Conversion therapy

The term homosexual was coined by German-speaking Hungarian writer Karl Maria Kertbeny and was in circulation by the 1880s.[12][4] Into the middle of the twentieth century, competing views of homosexuality were advanced by psychoanalysis versus academic sexology. Sigmund Freud, the founder of psychoanalysis, viewed homosexuality as a form of arrested development. Later psychoanalysts followed Sandor Rado, who argued that homosexuality was a "phobic avoidance of heterosexuality caused by inadequate early parenting".[4] This line of thinking was popular in psychiatric models of homosexuality based on the prison population or homosexuals seeking treatment. In contrast, sexology researchers such as Alfred Kinsey argued that homosexuality was a normal variation in human development. In 1970, gay activists confronted the American Psychiatric Association, persuading the association to reconsider whether homosexuality should be listed as a disorder. The APA delisted homosexuality in 1973, which contributed to shifts in public opinion on homosexuality.[4]

Despite their lack of scientific backing, some socially or religiously conservative activists continued to argue that if one person's sexuality could be changed, homosexuality was not a fixed class such as race. Borrowing from discredited psychoanalytic ideas about the cause of homosexuality, some of these individuals offered conversion therapy.[4] In 2001, conversion therapy attracted attention when Robert L. Spitzer published a non-peer-reviewed study asserting that some homosexuals could change their sexual orientation. Many researchers made methodological criticisms of the study, which Spitzer later repudiated.[4]

Gender Identity Change Efforts (GICE) refer to practices of healthcare providers and religious counselors with the goal of attempting to alter a person's gender identity or expression to conform to social norms. Examples include aversion therapy, cognitive restructuring, and psychoanalytic and talk therapies.[13] Western medical-model narratives have historically institutionalized transphobia: systemically favoring a binary gender model and pathologizing gender diversity and non-conformity.[14] This aided the development and proliferation of GICE.[15]

Early interventions were rooted in psychoanalytic hypotheses.[16] Robert Stoller advanced the theory that gender-nonconforming behavior and expression in children assigned male at birth (AMAB) was caused by being overly close to their mother. Richard Green continued his research; his methods for altering behavior included having the father spend more time with the child and mother less, expecting both to exhibit stereotypical gender roles, and having them praise their child's masculine behaviors, and shame their feminine and gender-nonconforming ones. These interventions resulted in depression in the children and feelings of betrayal from parents that the treatments failed.[16]

In the 1970s, UCLA psychologist Richard Green recruited Ole Ivar Lovaas to adapt the techniques of ABA therapy to attempt to prevent children from becoming transsexuals.[17] Deemed the "Feminine Boy Project", the treatments used operant conditioning to reward gender-conforming behaviors, and punish gender non-conforming behaviors.[17] They recruited George Rekers as a behavioral therapist for the project.[17] The project published several studies focusing on one subject and claiming that the child had been "cured" after 60 treatment sessions.[17][18][19][20][21] However, decades later at the age of 38, the subject died of suicide, with the family blaming psychological trauma from the program.[22][23]

Kenneth Zucker at CAMH adopted Richard Green's methods, but narrowed the scope to attempting to prevent the child from identifying as transgender. His model used the same interventions as Green with the addition of psychodynamic therapy.[16] In January 2015, members of Rainbow Health Ontario, a provincial health promotion and navigation organization, approached CAMH expressing their concerns regarding Zucker's clinic.[24] Rainbow Health Ontario submitted a review of academic literature and clinical practices for transgender youth, and expressed concern that the gender identity clinic was not following accepted practices.[25] Others linked the Gender Identity Clinic's practices to suicide of transgender youth caused by conversion therapy, and referenced the high-profile case of Leelah Alcorn, a transgender teen from Ohio.[24] In November 2015, an external review of the clinic was published.[26] The review noted numerous strengths of the clinic, but also described it as an insular entity with an approach dissimilar from other clinics and described it as being out of step with current best practices, including WPATH SOC Version 7.[26] After the review, CAMH shut down the clinic and fired Zucker. Kwame McKenzie, medical director of CAMH's child, youth, and family services, said "We want to apologize for the fact that not all of the practices in our childhood gender identity clinic are in step with the latest thinking" and that Zucker is, "no longer at CAMH."[27]

Some clinicians have begun using "gender exploratory therapy" as an alternative to gender-affirming approaches for youth with gender dysphoria.[28] Gender exploratory therapy uses talk therapy in an attempt to find pathological roots for gender dysphoria.[28] In a September 2022 review of gender exploratory therapy, bioethicist Florence Ashley found strong similarities to "conversion practices".[28]

