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Posts for May, 2012

Researcher Predicts Rising Unemployment Among Ex-Gay Therapists

Jim Burroway

May 25th, 2012

Dr Brian Mustanksi is the director of the IMPACT LGBT Health and Development Program. He has also published several research papers on sexual development and mental health issues of LGBT populations. Today, Dr. Mustanski published a blog post at Psychology Today which gives a run-down on recent events — Dr. Robert Spitzer’s apology, the Pan American Health Organization resolution, the California proposal to regulate ex-gay therapy among licensed therapists — and concludes that “job prospects are not looking good” if you’re an ex-gay therapist. While times may be getting tough for licensed ex-gay therapists, Dr. Mustanski says that California’s so-called “ban” will not eliminate the ex-gay programs altogether:

While I mentioned in a previous blog that a bill was introduced in the California legislature to outlaw so called “conversion therapy,” I suspect in the U.S. that public policies will have a hard time eliminating the practice in places where it is entrenched. That’s because anyone in the U.S. can call themself a “psychotherapist,” “therapist,” or “counselor” because these are not legally regulated terms (however, calling yourself a psychologist or psychiatrist would be illegal if you don’t have the proper credentials and license). Unfortunately, consumers don’t always know the credentials of their therapist, and I suspect most of the “conversion therapy” practitioners are not licensed psychologists, psychiatrists, or other licensed mental health professionals. If you don’t have a license, you can’t have it taken away.

This goes along with what I noted earlier concerning the limitations of the proposed legislation. A significant chunk of ex-gay counseling is provided by religious ministries rather than professional licensed therapists.

Why I oppose the ‘Don’t Say Ex-Gay’ bill

A Commentary

Timothy Kincaid

April 26th, 2012

As has been discussed on other threads, the California State Legislature is proposing a bill that will prohibit licensed mental health professionals from offering therapy to minors with the goal of diminishing same-sex attraction or encouraging opposite-sex attraction. Many in our community, including other Box Turtle Bulletin authors, see this as at least a partially positive action. I see it a horrific.

There are many reasons, some philosophical – some pragmatic, why I oppose this bill. Here are a few:

It isn’t needed

No mental health organization has called for this action. But that is not because of ignorance about the issue or a lack of willingness to address it.

In August 2009 the American Psychological Association Task Force Task Force on Appropriate Therapeutic Response to Sexual Orientation issued it’s report. The conclusion was

The American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation conducted a systematic review of the peer-reviewed journal literature on sexual orientation change efforts (SOCE) and concluded that efforts to change sexual orientation are unlikely to be successful and involve some risk of harm, contrary to the claims of SOCE practitioners and advocates. Even though the research and clinical literature demonstrate that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality, regardless of sexual orientation identity, the task force concluded that the population that undergoes SOCE tends to have strongly conservative religious views that lead them to seek to change their sexual orientation. Thus, the appropriate application of affirmative therapeutic interventions for those who seek SOCE involves therapist acceptance, support, and understanding of clients and the facilitation of clients’ active coping, social support, and identity exploration and development, without imposing a specific sexual orientation identity outcome.

However, the findings seem to stop short of banning change therapy. And this is an important distinction.

The Task Force also found

The conflict between psychology and traditional faiths may have its roots in different philosophical viewpoints. Some religions give priority to telic congruence (i.e., living consistently within one’s valuative goals) (W. Hathaway, personal communication, June 30, 2008; cf. Richards & Bergin, 2005). Some authors propose that for adherents of these religions, religious perspectives and values should be integrated into the goals of psychotherapy (Richards & Bergin, 2005; Throckmorton & Yarhouse, 2006). Affirmative and multicultural models of LGB psychology give priority to organismic congruence (i.e., living with a sense of wholeness in one’s experiential self (W. Hathaway, personal communication, June 30, 2008; cf. Gonsiorek, 2004; Malyon, 1982). This perspective gives priority to the unfolding of developmental processes, including self-awareness and personal identity.

This difference in worldviews can impact psychotherapy. For instance, individuals who have strong religious beliefs can experience tensions and conflicts between their ideal self and beliefs and their sexual and affectional needs and desires (Beckstead & Morrow, 2004; D. F. Morrow, 2003). The different worldviews would approach psychotherapy for these individuals from dissimilar perspectives: The telic strategy would prioritize values (Rosik, 2003; Yarhouse & Burkett, 2002), whereas the organismic approach would give priority to the development of self-awareness and identity (Beckstead & Israel, 2007; Gonsiorek, 2004; Haldeman, 2004). It is important to note that the organismic worldview can be congruent with and respectful of religion (Beckstead & Israel, 2007; Glassgold, 2008; Gonsiorek, 2004; Haldeman, 2004; Mark, 2008), and the telic worldview can be aware of sexual stigma and respectful of sexual orientation (Throckmorton & Yarhouse, 2006; Tan, 2008; Yarhouse, 2008). Understanding this philosophical difference may improve the dialogue between these two perspectives represented in the literature, as it refocuses the debate not on one group’s perceived rejection of homosexuals or the other group’s perceived minimization of religious viewpoints but on philosophical differences that extend beyond this particular subject matter. However, some of the differences between these philosophical assumptions may be difficult to bridge.

In a nutshell, that says that different people with different worldviews benefit from different types of therapy. Not exactly a shocking revelation.

The APA is taking a measured and cautious approach designed to address the needs of patients. They are looking to efficacy, but not only to results. They are also considering the side effects – positive and negative – of such therapy. And they are seeking ways to improve communication between differing people so as to maximize mental health consequences.

