What is Conversion "Therapy"?
The lack of any clear professional or legal definition is causing harm to patients.
Introduction:
In the wake of the pending Chiles v. Salazar case going before the Supreme Court in the next year or so, the topic of conversion “therapy” has come up again and again in both media and professional circles. The history of the term “conversion therapy” is more than we need to delve into for the purposes of this Substack. It is sufficient to say that there has been a lack of any concrete, testable legal or professional definition of “conversion therapy”.
(I, bristle at the attachment of the two words in and of itself, which is why I put “therapy” in quotes when next to “conversion”. There is nothing about “conversion therapy” that is therapeutic in nature.)
This lack of clarity regarding what it means to apply conversion within the context of therapy has led to the endorsement of actual attempts to convert patients and repudiation of actual psychoanalysis by both major mental health organizations and legislatures across America. We have now reached a boiling point where individual therapists are at risk of losing their license for simply asking patients questions about sexuality, gender, religion, race, or any other identification marker a legislative system has decided to include within civil rights.
To be clear, these aren’t therapists seeking to convert their patients from one sexuality to another. There aren’t therapists even attempting to change their patient’s beliefs about gender. These are therapists simply exploring those topics with their patients. It seems, some state boards have determined that refusing to simply affirm a patient’s self ID as a part of a predetermined minority, protected, or marginalized group is enough to constitute conversion.
In transparency, sometimes exploration of a patient’s sense of self includes pointing out inconsistencies or incongruencies in the patient’s expressed beliefs, opinions, or actions.
For example, if a patient tells his therapist he is a devout traditional, Catholic who desires to live within traditional church doctrine and become an ordained priest within the Vatican and also wants to cut off his penis to appear more like a girl; it would be a negligent denial of the conflicts between church doctrine regarding God’s creation as well as boundaries regarding the priesthood and the desire to change biological sex, as is the argument of Ms. Chiles. The therapist has an obligation to explore with the patient the conflicts within the patient’s stated goals and beliefs. Failure to do so would result in the therapist colluding with the patient in pretending he can pursue priesthood within the Vatican while altering his God given biological sex and presenting as a female. Such gross negligence on behalf of the therapist would mean increasing the patient’s daily discomfort with his own conflicting goals and inability to obtain them.
The therapist has no need for the patient to identify as a man, women, priest, or anything else in particular. The therapist is not attempting to convert the patient to any particular identity. The therapist is simply exploring the conflicts that arise within the patient’s own statements. Now, further along in this essay, I will make the case that affirmation of gender incongruent with biological sex is more closely aligned with conversion than exploratory therapy. (*For a brief rebuttal of gender divorced from biological sex, look for the asterisk at the end of this essay.) For now, we need to get our definitions straight.
Terms:
Conversion is broadly and consistently defined as the process of changing or causing something to change from one form to another. Colloquially, we have used the term “convert” for centuries to describe a change in religious beliefs or political affiliations. There seems to be little debate regarding the definition of “conversion.” Conversion requires the ability to identify the change in form that has occurred.
Reconciling incongruent beliefs may mean changing one’s mind, opinion, or feeling about something. A reduction in symptoms of anxiety or distress may indicate a change in form, as in a new way of behaving is occurring due to a change of mind, opinion, or feeling. Do we really want to declare the reduction of mental health complications to be conversion therapy?
There is evidence that a reduction in symptoms of distress related to one’s biological sex if done via psychotherapy rather than affirmation is considered conversion therapy by some states. Colorado, for example, defines conversion therapy as, “efforts to change an individual's sexual orientation, including efforts to change behaviors or gender expressions or to eliminate or reduce sexual or romantic attraction or feelings toward individuals of the same sex.” That seems to suggest that efforts like psychotherapy that result in a reduction of behaviors such as a self-harm related to distress or anxiety due to incongruence between one’s declared gender and one’s body is illegal.
(One may also wonder what Colorado is implying regarding the attempt to reduce pedophilic thoughts or behaviors given their definition of sexual orientation. It is interesting to note Colorado specifically mentions feelings toward individuals of the same sex, but fails to protect feelings of individuals of the opposite sex.)
If there is a change in substance (physical form) or behavior (form of operating or being), there may be measurable change in form, a conversion. Is Colorado banning the reduction of efforts to reduce behaviors rooted in distress related to gender or sexuality?
Therapy is a bit harder to define than conversion. There are at least 8 well known theories of therapy with even more modalities and exponentially more interventions. The most basic and broad definition of therapy I could find (via Google) is “treatment intended to relieve or heal a disorder.” Historically, the main method of treatment has been talk therapy.