Aversion therapy used on homosexuals included electric shock and nausea-inducing drugs during presentation of same-sex erotic images. Cessation of the aversive stimuli was typically accompanied by the presentation of opposite-sex erotic images, with the objective of strengthening heterosexual feelings.[32] Another method used was the covert sensitization method, which involves instructing patients to imagine vomiting or receiving electric shocks, writing that only single case studies have been conducted, and that their results cannot be generalized. Haldeman writes that behavioral conditioning studies tend to decrease homosexual feelings, but do not increase heterosexual feelings, citing Rangaswami's "Difficulties in arousing and increasing heterosexual responsiveness in a homosexual: A case report", published in 1982, as typical in this respect.[33]

Aversion therapy was developed in Czechoslovakia between 1950 and 1962 and in the British Commonwealth from 1961 into the mid-1970s. In the context of the Cold War, Western psychologists ignored the poor results of their Czechoslovak counterparts, who had concluded that aversion therapy was not effective by 1961 and recommended decriminalization of homosexuality instead.[34] Some men in the United Kingdom were offered the choice between prison and undergoing aversion therapy. It was also offered to a few British women, but was never the standard treatment for either homosexual men or women.[35]

In the 1970s, behaviorist Hans Eysenck was one of the main advocates of counterconditioning with malaise-inducing drugs and electric shock for homosexuals. He wrote that this type of therapy was successful in nearly 50% of cases. However, his studies were disputed.[36] Behavior therapists, including Eysenck, used aversive methods. This led to a protest against Eysenck by gay activist Peter Tatchell in a London Medical Group Symposium in 1972. Tatchell said that the therapy promoted by Eysenck was a form of torture.[36] Tatchell denounced Eysenck's form of behavioral therapy as inducing depression and suicide among gay men who were subjected to it.[37]

In the 1940s and 1950s, U.S. neurologist Walter Freeman popularized the ice-pick lobotomy as a treatment for homosexuality. He personally performed as many as 3,439[38] lobotomy surgeries in 23 states, of which 2,500 used his ice-pick procedure,[39] despite the fact that he had no formal surgical training.[40]

In West Germany, a type of brain surgery usually involving destruction of the ventromedial nucleus of the hypothalamus was done to some homosexual men. The practice was criticized by sexologist Volkmar Sigusch.[41]^: 526

Friedrich-Paul von Groszheim (1908–2006) was spared from a concentration camp after agreeing to castration under pressure in 1938.

In early twentieth century Germany experiments were carried out in which homosexual men were subjected to unilateral orchiectomy and testicles of heterosexual men were transplanted. These operations were a complete failure.[42]

Surgical castration of homosexual men was widespread in Europe in the first half of the twentieth century and was also practiced in the United States.[43] SS leader Heinrich Himmler ordered homosexual men to be sent to concentration camps because he did not consider a time-limited prison sentence was sufficient to eliminate homosexuality.[44] Although theoretically voluntary, some homosexuals were subject to severe pressure and coercion to agree to castration. There was no age limit; some boys as young as 16 were castrated. Those who agreed to castration after a Paragraph 175 conviction were exempted from being transferred to a concentration camp after completing their legal sentence.[45] Some concentration camp prisoners were also subjected to castration.[46] An estimated 400 to 800 men were castrated.[47]

Endocrinologist Carl Vaernet attempted to change homosexual concentration camp prisoners' sexual orientations by implanting a pellet that released testosterone. Most of the victims, non-consenting prisoners at Buchenwald, died shortly thereafter.[48][49]

An unknown number of men were castrated in West Germany and chemical castration was used in other Western countries, notably against Alan Turing in the United Kingdom.[50]

OneByOne booth at a Love Won Out conference

Some sources describe ex-gay and ex-trans ministries as a form of conversion therapy, while others state that ex-gay organizations and conversion therapy are distinct methods of attempting to convert gay people to heterosexuality.[51][52][53][54] The umbrella organization Exodus International in the United States ceased activities in June 2013, and the three member board issued a statement which repudiated its aims and apologized for the harm their pursuit has caused to LGBT people.[55] Ex-gay/ex-trans organizations often overlap and portray being trans as inherently sinful or against God's design, or pathologize gender variance as due to trauma, social contagion, or "gender ideology."[56][57]

