April 25th, 2012
There has been a lot of very brief reporting on a proposed California law to curb ex-gay therapy. Two things stood out for just about everyone who picked it up: 1) the law would ban ex-gay therapy for those who are under the age of 18, and 2) the law would require that two specific paragraphs be a part of the informed consent form that the patient would have to sign before therapy can begin. That’s a very brief summary of a 1200-word bill, so as you can expect, there are a lot of details being glossed over (that includes our initial report on the proposed law).
1: The Proposed Law Does Not Ban All Ex-Gay Therapy For Those Under 18.
There are a set of definitions that are critical to understanding what this law would do. Under Article 15, we read:
(b) “Psychotherapist” means a physician and surgeon specializing in the practice of psychiatry, a psychologist, a psychological assistant, a psychiatric technician, a marriage and family therapist, a registered marriage and family therapist, intern, or trainee, an educational psychologist, a licensed clinical social worker, an associate clinical social worker, a licensed professional clinical counselor, or a registered clinical counselor, intern, or trainee.
Pay attention to what is not included in this list: pastors, ministers and lay counselors. What this list conveys is that those who are licensed or registered, or who are in training to become licensed or registered, would be subjected to the proposed law. In other words, California would be acting under its licensing and registration authority, and that authority does not extend to the religious sphere. Nor can it under the U.S. Constitution’s First Amendment.
The next two important definitions build on the one above:
(c) “Psychotherapy” means the professional assessment, evaluation, treatment, or counseling of a mental or emotional illness, symptom, or condition by a psychotherapist.
(d) “Sexual orientation change efforts” means psychotherapy aimed at altering the sexual or romantic desires, attractions, or conduct of a person toward people of the same sex so that the desire, attraction, or conduct is eliminated or reduced or might instead be directed toward people of a different sex. It does not include psychotherapy aimed at altering sexual desires, attractions, or conduct toward minors or relatives or regarding sexual activity with another person without that person’s consent. [Emphases mine.]
Having defined “Psychotherapist” in (b), and having restricted “Psychotherapy” to being a practice done according to the person defined as a “Psychotherapist” in (c), and having restricted the definition of “sexual orientation change efforts” according to the definition of “Psychotherapy” in (d), the proposed law narrowly restricts the laws effects to licensed and registered members of the medical and mental health professions.
And so when we get to the ban that everyone’s talking about:
865.2. (a) Under no circumstances shall a patient under 18 years of age undergo sexual orientation change efforts, regardless of the willingness of a patient’s parent, guardian, conservator, or other person to authorize such efforts.
(b) The right to refuse sexual orientation change efforts is not waived by giving informed consent and that consent may be withdrawn at any time prior to, during, or between sessions of sexual orientation change efforts.
(c) Any act of duress or coercion by any person or facility shall invalidate the patient’s consent to sexual orientation change efforts. [Emphasis mine.]
What we see is the consistent use of the phrase “sexual orientation change efforts” which was defined earlier to be very specific to “psychotherapy” offered by “psychotherapists,” each with their own specific definitions under this law.
This is critical, because it won’t prevent kids under 18 from being sent to, say, Exodus Board Member Don Schmierer’s His Way Out Ministries, or Living Stones Ministries or to dozens of other ex-gay ministries or churches. And the provisions covering duress or coercion won’t apply either, because they would apply only to those conditions set up in the definitions, and those definitions do not religious or church-based exgay ministries.
What the bill would do is pose a problem for any licensed professionals who work in those ministries. They would be confronted with a choice between giving up their work in those ministries or giving up their licenses. For those whose practice centers solely on ex-gay therapy, the choice will be an easy one: they will give up their licenses. But for those who depend on income from their practices in providing other forms of therapy, this could be a serious dilemma.
But more importantly, it really places the issue of religious freedom in much sharper focus. Already, the National Association of Research and Therapy of Homosexuality (NARTH) was quick out of the gate calling the prosed law “a not so subtle attack on religious liberty.” But it is no such thing. Quite the contrary. For those under 18 and their parents, if they want to enter a program that reinforces their religious beliefs, then they will rightly have the option of turning to a religious organization to do so. Which is as it should be. It is not the responsibility of the mental health establishment to enforce parents’ religious beliefs on those under 18.
2. The Proposed Law May Not Eliminate All Ex-Gay Therapy for Those Under 18 By Licensed Professionals.
This is trickier but equally important, and it goes to the very heart of the dishonesty of some of the ex-gay therapists who are licensed. Professional therapists already have a problem in billing insurance companies for their clients who are trying to change their sexual orientation: Insurance companies won’t foot the bill. There is no code in the Diagnostics and Statistical Manual (DSM) for homosexuality, and a code is always required in insurance forms in order to be compensated. So how do those therapists get paid?
