An Ethical Analysis of Conversion Therapy
by Darren McDonald
To attempt futile treatment is to display ignorance that is allied to madness – Plato
Anne Paulk, of the Restored Hope Network (a network advocating for ex-gay conversion therapists and ministries), is proposing that the systematic shaming and spiritual abuse of clients that conversion therapy offers is acceptable as a talk therapy because it might influence the unsettled sexual orientation of young adults. In the process she ignores that the very research project she cites about the fluidity of sexual orientation found no meaningful difference between people who identified as 100% heterosexual and 100% homosexual in how those orientations stay the same over time. Likewise, she ignores decades of research findings that confirm Alan Chambers’ claim that reparative therapy does not succeed in changing sexual orientation.
The guiding principle in therapy that clinicians should strive to “above all do no harm” (the principle of non-maleficence) poses serious ethical challenges for those who would seek to offer, or refer others for, conversion therapy. The American Psychiatric Association, in a 2000 position statement on conversion therapy warned that conversion therapies pose “great risk…including depression, anxiety, and self-destructive behavior.” A 2009 report by a task force convened by the American Psychological Association to offer a position on “Appropriate Therapeutic Responses to Sexual Orientation” found that sexual orientation change efforts were connected with reports of increased “confusion, depression, guilt, helplessness, hopelessness, shame, social withdrawal, suicidality, substance abuse, stress, disappointment, self-blame, decreased self-esteem and authenticity to others, increased self-hatred, hostility and blame toward parents, feelings of anger and betrayal, loss of friends and potential romantic partners, problems in sexual and emotional intimacy, sexual dysfunction, high-risk sexual behaviors, a feeling of being dehumanized and untrue to self, a loss of faith, and a sense of having wasted time and resources.”
In order to ethically justify these risks, advocates of conversion therapy would need to point to significant therapeutic gains that one could expect to outweigh those risks. Given that there is no objective clinical evidence showing that conversion therapy is effective at changing sexual orientation, the principle of beneficence does not appear to override the therapist’s duty to protect the client from harm. At the very least, potential clients should be informed of these risks, and the limited efficacy and benefits of therapy. Rather than ethically demonstrating transparency, however, advocates of conversion therapy seek to minimize and argue against these potential risks.
The ethical principle of justice, as it applies to counseling and therapy, points to the right of all clients to expect equitable quality of treatment that is not limited by their personal characteristics. For therapy to be just, clinicians need to limit the impact of their personal biases upon the treatment of clients. For treatment to be of equitable quality, clinicians need to be competent in working with a particular population. Even if we ignore conversion therapy’s disregard for cultural competency guidelines that have been developed for working with sexual minorities, we cannot ignore how the treatment of sexual minorities is governed by the biases of conversion therapists without collaboration with the people group they are trying to serve. Likewise, the lack of manualized treatment, standardized training, submission to peer scrutiny, and rigorous outcome trials indicate that conversion therapy is underdeveloped as a therapeutic approach. The ongoing failure of conversion therapists to inform clients that their approach to therapy has no demonstrated efficacy, poses potential risk for harm, and is a developing and as yet untested theory based approach to therapy severely limits any claims conversion therapists can make to practicing competently.
Conversion therapists and their advocates also fail to abide by the ethical principles of fidelity, responsibility, and integrity. They refuse to report findings that strongly challenge the efficacy of the treatment they offer. They do not participate in the broader community of mental health providers by subjecting their treatment to objective clinical trials. Worse, they capitalize upon the public’s confusion by closely imitating the brand identity of professional organizations (compare the American Academy of Pediatrics to the ex-gay advocacy group the American College of Pediatricians) in order to spread misinformation about public health while purporting to represent serious medical authorities.
Proponents of conversion therapy will likely argue that the ethical principal of autonomy counters these critiques. This claim is highly questionable for several reasons. First and foremost, client autonomy requires informed consent. The assiduous efforts of conversion therapists and their advocates to deny, minimize, hide, and obscure the limited efficacy and potential risks of conversion therapy makes true client autonomy impossible. Second, the client’s right to autonomy is held in dialectical tension with the therapist’s responsibility to limit client harm and promote client welfare. Third, outside factors (parental influence, the threat of discipline from school or church, and an anti-LGBTQ cultural context) can all impinge upon the freedom of clients to choose conversion therapy of their own free will. Many of the schools whose LGBTQ students are served by Safety Net deny students the right to autonomy in making informed decisions about their professional mental health care, as students are threatened with discipline (and sometimes even expulsion) if they refuse to attend conversion therapy. Likewise, children who are forced into conversion therapy by their parents are pushed into a risky form of treatment without the right to consent on their own and without their parents receiving appropriate warnings about the risks and limits of conversion therapy in order to be able to offer truly informed consent on their behalf.
Sexual orientation conversion therapy offers little benefit and poses substantial risk for students. Safety Net urges Christian College and University administrators to consider whether they can afford the risk of referring students to an ethically questionable movement that has drawn criticism from the American Psychiatric Association, the American Psychological Association, the American Counseling Association, the American Association of Marriage and Family Therapists, and the National Association for Social Workers. Consequently, professional organizations for Christian counselors including the British Association for Christian Counsellors and the American Association for Christian Counselors have stopped encouraging the use of conversion therapy, with the British organization going a step further and asking its counselors to cease the practice of conversion therapy, and the advertising of that practice, out of concern for public safety. Even if one agrees with the goals of reparative therapy, we would argue that current approaches to reaching those ends currently fail to meet basic ethical standards for therapeutic treatment related to transparency, accountability, peer scrutiny, and informed consent. If our schools insist on referring students for conversion therapy, we urge them to consider that ethical practice, and the student’s right to autonomy, are best served through providing students with informed consent regarding the limited efficacy, lack of scientific rigor and accountability, and potential risks involved in conversion therapy.