Talk therapy seems pretty straight forward. A trained mental health professional and patient talk until the patient discovers what they need in order to accomplish their goals. If it were as simple as that, licensed practitioners have been paying hundreds of thousands of dollars in education, licensing, and credentialing fees to do what your local bartender does on an average Friday night. (Props to the bartenders out there using active listening, motivational interviewing, and mild confrontation to keep your patrons on an even keel while you make them a mean Purple Haze that will knock them on their ass and render them incapable of coherent thought.)
In all sincerity, talk therapy is more psychoanalysis than armchair analysis. The formation of the therapeutic bond requires the therapist to believe in the inherent worth and dignity of every patient and remain centered, but not necessarily patient led. Patients will often avoid talking about things they tell their therapist are deeply important. Patients may not realize they are minimizing crucial details that would help them better understand themselves. They may not recognize they are magnifying inconsequential points in order to avoid the difficult task of using their own agency to set healthy boundaries. The therapist must be free to explore any and all, if necessary, of the patient’s areas of life in order to help the patient have a better understanding of themselves and how they can impact their own lives.
Until social justice took over the mental health profession when social work was declared synonymous with therapy, psychotherapy was free of any political ideology. That isn’t to say politics failed to impact patients or practitioners were never politically motivated. Of course, both of those things have always been the case and will always be the case. However, it is to say the profession as a whole was not aligned with any particular political ideology. If you really want to explore the history of how politics took hold of the mental health profession, I encourage you to begin by researching the history of the ties between political activists, lobbyists, and the American Psychological Association in the 1960s. Or look into the creation and evolution of the DSM-V. Both of those histories are far too expansive to cover here.
For our purposes here, I am reclaiming psychotherapy to be using whatever theories, modalities, and interventions are best suited to the patient in order to assist the patient in reaching their goals regarding mental health. The vehicle for the implementation of those theories, modalities, and interventions is speech. However, speech is not the act of therapy in and of itself. You could talk all day to or at patients for years and never do a second of therapy.
I would argue that the therapist’s version of a prescription pad is when speech becomes advice. If a therapist is telling a patient to act, the therapist is prescribing something that will impact the physical body of the patient. Therapists are trained to avoid giving advice as much as possible. It is much preferrable for the patient to develop their own ideas of ways they can change their own behaviors to impact their lives. That isn’t to say a therapist never gives advice. “Have you tried” and “what would it be like to” are two of the most common ways therapist move from active listening towards prescription. These phrases are still exploratory in nature as they are questions, not commands. However, they imply an alternative method of behavior. Making a suggestion to implement a new boundary or trying a new communication skill is part of therapy. It is also advice. Once that advice has occurred, a therapist is liable for that advice like a doctor is liable for the prescription medication they offer.
Even within the acknowledgement of the liability of prescription advice, I am cautious to give any government regulatory power over speech. We already have overall regulations of speech for all citizens including therapists, which can be found here. I would argue that laws like Tarasoff , which nearly every state has some version of found here, and Red Flad laws are forced speech. Like those laws which compelling a therapist to disclose patient information, laws demanding affirmation also compel a therapist’s speech.
This brings us to the danger of the legislative or judicial system declaring speech to be the act of therapy. To regulate a therapist’s speech as an intervention is to remove the individual and unique experience each patient requires because they are individual and unique and to prescribe scripts the therapist must or must not follow. A case could be made this is an intentional shift from human interaction to AI interaction within mental health. That is a topic for another Substack, but I do hope you can see the connections here. We already have some companies attempting to employ scripts for human and AI therapists based on the developer’s worldview. These scripts prescribe to the patient a right and wrong perspective of the world and themselves. That is the heart of conversion.
So, what is conversion therapy?
In my opinion, conversion in the context of therapy is the attempt to manipulate, coerce, or otherwise convince a patient they are something or someone they do not identify as, desire to be, or an identity opposed to measurable, testable, and provable biological reality because it is the practitioner's preference, which lacks just cause as necessary and sufficient to protect a patient's life. To be clear, the last part of this definition is extremely important in that some diagnoses require a therapist to work against patient preferences in order to protect the patient's life. This is pertinent to this conversation because of the gross misuse of threats of suicidal ideation to justify unnecessary medical intervention not at all proven to be sufficient or necessary to reduce suicidal ideation, such as puberty blockers or surgical removal of healthy body parts, in patients with dysphoria or dysmorphia. Let me break this definition down into elements that are necessary, sufficient, or both.
