In early April, the Obama administration responded to an online petition calling for a “Leelah’s Law” that would ban “conversion” therapies. The petition, launched in response to the suicide of a child born a boy and given the name Joshua Ryan Alcorn who felt himself to be a girl and called himself Leelah, conflated therapeutic practices aimed at treating gender dysphoria and those aimed at sexual orientation change. In response to the petition, the White House added its voice to a growing chorus of opposition to such therapies while doing little to clarify the petition’s confusion: “We share your concern about its potentially devastating effects on the lives of transgender as well as gay, lesbian, bisexual and queer youth,” wrote Valerie Jarrett, a senior adviser to Obama. “As part of our dedication to protecting America’s youth, this administration supports efforts to ban the use of conversion therapy for minors.”
In order to get a sense of the therapeutic implications of this growing movement, First Things talked to Mark A. Yarhouse, professor of psychology and the Hughes Endowed Chair at Regent University.
FT: What led up to the administration's decision to come out against so-called “conversion therapies”?
I am not entirely clear on all that contributed to the administration’s decision. It is such an unusual step for a sitting president to weigh in on the complexities of clinical practice. But we do see concerted efforts to bring about legislation in some states around sexual orientation change efforts and specific approaches to gender dysphoric youth. At present these seem to center on professional therapists who hold a license and on clinical practice with minors. I think what is surprising to some observers is that you would normally expect decisions about clinical practice to take place at the level of the boards that oversee mental health professionals, such as a board of psychology or a board of counseling in a given state. Many national organizations have produced documents in which concerns have been expressed about sexual orientation change efforts, of course, but that is different than legislation and still different from using the weight of the White House to support legislation.
FT: What are the merits of the sorts of therapy under question? Can they be effective?
That’s the controversy. I am not familiar with much research specifically on youth, which is why this legislation is so interesting. I think the 2009 report on appropriate therapeutic responses to sexual orientation from an American Psychological Association task force even noted that there was little research on adolescents per se. I think some observers see it as a foot in the door to ultimately make any sexual orientation change effort with minors or with adults, by professionals or in religious organizations, a legal concern. In any case, there have been several studies conducted in the 1960s, 1970s, and 1980s that looked at whether these therapies were helpful to adults seeking to change their sexual orientation. Most of these studies reported what some would consider meaningful success rates. However, the problem was that the studies were not well designed by today’s standards. Critics today would also say that the studies were based on assumptions about pathology that are not warranted today. When we look at the methodology, some studies relied upon asking the clinician if the therapy was successful. Other studies measured behavior change or identity change. Some did attempt to measure attraction or orientation, but few used control groups.
So critics are right to point out that many of these reports may not really have gotten at the underlying pattern of sexual attraction or orientation because in many cases that was not being measured. However, these studies were in keeping with other research conducted at the time, and poor methodology by today's standards does not disprove success. I think some would conclude that there is insufficient evidence to say with certainty how potentially helpful or harmful such therapies may be. What has filled that void are personal stories of success or harm, which can be important and compelling but do not substitute for well-designed research studies. Very few people conduct research on the question of change today, so I don’t know how much more we will learn in the years ahead. In some ways it is incumbent upon those who provide reorientation therapy to conduct that research. At the same time, I recognize that it would be nearly impossible to receive funding for such lines of research today.
When we look at therapy to intervene with gender dysphoria, it is important to note that it is a different topic. Gender dysphoria is about an incongruence between one’s biological or birth sex and one’s gender identity. It is not about sexual attraction or orientation. The options for intervening around gender dysphoria in childhood range from facilitating congruence between one’s gender identity and one's biological sex, facilitating a cross-gender identification, or waiting to see what will occur over time. Interestingly, most cases of gender dysphoria resolve before a child reaches adulthood. An estimated 75 percent of cases resolve, so many people are in favor of waiting to see what happens. The controversies exist around steps to actively intervene, but my understanding is that there is some research to support efforts in either direction—toward identification with one’s birth sex and with cross-gender identification, so legislation here seems to be ahead of the research and also to conflate different phenomena.
FT: Why are many turning on previous approaches to these questions?
There are many reasons. As our culture has changed dramatically over the past forty years there has arisen a new lens through which more people now see this topic and LGBT people. I call that a diversity lens or framework. When seen through that lens, which is essentially a framework that emphasizes LGBT identity and community as a people group, any effort to intervene to change is experienced by many members of that group as quite offensive. Following the analogy of race, it is sometimes likened to providing skin bleaching to an African American who is unhappy with his or her racial identity. I think this analogy is an emotionally compelling image but it oversimplifies a complex topic. Nonetheless, it is an image that is in keeping with a diversity lens with its emphasis on identity and community that resonates with many people today. So on the one hand you have a prominent lens that celebrates being LGBT and being part of a broader community of LGBT persons. You can imagine that when others, particularly conservative Christians, look at these concerns through a different lens, perhaps a theological lens of gender complementarity from creation that informs both sexual ethics and gender identity, these groups can quickly speak past one another.