Which, of course, is of no concern to the California State Legislature. Their agenda is political, not therapeutic.

This removes all therapy for some individuals

Our community tends to focus on the potential harm of change therapy. And there is potential harm. But we are reluctant to admit that some people benefit from this therapy.

No, they don’t change their orientation. But we have heard many people share with us that through their therapy with a change therapist they were able to deal with other issues: finding their own worth, identifying their values, determining what matters, and overcoming messages of condemnation and rejection.

Change therapy has much to be criticized about. But change therapists do attempt to dispel some of the erroneous messages that their patients have heard, including “God hates you” and “you are an abomination” and “you choose to be this way”.

Some may argue that the bad outweighs the good. And in some instances that may be true. But the truth that many forget is that this is the only option for some gay Christian youth. They are not going to have access to an affirmative counselor. They are not going to want access to an affirmative counselor.

And any suggestion on our part that they seek an affirmative therapist is flippant, at best.

This is an extension of a micromanagement ‘government knows best’ approach

Were this coming from a psychiatrist turned state senator, I might see it as a matter of advancing and protecting the interests of the profession. But Senator Ted Lieu is not known for his desire to administer solutions to problems. Rather, it might be best to describe Senator Lieu as a man who is quite convinced that he knows what is best for you and is more than ready to force you to do it. He shares more than a little instinct with Dr. James Dobson – just from the opposite side.

Lieu lists his 2011 Legislative Accomplishments. They consist of a bill to establish committees to decide what job Californians should have, a bill “requiring all pets to be microchipped with the owner’s contact information”, a bill “prohibiting children under the age of 18 from using ultra violet tanning beds”, a bill designed to require out of state employers whose work force is predominantly out of state to provide domestic partner benefits to any employee within the state, a bill which eliminates the right of employers to collect costs or expenses resulting from an illegal strike, a bill which sought to “impose time and place restriction for funeral protests”, and a bill which “prohibits the practice of selling puppies and kittens in parking lots and sidewalks”.

Whether one thinks that these are all good things or all bad things, it’s pretty clear that Lieu has a consistent approach to individual rights: restrict them.

The motivations behind it are less than honorable

In the State of California, there are no more bills that can be passed to put gay people on an equal standing. They have passed them all. The only remaining hurdle is marriage and that is out of the hands of the legislature.

But certain elected officials, and certain gay advocacy groups desperately need for there to be conflict. They regularly send “call your assemblyman, send us money” emails so as to make sure that some unnecessary bill isn’t Defeated by the Right Wing which Wants to Take Away Your Freedom, before it passes overwhelmingly along a party line vote.

This is political cynicism. It is barely even masquerading as anything else. And we are fools if we let ourselves be so easily manipulated.

I was ambivalent about Harvey Milk Day. There’s no need for such a day. There’s no purpose for such a day. But it didn’t harm anyone and wasn’t an expensive waste so I really didn’t much care.

I was troubled about legislation which would require teaching about the contributions to early California history by gay, lesbian, bisexual and transgender people (which would involve some pretty creative revisionist storytelling) while banning anything whatsoever that might “negatively reflect” on gay, lesbian, bisexual and transgender people. This was a purely undisguised propaganda bill related in spirit to St. Petersburg’s bill to ban “homosexual propaganda”. Both are attempts to push a point of view while silencing any differing views. You may recall that I didn’t rejoice over that piece of Big Brother heavy-handedness.

This is the next logical step.

Having banned divergent views in the classroom, the legislature now is entering the private sphere to dictate what can and cannot be said.

Before we get all giddy that our views are winning and their views are banned, let’s ask ourselves what it is that we believe.

I hear so very much about “the h8ters”. But is it hate that we oppose, or just the target? If it is hate, then why do those who complain about them the most do so in terms or bald unvarnished hatred?

I hear that it is awful that Tennessee legislators want to ban support for gay kids in school. Is it the refusal to support that is bad, or is it only the target? Because if it is the refusal to support, why are we not upset about conservative kids who will not no longer be allowed to seek therapy that they find supportive?

Before we go down the “I’m right, so what I do is right” road, let’s recall that history and politics are a pendulum. It is swinging in our direction at the moment. But let our behavior and our responses be such that when it reverses, the structures and principles we set in place will ensure that we are not harmed.

Because the laws we pass today to punish, inhibit, and deny rights to those whom we feel are wrong or bad or inferior will give birth to the laws that will be used against us in the future.

Three Things You Should Consider About CA’s Proposed Ex-Gay Therapy Curbs

A commentary.

Jim Burroway

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.

California Senate Proposes Limits On Ex-Gay Therapy

Jim Burroway

April 24th, 2012

California state Sen. Ted Lieu (D) has introduced legislation in the California Senate that would prohibit performing ex-gay thearpy on children under the age of 18. The full text of SB 1172, which was approved with changes by a Senate Subcommittee yesterday, can be found here. It  would also prohibit providing ex-gay therapy to anyone without written informed consent, specifies that the informed consent form must have the following statement:

“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.”

The bill would also specify that “Any act of duress or coercion by any person or facility shall invalidate the patient’s consent to sexual orientation change efforts.” Failure to adhere to these provisions would leave practitioners open to minimum fines of $5,000. It does not, however, ban ex-gay therapy outright. Nevertheless, NARTH is upset over the proposal. While NARTH tries to position itself as a secular, scientific organization, their first fundraising appeal attacking SB 1172 calls the proposal “a not so subtle attack on religious liberty.” NARTH’s more complete objections to SB 1172 can be found here.

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