Necessary Elements for Conversion therapy:
Necessary elements for conversion include intent to change the patient's sense of self in the direction of something or someone they do not identify as, desire to be, or an identity opposed to measurable, testable, and provable biological reality because it is the practitioner's preference; use of either mental or physical manipulation to effect the therapist's desired change; and the application of some type of physical intervention, be it confinement manual labor, physical discipline, or alterations of the body via medical application.
While the intent to change the patient's sense of self in the direction of something or someone they do not identify as, desire to be, or an identity opposed to measurable, testable, and provable biological reality because it is the practitioner's preference is necessary for conversion, it is not sufficient because intent without action does not impact the patient. It is, perhaps, a thinking error, but not sufficient alone to cause change. Therapists have what the kids refer to as “inside thoughts” all the time during therapy sessions. The key is that the therapist in no way shares those thoughts with the patient.
For example, it is not uncommon for a therapist to prefer their patient not act as a domestic abuser. The desire to change the propensity for violence in a patient is not inherently wrong or bad. Discussing the risks and consequences of continued acts of violence is not wrong. It is a simple exploration of the possible outcomes of a patient’s worldview. Additionally, it would not be wrong for the therapist to explore how the patient came about their point of view regarding violence towards loved ones. Such exploration is not an effort to change the patient’s perspective. It is an invitation for the patient to fully understand themselves within the context of nature and nurture throughout their lifespan. Forcing the patient to seek that change would be a violation of the patient’s consent.
The use of either mental or physical manipulation to effect the therapist's desired change is necessary but not sufficient because mental or physical manipulation can occur outside the realm of conversion. It is still unethical, but not conversion. For example, a practitioner could use their body language to manipulate a patient's emotions in a direction of romantic attachment. That would be unethical, but not conversion.
We must also be careful not to define any physical reaction as manipulation. Therapists have physical instincts just as strongly as anyone else. They also have their own triggers for emotions that may be activated in what is described as countertransference. For example, if a therapist who is a survivor of assault were to instinctively react to a patient entering their personal space without consent by taking a step backwards, that is not an inherent attempt at mental or physical manipulation. It may still impact the patient, but it is not necessarily a covert action with the intention of impacting the patient.
The application of some type of physical intervention is necessary because without it we have intent and manipulation on behalf of the therapist, but no testable and measurable impact on the patient. While patient self-report of manipulative behavior with malintent by the therapist may meet criteria for some type of liability of wrongdoing in civil court with a jury of peers, the state must be held to a higher standard given the power the state holds within a single position of authority (such as an attorney general or a licensing board) to negatively impact an individual’s life, liberty, and pursuit of happiness.
Licensing boards are not elected by the public or the body of practitioners at large. They are largely either appointed by another public official, such as a governor, or voted in by existing board members. In addition, licensing boards can suspend or revoke licenses without any court hearing. (Attorney generals are elected but also hold tremendous power to impact professionals without a hearing or ability to defend in front of a jury of peers.) Thus, a practitioner has very little recourse should a licensing board determine, without any physical evidence, the practitioner has engaged in conversion. This is all the more apparent when we see states enacting laws that attempt to define speech as conversion.
A practitioner in such a jurisdiction is no longer free to explore with their patient out of fear of the state determining a question regarding identify markers is a challenge to the patient’s identity rather than an attempt to fully understand the complexities of development over the lifespan or even an uncertainty on the part of the patient of their own identity. In such a hostile environment to the freedom of speech, the therapist is left with only the option to affirm what they think the patient wants to hear. Thus, therapy ceases to exist, and an environment of rubber stamping with no real ability to grow and regain agency to improve one’s own life flourishes.
For children, who are inherently still growing, changing, learning, and finding their own agency; this is an even more dire circumstance. They are being told by an adult they often view as an authority figure that any feeling they have is the truth, no matter how often their feelings change. They have no guidepost to tell them it is ok to be unsure of who they are as well as a lack of safeguarding against permanent physical, medical interventions. They are left to feel fully responsible for any decisions they made during their youth despite their inability to foresee, comprehend, or plan for the consequences and give informed consent. The adults in such therapy rooms have washed their hands of their responsibility for informed consent as well as safeguarding children from adults who would consent on behalf of a child who cannot predict or manage the outcomes.
