Conflicted: A Closer Look at Conversion Therapy

At the close of Pride Month, the Singapore Psychological Society (SPS) released a statement in support of the LGBTQ+ movement. SPS signed off a series of posts on “conversion therapy,” saying they stand with “every single person for their deepest “self” (i.e. who they really experience and identify themselves as).”

This lovely rhetoric that falls in line with the zeitgeist of the 2020s seems quite uncontroversial. Yet while this idea of self applies perfectly to the LGBT movement, it has a tortured relationship with the movement’s deviant, estranged cousin – the ex-gays. Like LGBT people, these misfits find themselves coming out of the closet, but into rather divergent spaces. While the former may be found revelling in their now-public identities, the latter are likely found wrestling with the same identities within churches, synagogues, or mosques. Belief in a higher power, religious rituals and community, are likely to form a huge part of the ex-gays deepest “self”. One cannot deny the role that identity politics and mental health play in shaping the experiences of both the LGBT community and the ex-gays. While the former may struggle with societal acceptance and discrimination on the basis of their sexual orientation, the latter grapple with the internal conflict of trying to align their faith with their perceived sexual identity. This internal struggle often leads to significant mental health challenges, as they navigate feelings of shame, guilt, and isolation within their religious communities. In this way, the intersection of identity politics and mental health becomes a crucial aspect in understanding and addressing the experiences of both of these marginalized groups.

SPS touts an evidence-based approach

The SPS’ strong support for such a “self” does not seem to apply to the ex-gay movement. In their statements on “conversion therapy,” they cite research that is highly dismissive of anything vaguely religious in nature. Touting “current research” that “indicates the inefficacy and possible harmful effects of conversion therapy,” the SPS then recommends “evidence-based therapy” for clients that involves “exploring or affirming their orientation/identity.”

Surveying SPS’s sources

A quick look would show titles of research papers on the matter and register that there are multiple sources of evidence. Yet if the evidence was so clear, why was there even any pushback on conversion therapy bans worldwide? Was it merely due to the evil intentions of brainwashed religious bigots? Or are there genuinely debateable points?

Taken at its highest, a deeper look at the sources provided paint a conflicting picture, and at its lowest, a misleading one. The list of sources are reproduced here:

• “Can Sexual Orientation Be Changed?” by Jack Drescher, MD – cited on picture 5
• “Society’s Request for Conversion Therapy: Is it Effective and Ethical to be Done?” by Stefany Valentia and Elizabeth Kristi Poerwandari – cited on picture 5
• “Sexual Orientation Change Efforts and the Search for Authenticity” by Jo Fjelstrom, LCSW – cited on picture 5
• “Weighing the Evidence: Empirical Assessment and Ethical Implications of Conversion Therapy” by Robert J Cramer, and Frank D Golom, et al. (referred to as “Weighing the Evidence”) – cited on picture 5
• “Undoing the Damage, Working with LGBT Patients in Post-Conversion Therapy” by Jessica Horner – cited on picture 5
• “Conversion Therapies for Same-Sex Attracted Clients in Religious Conflict” by Lee Beckstead and Susan Morrow (referred to as “CT in Religious Conflict”) – Footnote 2
• “Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence” by Ilan Meyer – Footnote 5

At first glance, it becomes apparent that none of the sources conduct quantitative research, i.e. numerical research which can be generalised, to prove the claimed harms of conversion therapy. Such research would provide a strong basis for claims of being “evidence-based.” Two of these were literature reviews or expert opinion on the evidence of conversion therapy effects. Another two provided anecdotal data – one had one source, while another had 15. These are measures of qualitative analysis.

Interestingly, most of the studies quoted by SPS’s sources are qualitative studies – that is, non-numerical studies. One prominent research study, “Mormon Clients’ Experiences of Conversion Therapy: The Need for a New Treatment Approach” by Lee Beckstead and Susan Morrow (referred to as “Mormon Study”) outlines the implication. Their study “cannot be used to generalize to the larger population of individuals who have undergone conversion therapies” (Mormon Study at 683). The same researches attributed this to the dearth of information in this area (Mormon Study at 654).  Their observations are echoed by other sources. For example, in “Weighing the Evidence” cited by SPS, authors admit that while the American Psychological Association “stated that no empirical evidence has documented the efficacy of reparative systems,” there must be an acknowledgement of “a similar lack of empirical data on affirmation therapy approaches” (Weighing the Evidence, at 110).

There are also traces of double standards, as experts lists limitations of studies that show benefits of CT, while supporting other studies that bear similar limitations. For example, almost all of the studies of actual subjects rely on self-report (also known as a “convenience sample”) and most suffered from researcher bias. These samples, as mentioned above, are unable to be generalised.

