Therapy bans, APA talking points and counseling choice

A multitude of states, counties and cities have banned “conversion therapy,” usually for minors only, with efforts underway to issue a national ban for all through the so-called “Equality Act” (HR 5). Yet, “conversion therapy” is a misrepresentative, maligning and summarily ill-defined term employed as a jamming tactic to capitalize on an allusion to implicitly forced religious conversion while stigmatizing and intimidating any therapist who would engage in change-allowing therapy. It implies coercion and suffering, neither of which are true of modern change-allowing therapy (aka SOCE for sexual orientation change efforts). Modern SOCE therapists uniformly view old aversive techniques (think shaming, electric shocks, etc.) as unethical and ineffective. Tellingly, no state or municipality enacting a therapy prohibition has yet to ban aversive practices, only counseling that allows clients to explore their potential for change of SOGI (sexual orientation, gender identity). Why not ban aversive measures too, if abuse is really the issue?

Counseling therapy for any issue requires a willing and motivated client who determines the aims of the therapy. Simply put, no ethical therapist accepts a coerced SOGI patient nor coerces them. Client autonomy and client directed-therapy are the ethical standard of care in the mental health field. So the desire for help in addressing unwanted same-sex attraction and gender dysphoria is usually and necessarily driven by the patients themselves, though critics often frame therapy as otherwise. Were it otherwise, change-allowing therapy would have collapsed long ago. Supply and demand dictate there is no market for what is not wanted.

Nicholas Cummings, past president of the American Psychological Association (APA) and chief of the Kaiser-Permanente’s mental health division for decades, expressed that most of the 18,000 or so clients seen by him and his team were those simply desiring a “happier and more stable homosexual lifestyle.” It is not people of faith “creating a problem” with change-allowing therapy, it’s patients of all walks wanting help.

A recent APA webinar, “Psychology and LGBTQ+ State Legislative Advocacy 2021,” listed the following four items as “suggested talking points” in opposing therapy:

1. Ever since the American Psychiatric Association removed homosexuality from its diagnostic manual in 1973, it has been widely known that someone’s minority sexual orientation is not mental disorder to be “cured” or “treated.” Rather, it encompasses an individual’s sense of personal and social identity based on their attraction to men, women, or more than one gender (Institute of Medicine, 2011). In 2013 the American Psychiatric Association removed “gender identity disorder” from the manual (American Psychiatric Association, 2013). Gender identity “refers to a person’s basic sense of being male, female, or of indeterminate sex,” and every person has a gender identity (APA, 2009b).
2. Efforts to change an individual’s sexual orientation or gender identity may encourage people to hide these aspects of their identity, which can lead to mental health problems such as depression, sexual problems, low self-esteem, and suicide (Beckstead & Morrow, 2004; Blosnich, et al., 2020; Dehlin, et al., 2015; Green, et al., 2020; Ryan et al., 2018).
3. Experts at the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) have concluded that sexual orientation or gender identity change efforts are “coercive, can be harmful, and should not be part of behavioral health treatment” (SAMHSA, 2015).
4. Many who offer change efforts are not licensed mental health practitioners, so it is unclear what, if any, training or education they may have received to represent themselves as qualified. As of January 2018, an estimated 57,000 LGBTQ+ youth will undergo this practice from a religious or spiritual advisor (Mallory, et al., 2019).

These APA talking points are highly contestable.

APA Talking Point 1
The insinuation that minority sexual orientation (orientation essentialism is itself an ideological term) is considered a mental disorder is a straw argument. Even viewing such as a disordered sexuality should not be conflated by the APA with terming it a mental health disorder. Even so, it does not follow that patient-initiated-and-directed therapy has no relevance. Mental health experts routinely provide counseling for people without pathology, bereavement being an obvious case in point.

Furthermore, many sexual minority individuals would take issues with the assertion that such status “encompasses an individual’s sense of personal and social identity.” Many can and do reject LGBT identification and wish to live otherwise, finding their identity in factors more foundational than sexuality.^[1],[2],[3] Studies addressing who they are and why they exercise their autonomy in this direction abound.^[4],[5],[6] And they are not alone in using change-allowing therapists.