The permanent conversion from a human with a healthy, functioning body to a medical patient forever dependent upon the continued breaking of their bodies attempts to heal itself is the outcome of affirmation therapy. It is the most blatant example of the necessary and sufficient conditions for conversion therapy. The therapist was intent upon defying the biological reality of the patient, without or without the ability of the patient to consent, in order to further the therapist’s worldview of gender.
Gender is not measurable, testable, or provable. It is, at best, a religious view of a soul type entity within oneself. At worst, it is a lie designed to profit via exploitation of those who are struggling with their sense of self and worth.
A therapist affirming gender is not acting out of a desire to help the patient understand the conflict between their biological reality and their feelings. The therapist isn’t acting out of a desire to help the patient know all of their options for management of their symptoms and causes of distress. The therapist is simply affirming their own need to be known as a part of an in-group that has declared themselves the most kind and compassionate. This declaration comes without evidence they are truly helping anyone and plenty of broken bodies to prove the folly of their attempts to convert their patient’s biological sex.
Such an affirmation is the use of either mental or physical manipulation to affect the therapist's desired change. It isn’t the speech that is the manipulation. “I agree” is not an inherently manipulative phrase. It is the shift in accountability that is the manipulation. The therapist’s repeated denial/avoidance of biological reality, refusal to explore other causes of distress or confounding variables, and lack of exploration of risks of such an endeavor are the manipulations.
By accepted self-ID and neglecting to provide any actual therapy, more or less an attempt at informed consent, the therapist has manipulated the patient into believing they are the mental health expert. The therapist washes their hands of liability proclaiming they were just giving the patient what they wanted, as if therapist’s hold no liability for challenging patients when they are incongruent or when what they want could have extremely negative impacts on their future.
Once the therapist moves beyond words and into action, such as writing a referral letter or endorsement for HRT or surgery, the therapist has moved onto the necessary component of some types of physical intervention.
Sufficient elements for conversion:
The sheer magnitude of the evidence that changing biological sex is not possible and serves to create all manner of medical complications and tragedies indicates some types of physical intervention could be necessary and sufficient on their own to be deemed conversion therapy.
(The difference between physical manipulation and physical intervention is whether the physical action is done within the therapist or applied to the patient's body. As an example, a therapist can change their posture and facial expressions in such a way as to signal disapproval or discontent with a patient. If done with intent to change a patient's sense of self, that would be physical manipulation. Making a patient do physical labor to associate certain thoughts with physical pain would by physical intervention.)
A practitioner could engage in attempts at conversion without ever speaking to the patient if they were responsible for a physical intervention such as writing a referral, writing a script, injecting a substance, or performing surgery; but did not speak with the patient.
The very act of engaging in such physical and/or medical interventions implies the necessary elements of intent to change the patient's sense of self in the direction of something or someone they do not identify as, desire to be, or is opposed to measurable, testable, and provable biological reality because it is the practitioner's preference in that is the justification for the physical intervention and mental or physical manipulation to effect the therapist's desired change is present in the practitioner's use of their body to physically impact the patient's body. This would also be true of practitioners who engaged in the conversion therapy most of the population has heard of involving driving homosexual individuals to “camps” designed to “cure” them of their sexuality, engaged in the abuse perpetuated at those “camps”, or held patients against their will at those “camps.” All of these actions physically impact the patient in measurable, testable, and provable ways.
If all 3 necessary elements are present, intent to change the patient's sense of self in the direction of something or someone they do not identify as, desire to be, or an identity opposed to measurable, testable, and provable biological reality because it is the practitioner's preference; use of either mental or physical manipulation to effect the therapist's desired change; and the application of some type of physical intervention, there is necessary and sufficient intervention to declare an attempt at conversion.
Why Isn’t speech a necessary or sufficient element of conversion?
In my opinion, speech alone is not sufficient or even necessary to be considered conversion. Speech could be enough to meet other ethical violations, such as violations of confidentiality or establishment of inappropriate boundaries. As an example, a practitioner telling a patient, "I do not think you are a girl, boy, gay, straight, bi, trans, black, white, muslim, jewish, christian," or any other demographic category is not in and of itself conversion or an attempt at conversion. It is definitely a confrontation. It may be unethical for any number of reasons based on the circumstances.
However, to be conversion, there would need to also be the elements of intent to change the patient's sense of self in the direction of something or someone they do not identify as, desire to be, or is opposed to measurable, testable, and provable biological reality, use of either mental or physical manipulation to effect the therapist's desired change, and application of some type of physical intervention taken to effect the change the practitioner desires to see.