I also want to be clear that you can hold this theological position as a conservative Christian and also express concern about sexual orientation change efforts. I am seeing more of that for additional reasons. One is the recent decision to close Exodus International, the flagship ministry in this area. That was a controversial decision, to be sure, and it has taken the wind out of the sails for some people who otherwise assumed that an emphasis on healing and heterosexuality was the default way to minister to people. You also see more visible stories of ex-ex-gays or people who claimed at one time to be ex-gay but now recant. Even among conservative Christians who are committed to a life of celibacy, you hear stories of attempted change. Some of the people I have met who are celibate and gay may have benefited from religiously affiliated support groups primarily because of the opportunity to be honest and to receive support as they were navigating sexual identity questions or concerns, but they, too, often say that the promise of change or healing was overstated and that the emphasis on achieving heterosexuality was unhelpful to them psychologically and spiritually. So I suspect all of these factors and perhaps many more are a part of what you might call a diminishing ex-gay narrative today.
When we turn to the question of gender dysphoria, it is unclear to me that people are turning against efforts to help children align their gender identity with their biological sex. I don't think most people have given it much thought, to be honest with you. Gender dysphoria is much less common than experiences of same-sex attraction or orientation, and my experience is that most people do not know much about it, nor are they familiar with the different approaches to intervention or the controversies surrounding them.
FT: Have people who have undergone these therapies been speaking up for them?
I think some have been organizing and contributing to amicus briefs for some of the legal cases that are pending. I know of others who would say they have benefited from sexual orientation change efforts, whether those were professional therapies or religiously affiliated ministries. I think that while it is uncommon to experience dramatic change, some have spoken of meaningful shifts along a continuum of attraction. Others have discussed changes in behavior and identity. Why don’t they speak up? I’m not sure how many there are, but some who I know want to live quiet lives and are simply not interested in the kind of scrutiny or criticism they know they would receive if they did speak up.
FT: What is the role of government in regulating these sorts of therapeutic relationships?
It is an unusual occurrence. I can think of only a few times when laws have been passed regarding specific therapies. For example, there was a case years ago in which a child was tragically killed in the course of an unusual rebirthing intervention for attachment disorder. That clinician was prosecuted, I believe, and subsequently there was legislation introduced in that state around such interventions.
Again, as we consider gender dysphoria along with sexual identity concerns, we have to recognize that these are two different concerns with different pathways for possible therapy. Sexual identity concerns and gender identity concerns are not the same thing. To put them together into legislation reflects the very limitations in having government attempt to regulate the complexities of clinical practice; they are not the same concerns, nor are the therapies offered the same. Even the issues that make such therapies controversial vary considerably.
I think the government's role involves supporting the regulatory bodies that oversee licensed mental health professionals in a given jurisdiction. Those regulatory boards are concerned with protecting the public, among other things, while balancing that concern against the right to self-determination. These issues become more complex when minors are involved and for good reason. However, most of the trends today are toward increasing the rights of minors to various services in the areas of health care. I think the trends in the care of gender dysphoric children are actually a case in point. One of the trends today is to intervene at about age eleven or twelve to delay puberty by introducing hormone blockers, so that a decision can be made by that child in three or four years about gender identity without having gone through puberty. That is an intervention that puts more decision-making in the hands of a minor and that child's parents, whereas steps to legislate around these other therapies, as well as other options for resolving gender dysphoria, appear to some to limit what is available to a minor or to a family. Again, these are two different phenomena, so it is complicated. Another direction worth considering is developing more of an expanded informed consent that helps all involved make the most informed decision possible based on what we know and what we do not know. I know that there would be considerable debate about what to include in an expanded informed consent form, but such a step would seem more consistent across these concerns and more in keeping with other trends in health care services to minors.
Mark A. Yarhouse is professor of psychology and the Hughes Endowed Chair at Regent University, where he directs the Institute for the Study of Sexual Identity. He is the co-author (with Stanton L. Jones) of Ex-Gays? A Longitudinal Study of Religiously-Mediated Change in Sexual Orientation and author of the forthcoming book, Understanding Gender Dysphoria: Navigating Transgender Issues in a Changing Culture.