The APA did remove “gender identity disorder” from the DSM-5, but the reasons were arguably ideological more than scientific.^[7] As I have previously written, decades of professional literature confirm that, conservatively, 85 percent of children with gender dysphoria become comfortable with their bodies; and the overwhelming majority of people with gender dysphoria have additional mental health conditions (depression, anxiety, bipolar disorder, psychoses, personality disorders, histories of self-harm or suicidality, etc.), neuro-developmental disabilities (autism spectrum), adverse childhood events and family issues that pre-date or coincide with their gender incongruence.^[8]

There must be mental health advocacy for the majority of gender dysphoric/incongruent youth who will desist by adulthood, not just for those choosing transition to an opposite-sex persona. The APA Handbook on Sexuality and Psychology warns that “Premature labeling of gender identity should be avoided,”^[9] and explains why, “This approach runs the risk of neglecting individual problems the child might be experiencing and may involve an early gender role transition that might be challenging to reverse if cross-gender feelings do not persist….”^[10] Yet, the APA is advocating for therapy bans while there is mounting international scrutiny of routine transition affirmation due to lack of evidence of efficacy and safety (e.g., the UK High Court in Bell vs. Tavistock (2020), the Swedish National Council for Medical Ethics,^[11] Finland’s Council for Choices in Health Care in Finland (COHERE) (2020), among others).^[12]

APA Talking Point 2
Surveys claiming harm rarely define the term “conversion therapy” with any precision, routinely muddy the waters by combining simple pastoral or other ill-defined spiritual counseling with actual therapy by licensed clinical professionals, fall back on a simplistic “affirmation” versus “conversion” false dichotomy, and they use survey designs (notably convenience sampling) that all but assure the exclusion of those who benefitted from therapy (e.g. sampling from exclusively LGBTQ+ organizations, clubs and venues), among other weaknesses. Convenience sampling creates low-quality data.^[13] Gideon’s Handbook of Survey Methodology for the Social Sciences warns, “you cannot make statistical generalizations from research that relies on convenience sampling[,]” and “Convenience sampling is to be avoided always in survey research.” The lesson seems lost on much of the research in this field, demonstrating how compromised modern research methods can be at the altar of group think and foregone conclusions. As psychologist Christopher Rosik observed, “There is growing evidence that constructs and conclusions derived from LGBT identified samples may not be easily transferrable to non-LGBT identified sexual minorities with primary religious identities (Hallman, Yarhouse, & Suarez, 2018; Lefevor et al., 2019; Rosik, 2007).”^[14]

The selection of studies specified in the APA talking point demonstrate the previously stated shortcomings along with the citation bias prevalent in the literature. I will briefly address the newer studies they cited.

Dehlin, et al (2015)^[15] was a web-based retrospective survey of 1,612 ex-Mormons (only 29 percent were active LDS members) with recruitment and other biases further assured by the authors’ reputations as gay advocates with anti-SOCE views. It employed a strongly flawed rating scale: 1 = highly effective, 2 = moderately effective, 3 = not effective, 4 = moderately harmful, and 5 = severely harmful. Note the instrument midpoint was not neutral, and the scale merged the metrics of “effectiveness” and “harm” rather than using only one. Provider confounding occurred, combining reported results from both religious and professional SOCE providers, with 85 percent reporting using religious or private individual SOCE methods, but only 44 percent using a therapist or group-led SOCE. Even so, slightly positive outcomes were found for therapist-led, group therapy, group retreat and psychiatry methods, with about 44 percent finding them helpful.

Missteps in Ryan, et al (2018)^[16] were addressed in a letter by Psychologist Rosik.^[17] Ryan “measured parent-initiated SOCE during adolescence and its relationship to mental health…,” which is already a problem, excluding patient-initiated SOCE, which any ethical change-allowing therapist insists upon. Ryan’s team concluded it was “…associated with depression, suicidal thoughts, suicidal attempts, less educational attainment, and less weekly income.” But association is not causation. Rosik stated that Ryan’s team “did not disentangle participants’ perceptions of the effects of licensed therapists from that of unregulated and unaccountable religious leaders….” So, which was to blame for the perceived poor results? Rosik noted selection and recruitment bias, in that the sample was limited to LGBT-identified young adults, which “excludes by definition” those who felt they benefitted from religious and professional engagement, and who would also be far less likely to “go to LGBT bars, clubs, or service agencies where participants were recruited for this research.”