Please don't misunderstand me, I think a practitioner implementing both intent to change the patient from what the patient identifies as and mental or physical manipulation tactics used to coerce the patient in that direction are unethical and a violation of patient trust, the therapeutic relationship, ethical boundaries, and the purpose of therapy.
Absent the physical intervention, I think it falls short of the necessary requirements for conversion therapy as it has historically been defined and presented within the mental health profession. In my opinion, if we are going to set a standard by which we remove practitioner's licenses for attempts to convert a patient, there must be clear, identifiable, and provable violations as mentioned previously in this article.
That does not preclude a patient from raising concerns of practitioner conduct regarding intent to change a patient in a direction a patient does not wish to go and/or the use of mental or physical manipulation within a session to coerce a patient. I am in support of patients who experienced affirmation of gender by their therapist’s seeking compensation for the harm the shift of accountability by their therapist caused them. These are cases that need to be tried in civil courts, as we are now seeing in growing numbers. While the therapist may not lose their license, as that is a matter for the licensing boards determination, they would at least be held accountable for attempting to perpetuate the conversion of their patient’s biological sex and for failing to protect their patient’s when they were at their most vulnerable.
Also, as explored above, a practitioner could engage in attempts at conversion without ever speaking to the patient if they were responsible for the physical intervention (writing a referral letter, physical discipline, confinement without court order or just cause like danger to self or others, transportation to an area of confinement or intervention without court order or just cause, the use of puberty blockers without a medical diagnosis such a precocious puberty, the use of cross sex hormones without medical diagnosis of a deficiency from normal biological sex ranges, or surgery to remove healthy body parts, etc) but did not speak with the patient.
Conclusions:
In the end, the future of the effectiveness of therapy depends on the ability of both therapist and patient to speak freely within the session. Any attempt to prohibit freedom of speech via threat of losing their license, limits a therapist’s ability to assist the patient in self-exploration. Laws that force a therapist’s speech place the government between the patient and the therapist, with the government acting as the ultimate authority in an individual patient’s life, without ever even entering the therapy room. Such laws, like red flag laws, have a chilling effect on people seeking out therapy no matter how much it is needed.
In the end, should the Supreme Court fail to protect the freedom of speech between therapist and patient, the landscape of therapy will forever be changed. Anything deemed by the authorities that be to mean “conversion therapy,” would be banned from the therapy room. Can you imagine a world in which exploring homosexuality with a patient, who declares themselves heterosexual as they seek same sex sexual encounters, is deemed as conversion? I can. It wasn’t that long ago such conversations ended in mental health diagnoses and attempts to “cure” patients of homosexuality. When we give power to the government, the government enacts that power however they interpret it within the worldview of those in positions of power.
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The paragraph below is my rebuttal of attempts to declare gender as independent of biological sex, for those interested.
(*I realize there are some people who may attempt to point out that what is being changed is gender and not sex. However, I have yet to hear a definition of gender that requires physical alteration of the body that isn’t dependent upon adherence to primary, and often secondary, sex characteristics of biological sex. An attempt to change one’s sex organs from female to male or vice versa is an attempt to change one’s biological sex. If gender exists independent of biological sex, there is no need to alter sex organs. If gender is a feeling about one’s sense of self independent of biological sex, then no physical alterations are needed to engage with it. The circular reasoning attempted to define gender as a feeling or identity separate from biological sex, but also entirely dependent upon physical expression of biological sex for authenticity or congruence, but also existent outside of biological sex is neither convincing nor helpful here. For clarification, image a female patient telling a therapist she identifies, truly feel deep down in her bones/soul, she is obese and needs to go on a diet while weighing in at 90 pounds and is 5ft 7inches. She insists her feelings of being obese have nothing to do with her physical body. Yet, she needs to alter her physical body in order to feel more congruent with, affirm, her emotions; but her identity as obese has nothing to do with her body. Or imagine a male patient who is in the midst of addiction but declares his identity as a sober person separate from his repeated use of recreational opiates. He insists how he feels about himself, as a sober person, is separate from his body. His need to continue to use opiates is in no way related to his identity as a sober person, but he is facing drug court with a court mandated drug test in 3 days. Despite many efforts to make obesity a protected identity marker within “body positivity” movements, it has yet to become a civil rights issue. Addiction impacts so many people outside of the active user that it has yet to be positioned as a civil right. So, it is easier to see the issue for the therapist who is trying to keep the patient alive and aware of the consequences of their actions while refusing to affirm the patient’s incongruence between her feelings and her biological reality.)