One interesting case of researcher bias presents itself in another prominent study on the harms of CT that was quoted by SPS source, “CT in Religious Conflict”. “Changing Sexual Orientation: A Consumers’ Report” by Ariel Shidlo and Michael Schroeder was one of the first few studies to investigate the harms of conversion therapy. At first, it was titled “Homophobic Therapies: Documenting the Damage,” and the initial text for participation recruitment reads, “The National Lesbian and Gay Health Association is conducting a survey of lesbians, gay men, and bisexuals who have been in counselling that tried to change their sexual orientation. They intend to use the results to inform the public about the often harmful effects of such therapies.” The title and recruitment words were later changed to reflect the positive outcomes that were reported by some participants in the study. While it outlined the harms of CT, the researchers did not call for a complete ban. One of its interesting findings, at page 254, was that “Twenty-five participants had a history of suicide attempts before conversion therapy, 23 during conversion therapy, and 11 after conversion therapy”. This actually shows that more than half of those who were suicidal before CT, were no longer suicidal after.

Conflicting evidence over Conversion Therapy

Circling back to SPS’s push for evidence-based therapy, it appears that the evidence isn’t all that clear cut. In fact, one US Court of Appeals, in striking down bans on speech-related Sexual Orientation Change Efforts (SOCE) criticised the evidence on harms. It said, “when examined closely, these documents offer assertions rather than evidence, at least regarding the effects of purely speech-based SOCE. Indeed, a report from the American Psychological Association, relied on by the defendants, concedes that “nonaversive and recent approaches to SOCE have not been rigorously evaluated.” In fact, it found a “complete lack” of “rigorous recent prospective research” on SOCE.”

If all the different anecdotes – basically what most studies comprise – are taken together, a conflicted picture then emerges. On one hand there are proponents of some form of conversion therapy self-reporting its effectiveness, and on the other, opponents self-reporting its harms. This issue in the current research was raised by another of SPS’s sources, “CT in Religious Conflict” again by Lee Beckstead and Susan Morrow. It states that another limitation of “research on sexual reorientation therapy tends to represent only one viewpoint, either promoting or rejecting such therapy. ” In order to fairly evaluate the efficacy and potential harm of conversion therapy, future research should strive to include a diverse range of perspectives and experiences. Additionally, it may be valuable to compare the outcomes of conversion therapy to those of comprehensive sexuality education programs, in order to provide a more comprehensive understanding of the ways in which individuals can explore and understand their sexuality. This approach could help to inform policy and clinical practice regarding sexual orientation and identity.

Would it then be misleading to present only one form of therapy of exploration and affirmation despite claims that certain forms of non-affirming therapy have benefits? What about the claims where affirmation therapy has harmed individuals? These include the high-profile detransitioner Keira Bell, who won a legal suit against the Gender Clinic in London for failing to stop her from transitioning as a teenager. We note that the judgment may be appealed.

Nonetheless, Bell’s description of the deeply complex issues involved in therapy is insightful. She states, “At the Tavistock, practitioners provide “gender affirmative care”—in practice, this means that when children and teens declare a desire to transition, their assertions are typically accepted as conclusive. Affirmative care is being adopted as a model in many places. In 2018, the American Academy of Pediatrics released a policy statement on the treatment of young people who identify as transgender and gender diverse that advocated for “gender-affirmative care.” But former Tavistock practitioners have cited varied problems suffered by the kids who sought help, such as sexual abuse, trauma, parental abandonment, homophobia in the family or at school, depression, anxiety, being on the autism spectrum, having ADHD. These profound issues, and how they might be tied up with feelings of dysphoria, have often been ignored in favor of making transition the all-purpose solution. As the High Court found, much of the clinic’s treatment is not even based on solid evidence. At the time our case was accepted, the NHS was asserting that the effects of puberty blockers are “fully reversible.” But recently, the NHS reversed itself, acknowledging “that ‘little is known about the long-term side-effects’ on a teenager’s body or brain.” That didn’t stop them from prescribing these drugs to people like me.” Her court case followed strong undercurrents of discontent over the affirmation-only approach that the gender clinic had taken towards children.

Locally, there are also two competing narratives. One activist website has shared four accounts of conversion therapy’s harms. However, there’s also a group of ex-gays who stand by the benefits of non-affirming therapy.

In this clash of worldviews where there is much emotion and little middle ground, it is all the more important for professional bodies in Singapore to take a rigorous approach towards all evidence, and conduct their own studies. We must ask hard questions and avoid shallow analyses. Only then will we be able to navigate this particularly explosive issue of conversion therapy. By taking a rigorous approach, professional bodies can contribute to the dispelling of myths and misinformation surrounding conversion therapy. This in turn could help to reduce the mental health stigma in Singapore, as individuals struggling with their sexual orientation or gender identity may feel more supported and understood. It is crucial for professional bodies to lead the way in promoting evidence-based practices and advocating for the well-being of all individuals, regardless of their sexual orientation or gender identity.

P.S. SPS has released a second related statement here. Unlike other groups and jurisdictions, they are not calling for a ban on Sexual Orientation Change Efforts, but also seek to follow a largely American approach. The issues with its stated evidence still remain.