Blosnich, et al (2020) claimed, “Over the lifetime, sexual minorities who experienced SOCE reported a higher prevalence of suicidal ideation and attempts than did sexual minorities who did not experience SOCE.” Well, hold on. A forthcoming letter to the editor in the same journal (Rosik, Sullins, Schumm, Van Mol) listed three issues with the study.^[18]First, calculations were done using only the total sum of adverse childhood experiences (ACEs), yet different ACEs have differing levels of effect on suicidality. The SOCE group reported greater exposure to parental violence and more abuse (emotional, physical and sexual) than the non-SOCE responders. The model was not adjusted for the differences in ACE exposure and severity, thus failing to account for their contribution to suicidality. Second, it was speculative to blame SOCE for suicidality without a longitudinal design, a control for pre-SOCE levels of suicidality, and a comparison of suicide levels between clients in SOCE and non-SOCE therapy. Again, association is not causation. And third, the Generations study—the data source for Blosnich—only sampled people who were already LGBT identified, thereby excluding sexual minority individuals who do not so identify along with omitting their likely more positive experiences with SOCE. Finally, the Generations study was far too vague in defining SOCE (“treatment,” “tried to change” and “try to make”), thus confounding and invalidating interpretation and conclusions.

In Green, et al (2020), the Trevor Project conducted an online survey recruiting adolescents and young adults (AYA) who experienced “sexual orientation or gender identity conversion efforts (SOGICE)” and “who interacted with materials deemed relevant to the LGBTQ community.” This design excludes AYAs who do not or no longer identify as LGBTQ nor interact with the LGBTQ community or its materials, which would likely be the case with those who found therapy helpful. By excluding them, it can make no conclusions about them. Prior to survey “questions specific to youth mental health and suicidality,” the LGBTQ-identified AYAs were instructed to contact the Trevor Project crisis intervention hotline if needed, thus revealing the study sponsors and their well-advertised biases.

Green’s study defined SOGICE as coercive, “someone attempted to convince them to change,” which ethical change-allowing therapists do not do. The survey excluded 105 participants who said they experienced SOGICE but without someone trying to “convince them to change,” so it can claim nothing about non-coercive SOGICE. The study asserted that LGBTQ-identified youth who were more than two times more suicidal were more likely to have experienced SOGICE therapy. The researchers then fully commit to the association as causation fallacy by concluding, “The elevated odds of suicidality observed among young LGBTQ individuals exposed to SOGICE underscore the detrimental effects of this unethical practice…” No, they don’t. A more suicidal youth is more likely to experience therapy than one who is not. It does not follow that the therapy was causative of suicidality.

APA Talking Point 3
The 2015 report, “Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth,” was “prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by Abt Associates.” “Prepared for” and not by SAMHSA, and it includes this disclaimer, “The views, opinions, and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS.” The erroneous coercion and harm claims of this APA talking point have already been addressed above.

A group of 15 LGBT activist professionals, one of whom was lead author of the 2009 APA Task Force Report, stated in an otherwise harshly anti-therapy commentary: “As of this writing, to our knowledge, there have been no formal actions by a regulatory body against a provider for engaging in conversion therapy.”^[19]

The bans are needless. The legislatures already have a process in place to address complaints of harmful practice and clinician malfeasance through state licensing boards. If clients had been harmed or treated unethically, the licensing boards would already have known, documented and acted. No such complaints exist.

APA’s Gay and Lesbian Task Force’s 2009 report specified, “We found that nonaversive and modern approaches to SOCE since 1978 have not been rigorously evaluated.”^[20] This concedes SOCE have been non-aversive for more than 40 years. The “Efficacy and Safety” section (page 82) reiterates, “We found few scientifically rigorous studies that could be used to answer the questions regarding safety, efficacy, benefit, and harm” of modern change-allowing therapy.” That is far from concluding SOCE to be harmful or ineffective. The 11th Circuit Court of Appeals cited these statements of the APA Task Force Report in their 2020 ruling striking down a therapy ban for minors in Otto, et al v. City of Boca Raton.^[21]

APA Talking Point 4
If indeed “Many who offer change efforts are not licensed mental health practitioners,” why impose therapy bans that would only eliminate the qualified participation of licensed professionals? Wouldn’t that drive the willing and motivated people unhappy with experiencing minority sexuality to precisely the unlicensed “others?” The APA talking point’s reasoning seems circular.

ConclusionThe APA legislative talking points violate patient autonomy, misrepresent change-allowing therapy and those who offer it, seem founded on ideology rather than science, are replete with citation bias favoring weak studies with unmerited conclusions, and would block the availability of ethical psychotherapy and counseling choice for sexual minority people already at risk.

[1] Michael W. Hannon, Sexual Disorientation: The Trouble with Talking about “Gayness”, firstthings.com, Oct. 10, 2013. https://www.firstthings.com/web-exclusives/2013/10/sexual-disorientation-the-trouble-with-talking-about-gayness

[2] Andre Van Mol, Mistaken Identity: There is No Straight or Gay, Oct. 26, 2017. https://cmda.org/resources/publication/mistaken-identity-there-is-no-straight-or-gay

[3] Elizabeth Woning, Belonging. January 30, 2021. https://www.elizabethwoning.com/essays/2021/1/30/f2o3kflgwwj7c5ocd1oh5jnq5ra23b

[4] Christopher H. Rosik, G. Tyler Lefevor, A. Lee Beckstead, Sexual Minorities who Reject an LGB Identity: Who Are They and Why Does It Matter? Issues in Law & Medicine, Volume 36, Number 1, 2021. In press.