Easy. As I’ve personally heard a number of ex-gay therapists explain it, their clients are invariably distressed, anxious, depressed, and so forth. And there;s a whole smorgasbord of codes for them to chose from. And I know of at least one therapist who admitted that he is very careful about what he writes in his clinical notes. That way, if an insurance company wanted to see the records, it would be very difficult to tell that he was providing sexual orientation change therapy.
In other words, ex-gay therapists have already figured out ways around disclosing the kind of therapy they’re doing. Those practices will only become more widespread. And given the sanctity of client-patient privilege, it is very nearly impossible to investigate what a therapist is doing unless the client blows the whistle.
But that does bring us to a potential timebomb for licensed professionals:
865.3. (a) (1) A cause of action may be brought against a psychotherapist by a patient, former patient, or deceased former patient’s parent, child, or sibling if the sexual orientation change efforts were conducted without first obtaining informed consent or by means of therapeutic deception, or if the sexual orientation change efforts were conducted on a patient who was under 18 years of age at any point during the use of the sexual orientation change efforts.
(2) The patient, former patient, or deceased former patient’s parent, child, or sibling may recover actual damages, or statutory damages in the amount of five thousand dollars ($5,000), whichever is greater, in addition to costs and reasonable attorney’s fees.
(3) The time for commencement of the action shall be within eight years of the date the patient or former patient attains the age of majority or within five years of the date the patient, former patient, or deceased former patient’s parent, child, or sibling discovers or reasonably should have discovered that the patient was subjected to sexual orientation change efforts in violation of this article.
(b) Nothing in this article precludes or limits the right of a patient, former patient, or deceased former patient’s parent, child, or sibling to bring a civil action against a psychotherapist arising from other legal claims.
If a therapist does offer sexual orientation change therapy and the client reaches a point where he or she feels damaged by that therapy, the client can seek damages. But if the therapist’s notes and records were already written to obscure the fact that he was offering sexual orientation change therapy, then it would make the patients’ claims more difficult to press. On the other hand, merely defending himself against the charges would prove very costly for the therapist. All licensed therapists would have to carefully weigh that risk if this bill becomes law.
3. The Proposed Bill Inserts California Law Between the Client and Practitioner.
I raise this issue because it is one which should always be carefully considered whenever a bill like this comes along. There are times when I think health care would be much better if government butts out. Two examples are abortion and medical marijuana, which, in my view, have become far too politicized to the point where it’s virtually impossible to discuss the medical merits of those issues. We have right now legislatures mandating invasive and humiliating procedures before an abortion can be obtained under the guise of ensuring the woman’s “informed consent” — as if women had no idea what they were asking for. In my opinion, that’s where some state governments have gone way too far.
Government does play an important role in ensuring that the practice of medicine and psychotherapy (properly defined) is safe and, to a lesser extent, effective. But when government inserts itself between client and practitioner, it really needs to have a damn good reason to do so. It’s why we have FDA approval for drugs, and it is why doctors in my old hometown of Portsmouth, Ohio, are being rounded up for indiscriminately prescribing Oxycontin (a.k.a. “hillbilly heroin”) to all comers. Those are just two examples where government intrudes into the client-practitioner relationship, and I think we can agree that they are good ones. Medicine (and psychotherapy) is not without risks in the hands of the unscrupulous, unethical, unskilled, or the zealot.
So for me personally, I have no problems with banning ex-gay therapy for those under 18. Parents who have religious reasons for seeking ex-gay therapy for their children will still have plenty of options, and given the actual state of ex-gay therapy there is no reason to believe that those options would be any better or worse than those provided by so-called “experts.” And with regard to ex-gay therapy, informed consent has been a particularly troublesome area all along, which is the second major area this law proposes to address. But I do have one quibble with the legislation. It mandates that the following two paragraphs be included in the informed consent form for the prospective patient to read and sign:
“Having a lesbian, gay, or bisexual sexual orientation is not a mental disorder. There is no scientific evidence that any types of therapies are effective in changing a person’s sexual orientation. Sexual orientation change efforts can be harmful. The risks include, but are not limited to, depression, anxiety, and self-destructive behavior.
Medical and mental health associations that oppose the use of sexual orientation change efforts include the American Medical Association, the American Psychological Association, the American Psychiatric Association, the National Association of Social Workers, the American Counseling Association, the American Academy of Pediatrics, and the American Association for Marriage and Family Therapy.”
To be absolutely precise, those statements aren’t the medical establishment’s opinion on sexual orientation change efforts. Strictly speaking, they represent the California legislature’s interpretationof the medical establishment’s opinion. I think it happens to be a very accurate interpretation today, but it may not be accurate tomorrow. And the problem with California law — and any law — is that it has a way becoming indelibly written far past its prime. Remember, a 1955 law requiring California to conduct research on curing homosexuality wasn’t repealed until 2010. While I doubt that the science will change much, having this statement engraved in law may be good law for 2012, but it’s never good medical practice to have anything set in stone. It would be far better if the legislation directed the state health department to either compose the paragraph, or give it authority to revise it as conditions warrant.
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