The standard features of quackery are all there. Proponents of this particular therapy claim that a normal condition is a disease. They make false claims about the cause of this disease. They then charge thousands of dollars for their fake treatment to cure the fake disease, and claim success rates that are not backed by any statistics.
In this case the fake disease is homosexuality, for which there is now a solid consensus that it is a normal variation of human sexuality. The fake treatment is conversion therapy. Recently a New Jersey judge ruled that conversion therapists cannot claim that homosexuality is a disease or disorder. The Southern Poverty Law Center reports:
Superior Court Judge Peter F. Barsio Jr. found that it “is a misrepresentation in violation of [New Jersey’s Consumer Fraud Act], in advertising or selling conversion therapy services, to describe homosexuality, not as being a normal variation of human sexuality, but as being a mental illness, disease, disorder, or equivalent thereof.”
The judge also ruled that [New Jersey conversion therapy provider Jews Offering New Alternatives for Healing (JONAH)] is in violation of the Consumer Fraud Act if it offers specific success statistics for its services when “client outcomes are not tracked and no records of client outcomes are maintained” because “there is no factual basis for calculating such statistics.”
Anytime there is a ruling or new law or regulation that essentially makes it illegal to make fraudulent health claims, that is a win for the consumer. Health care consumers, including those for mental health services, are particularly vulnerable. Further, most consumers assume that such protections are already in place, and therefore have a (frequently false) sense of security that others cannot make fraudulent health claims.
(Note: I recognize that sexual orientation and gender identity are complex and represent spectrums, rather than clean dichotomies. However, since the dubious treatment and the current ruling address “homosexuality” I will use that term as a representative label.)
Homosexuality has been a target for many decades. By coincidence, a character in this season of Downton Abbey (which takes place in the 1920s), Thomas Barrow, is undergoing dubious and apparently dangerous medical treatments for his homosexuality.
Early psychiatrists differed on their views of homosexuality. Freud actually thought it was a natural variation of human sexuality, while others, such as Sandor Rado, argued that it was pathological. The pathological view prevailed, and the dominant theory was that homosexuality results from abnormal sexual development or even early childhood trauma and abuse. In the first half of the 20th century what little research was done supported the pathological hypothesis, but in retrospect this research was highly biased.
The turning point came with the research of Evelyn Hooker beginning in 1957. Her research into homosexuality addressed the inherent biases of earlier research. She studied subjects who were not already psychiatric patients. She also performed blinded evaluations in which personality traits were assessed by evaluators who did not know the sexual orientation of the subject.
With these biases eliminated, she found that homosexuals did not have any greater chance of having mental illness or poor adjustment than heterosexuals, which was a fatal blow to the view that homosexuality was a mental pathology. Her research was replicated by others, with similar results. A new consensus was forged around these more rigorous research results.
In 1974 homosexuality was removed from the DSM as a mental disorder. Now, forty years later, this remains the robust conclusion of psychological research, that homosexuality is part of the healthy spectrum of human sexuality and there is no evidence that justifies the conclusion that it is a disorder or disease.
Similarly, there is no evidence to support the claim that homosexuality results from early childhood trauma or abuse. Sexuality is a complex behavior, and there is no simple cause that can be identified. However, researchers have identified two significant contributors.
The first is genetics. While there is certainly no “gay gene”, studies have identified a genetic predisposition to homosexuality. This means that there are likely many genes that play a role, and no single gene (or even the totality of relevant genes) is deterministic.
The second biological factor is the hormonal environment in the womb, which has a known effect of brain development. There are several independent lines of evidence supporting this conclusion, from birth order effects to differences in brain scans.
The genetic and development research, however, overall is not definitive and both larger, more representative, and more nuanced research is considered necessary. The Harvard Kennedy School LGBTQ Policy Journal concludes:
Issues of sample size and selection bias, however, also plague these studies. Those who are willing to undergo brain scans, or have their brain examined upon autopsy (Swaab and Hofman 1990), may have a special and unique relationship with their sexuality. It would be more informative to study individuals across a range of sexualities and gender identities. While such studies would be unlikely to produce the striking results we currently see in the literature, they would better reflect the diversity of the human population and shed light on what differences may actually exist between people who identify as LGBT and those who do not.
Regardless of these finer points, it is clear that variations in sexual orientation and gender identity are not the result of childhood trauma or abuse, as is claimed by the conversion therapy industry.
Does conversion therapy (also called reparative therapy) work? The burden of proof, of course, is on those making claims for efficacy. The research, however, is scant and problematic. Most famously, in 2003 Spitzer published a case series in which he concluded that reparative therapy was effective. He wrote:
Either some gay men and lesbians, following reparative therapy, actually change their predominantly homosexual orientation to a predominantly heterosexual orientation or some gay men and women construct elaborate self-deceptive narratives (or even lie) in which they claim to have changed their sexual orientation, or both. For many reasons, it is concluded that the participants’ self-reports were, by-and-large, credible and that few elaborated self-deceptive narratives or lied.
The first sentence summarizes the difficulty with this research. Subjects are self-selected and they self-report their own outcomes. There are good reasons to believe that the social pressures that led them to seek out reparative therapy in the first place also motivate them to construct a narrative of efficacy. The problem was in Spitzer’s second sentence, concluding without adequate justification that the self-reports were not self-deception. In 2012 Spitzer then recanted this conclusion.
Sexual orientation and gender identity are complex behavioral traits that exhibit the full spectrum of possible manifestations and even flexibility. Decades of research suggest that the full spectrum is part of human sexual variation, and does not represent a pathological or disease state, nor any kind of disorder. They are not associated with any pathology, specifically with childhood trauma or abuse. Rather, sexual orientation appears to have a clear but complex biological component.
Claims for efficacy of conversion or reparative therapy are not supported by adequate clinical evidence.
The recent ruling in this ongoing case in New Jersey is encouraging, essentially ruling that practitioners of dubious conversion therapy cannot make fraudulent claims regarding the medical status of homosexuality or the efficacy of their treatment.