Hypnosis was used in conversion therapy since the 19th century by Richard von Krafft-Ebing and Albert von Schrenck-Notzing. In 1967, Canadian psychiatrist Peter Roper published a case study of treating 15 homosexuals (some of which would probably be considered bisexuals by modern standards) with hypnosis. Allegedly, 8 showed "marked improvement" (they reportedly lost sexual attraction towards the same sex altogether), 4 mild improvements (decrease of "homosexual tendencies"), and 3 no improvement after hypnotic treatment; he concluded that "hypnosis may well produce more satisfactory results than those obtainable by other means", depending on the hypnotic susceptibility of the subjects.[58]

Haldeman writes that psychoanalytic treatment of homosexuality is exemplified by the work of Irving Bieber et al. in Homosexuality: A Psychoanalytic Study of Male Homosexuals. They advocated long-term therapy aimed at resolving the unconscious childhood conflicts that they considered responsible for homosexuality. Haldeman notes that Bieber's methodology has been criticized because it relied upon a clinical sample, the description of the outcomes was based upon subjective therapist impression, and follow-up data were poorly presented. Bieber reported a 27% success rate from long-term therapy, but only 18% of the patients in whom Bieber considered the treatment successful had been exclusively homosexual to begin with, while 50% had been bisexual. In Haldeman's view, this makes even Bieber's unimpressive claims of success misleading.[59]

Haldeman discusses other psychoanalytic studies of attempts to change homosexuality. Curran and Parr's "Homosexuality: An analysis of 100 male cases", published in 1957, reported no significant increase in heterosexual behavior. Mayerson and Lief's "Psychotherapy of homosexuals: A follow-up study of nineteen cases", published in 1965, reported that half of its 19 subjects were exclusively heterosexual in behavior four and a half years after treatment, but its outcomes were based on patient self-report and had no external validation. In Haldeman's view, those participants in the study who reported change were bisexual at the outset, and its authors wrongly interpreted capacity for heterosexual sex as change of sexual orientation.[60]

The term "reparative therapy" has been used as a synonym for conversion therapy generally, but according to Jack Drescher it properly refers to a specific kind of therapy associated with the psychologists Elizabeth Moberly and Joseph Nicolosi.[8] The term reparative refers to Nicolosi's postulate that same-sex attraction is a person's unconscious attempt to "self-repair" feelings of inferiority.[61][62]

Previous editions of the World Health Organization's ICD included "sexual relationship disorder", in which a person's sexual orientation or gender identity makes it difficult to form or maintain a relationship with a sexual partner. The belief that their sexual orientation has caused problems in their relationship may lead some people to turn to a marriage therapist for help to change their sexual orientation.[63] Sexual orientation disorder was removed from the most recent ICD, ICD-11, after the Working Group on Sexual Disorders and Sexual Health determined that its inclusion was unjustified.[64]

Gender exploratory therapy, or GET, is a form of conversion therapy in which the administrator attempts to delay transition (both medical and social) for as long as possible, often indefinitely. This is done in an effort to get the patient to desist altogether, and is undertaken using the pretext of taking an extended period of time to explore potential causes for the patient identifying as a different gender from their assigned sex at birth which are then used to deny access to treatment entirely, including mental health issues, trauma, sexual fetishism, internalized bigotry, and autism.[65][66][67] Gender exploratory therapy is often mandated or recommended for use on gender dysphoric patients in jurisdictions where access to gender-affirming healthcare is banned or heavily restricted.

In 2020 the International Rehabilitation Council for Torture Victims released an official statement that conversion therapy is torture.[79] The same year, UN Independent Expert on sexual orientation and gender identity, Victor Madrigal-Borloz, said that conversion therapy practices are "inherently discriminatory, that they are cruel, inhuman and degrading treatment, and that depending on the severity or physical or mental pain and suffering inflicted to the victim, they may amount to torture". He recommended that it should be banned across the world.[82] In 2021 Ilias Trispiotis and Craig Purshouse argue that conversion therapy violates the prohibition against degrading treatment under Article 3 of the European Convention on Human Rights, leading to a state obligation to prohibit it.[77][83] In February 2023 Commissioner for Human Rights, Dunja Mijatović, qualified those practices as “irreconcilable with several guarantees under the European Convention on Human Rights" and having no place in a human rights-based society urging the Member States of the Council of Europe to ban them for both adults and minors,[84] later in July 2023 she advocated for clear actions during a public hearing at the European Parliament studying different approaches to legally ban "conversion therapies" in the European Union.[85]