to act on homosexual desires, as in the case of Turing’s chemical castration.

Attempts to change sexual orientation, not just behaviour, can involve intensive psychotherapy. One survivor of conversion therapy, which took place in a church basement after school when he was 15 years old, recalls the range of tactics employed: “Aversion therapy, shock therapy, harassment and occasional physical abuse. Their goal was to get us to hate ourselves for being LGBTQ (most of us were gay, but the entire spectrum was represented), and they knew what they were doing … The second step of the program, they ‘rebuilt us in their image’.”3

Research by Bartlett, Smith & King reveals that conversion therapy is alive in the UK and within the psychiatric profession. It is not a phenomenon unique to the US context or to religious and unlicensed institutions—although the means employed are usually very different. Surveying 1,328 practitioners registered with one of the professional bodies overseeing psychiatry and psychotherapy, they found that 222 (17%) of psychiatrists and therapists admitted they had provided some form of conversion therapy for patients to reduce homosexual feelings and behaviours.4 They voluntarily reported 413 cases in which some form of conversion therapy had been applied, most since 1980. 40% of those patients were seen in NHS practice. But conversion therapy is more routinely practiced outside of a professional therapeutic context, and the prevalence of conversion techniques is likely to be far higher.

The response to the UK petition came from the Secretary of State for Health, Jeremy Hunt. That the reply came from the Department of Health shows that the British government classifies conversion therapy as a putative health intervention. The government did not push for a ban. Instead, Jeremy Hunt criticised the evidence base for conversion therapy: “There is no evidence that this sort of treatment is beneficial, and indeed it may well cause significant harm to some patients.”5 A further response came from Nicola Blackwood, the Parliamentary Under Secretary of State for Public Health and Innovation. She stated: “the Government has consistently condemned gay conversion therapy, and stressed that no public money should ever be used to fund such a practice”, but that a ban was out of the question: “we consider that legislation is a blunt instrument … there is a real risk, in taking a legislative option, that we overly restrict access to therapies and capture, in any legal definition, therapies that may help some people in working through issues and feelings they have about their sexuality”.6

Part of the reason that the government’s line comes across as strange is the focus on the lack of evidence that conversion therapy works. To be sure, the evidence base for conversion is scant. The most prominent study in favour of conversion therapy was performed by Robert Spitzer, and published in 2003. His study reported 200 cases of both men and women changing their sexual orientation through conversion therapies. Spitzer claimed: “The majority of participants gave reports of change from a predominantly or exclusively homosexual orientation before therapy to a predominantly or exclusively heterosexual orientation in the past year.”7 But Spitzer’s study was based only on self-reports of patients in telephone interviews. He compiled no evidence of actual behavioural or psychological change beyond those self-reports. He made no attempt to measure self-deception. In 2012, Spitzer formally retracted his study and offered a public apology: “I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy”.8

But the point is that the evidence base for conversion therapy is largely irrelevant. Even if conversion therapy had a high success rate and did not lead to increased rates of psychological distress and suicide, it would not and could not be part of scientific medicine. As the UK Council for Psychotherapy put it in their professional conduct guidelines: “It is exploitative for a psychotherapist to offer treatment that might ‘cure’ or ‘reduce’ same sex attraction as to do so would be offering a treatment for which there is no illness.”9

Homosexuality is no longer regarded as a disease. The Diagnostic and Statistical Manual of Mental Disorders (DSM), regarded by many as the definitive statement of what does and does not count as a psychiatric disorder, removed homosexuality from its lists in 1974.10 The change was prompted by meetings with gay rights activists and research by the psychologist Evelyn Hooker. The new diagnosis of “ego-dystonic homosexuality” was then introduced, and persisted into the 3rd edition of the DSM. Ego-dystonic desires and behaviours clash with the person’s ideal self-image. Ego-dystonic homosexuality was conceived to cover cases in which an individual’s sexual orientation conflicted with their ideals, such as cases of religious believers whose homosexuality was in direct conflict with their beliefs. The American Psychological Association subsequently removed this category from the DSM and issued a statement condemning its use in 1987.11

“A treatment for which there is no illness” cannot be part of scientific medicine. The scientific canon excludes homosexuality, even if the individual’s sexual orientation causes them distress, from the category of psychological disorders. This renders the evidence for or against conversion therapy irrelevant. Had there been substantial evidence that conversion therapy succeeds, it would have fallen into that gap of evidence-based alternative medicine—a therapy that cannot be part of scientific medicine, yet for which there is evidence of effect.

Treating a disease which doesn’t exist or is not recognized is one way to be disqualified from scientific status. Another is to flagrantly contradict established medical principles. A treatment might work, yet the underlying principles be incompatible with medical knowledge. In this case, one or the other must give ground. This happened also in the case of conversion therapy, and provided a second reason why the evidence, or lack thereof, was not the most relevant factor excluding the therapy. Conversion therapy rests on a fundamental precept: it is possible to intervene to change or choose sexual orientation. This notion is not consistent with established psychological principles.

References (from The Positivity Machine):

2. ‘Petition: Make Offering Gay Conversion Therapy a Criminal Offence in the UK’. Petitions – UK Government and Parliament, 3 May 2017.

3. Nichols, James Michael. ‘A Survivor Of Gay Conversion Therapy Shares His Chilling Story’. Huffington Post, 17 November 2016, sec. Queer Voices.

4. Bartlett, Annie, Glenn Smith, and Michael King. ‘The Response of Mental Health Professionals to Clients Seeking Help to Change or Redirect Same-Sex Sexual Orientation’. BMC Psychiatry 9 (26 March 2009): 11.

5. ‘Petition: Make Offering Gay Conversion Therapy a Criminal Offence in the UK’. Petitions – UK Government and Parliament, 3 May 2017. – Government Response

6. Blackwood, Nicola. ‘Letter to the Petitions Committee, Helen Jones MP’, 23 March 2017.

7. Spitzer, Robert L. ‘Can Some Gay Men and Lesbians Change Their Sexual Orientation? 200 Participants Reporting a Change from Homosexual to Heterosexual Orientation’. Archives of Sexual Behavior 32, no. 5 (1 October 2003): 403–17.

8. Spitzer, Robert L. ‘Spitzer Reassesses His 2003 Study of Reparative Therapy of Homosexuality’. Archives of Sexual Behavior 41, no. 4 (August 2012): 757.

9. UK Council for Psychotherapy (UKCP). ‘UKCP’s Ethical Principles and Codes of Professional Conduct:  Guidance on the Practice of Psychological Therapies That Pathologise and/or Seek to Eliminate or Reduce Same Sex Attraction’. London: UKCP, 28 February 2011.

10. American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed., 7th printing. Washington, D.C.: APA, 1974.

11. Fox, R E. ‘Proceedings of the American Psychological Association, Incorporated, for the Year 1987: Minutes of the Annual Meeting of the Council of Representatives: Use of Diagnoses “Homosexuality” & “Ego-Dystonic Homosexuality”’. American Psychologist 43 (1988): 508–31.

Featured image credit: “Alan Turing” by John Callas. This file is licensed under the Creative Commons Attribution 2.0 Generic license.