[5] G. Tyler Lefevor, Sydney A. Sorrell, Grace Kappers, Ashley Plunk, Ron L.

Schow, Christopher H. Rosik & A. Lee Beckstead (2019): Same-Sex Attracted, Not LGBQ: The Associations of Sexual Identity Labeling on Religiousness, Sexuality, and Health Among Mormons, Journal of Homosexuality, DOI: 10.1080/00918369.2018.1564006

[6] G. Tyler Lefevor, A. Lee Beckstead, Ronald L. Schow, Marybeth Raynes, Ty

1. Mansfield & Christopher H. Rosik (2019): Satisfaction and Health Within Four Sexual Identity Relationship Options, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2018.1531333

[7] Quentin L. Van Meter. Bringing Transparency to the Treatment of Transgender Persons. Issues in Law & Medicine, Vol. 34, Iss. 2, Fall 2019, pp. 147-152.

[8] “Mental Health Advocacy for Gender Dysphoric Youth,” CMDA’s The Point Blog, Feb. 27, 2020. https://cmda.org/mental-health-advocacy-for-gender-dysphoric-youth/

[9] W. Bockting, Ch. 24: Transgender Identity Development, in 1 American Psychological Association Handbook on Sexuality and Psychology, 744 (D. Tolman & L. Diamond eds., 2014).

[10] W. Bockting, Ch. 24: Transgender Identity Development, in 1 American Psychological Association Handbook on Sexuality and Psychology, 750 (D. Tolman & L. Diamond eds., 2014).

[11] https://www.transgendertrend.com/wp-content/uploads/2019/04/SMER-National-Council-for-Medical-Ethics-directive-March-2019.pdf.

[12] https://palveluvalikoima.fi/documents/1237350/22895008/Summary_minors_en.pdf/aaf9a6e7-b970-9de9-165c-abedfae46f2e/Summary_minors_en.pdf

[13] Bornstein, M. H., Jager, J., & Putnick, D. L. (2013). Sampling in developmental science: Situations, shortcomings, solutions, and standards. Developmental Review, 33(4), 357–370. https ://doi.org/10.1016/j.dr.2013.08.003.

[14] Christopher H. Rosik (2021) RE: Ryan, Toomey, Diaz, and Russell (2018),

Journal of Homosexuality, 68:2, 181-184, DOI: 10.1080/00918369.2019.1656506

[15] Dehlin, J. P., Galliher, R. V., Bradshaw, W. S., Hyde, D. C., & Crowell, K.A. (2014). Sexual orientation change efforts among current or former LDS church members. Journal of Counseling Psychology. Advance online publication. doi: 10.1037/cou0000011.

[16] Ryan, C., Toomey, R. B., Diaz, R. M., & Russell, S. T. (2018). Parent-Initiated sexual orientation change efforts with LGBT adolescents: Implications for young adult mental health and adjustment. Journal of Homosexuality, 1–15. Advance online publication. doi:10.1080/00918369.2018.1538407

[17] Christopher H. Rosik (2019): RE: Ryan, Toomey, Diaz, and Russell (2018),

Journal of Homosexuality, DOI: 10.1080/00918369.2019.1656506

[18] Rosik CH, Sullins DP, Schumm WR, Van Mol A. Sexual orientation change efforts, adverse childhood experiences, and suicidality. Am J Public Health. 2021;111(4): e1–e2. Acceptance Date: December 30, 2020. DOI: https://doi.org/10.2105/AJPH.2021.306156

[19] Drescher, J., Schwarz, A., Casoy, F., McIntosh, C., Hurley, B., Ashley, K., Barber, M., Goldenberg, D., Herbert, S., Lothwell, L., Mattson, M., McAfee, S., Pula, J., Roario, V., Tompkins, A. (2016), The growing regulation of conversion therapy: What state medical boards need to know, Journal of Medical Regulation, 102, p. 10, http://jmr.fsmb.org/archives/archive-2010s/

[20] American Psychological Association, Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Retrieved from http://www. apa.org/pi/lgbc/publications/therapeutic-resp.html

[21] https://lc.org/newsroom/details/112020-court-of-appeals-strikes-down-fl-counseling-ban-1