Serious Inaccuracies and distortions abound: Are politicians willing to listen?

Christopher H. Rosik, Ph.D.

The same week California Governor Jerry Brown announced that the state was now $16 billion over budget, with the implication that more social-welfare cutbacks affecting thousands of children will be necessary, SB 1172 was passed by the Senate Judiciary Committee.  It will now enter deliberation by the full California Senate, in the hopes of protecting an unknown number of minors and others from the “dangers” of Sexual Orientation Change Efforts (SOCE).

Even the L.A. Times, not known to be a voice of conservatism, has come out against this legislation, saying it constitutes unnecessary government intrusion into what should be mental-health-association policy matters. (However on matters of science, the Times naively accepted the picture spun by the sponsors of SB 1172; see htttp://articles.latimes.com/2012/may/11/opinion/la-ed-0511-therapy-2012051).

But will this legislation really do much to protect minors and adults who might otherwise avail themselves of SOCE?  When we examine some of the contentions SB 1172 touts as “facts,” greater clarity can be obtained regarding the partisan nature of this bill.

SB 1172 states:
SOCE practitioners use aversive treatments such as electric shock or nausea inducing drugs.

Fact: Aversive treatments were common for a wide variety of psychological conditions in the 1960s and 1970s, including sexual orientation (see http://narth.com/2011/05/facts-and-myths-on-early-aversion-techniques-in-the-treatment-of-unwanted-homosexual-attractions/).  However, they eventually were determined to be ineffective regarding sexual orientation and have not been utilized for decades.  In fact, in a quick analysis of the psychological and medical databases, I could find no published new research on aversive treatments and homosexuality after 1981. Similarly, the APA’s (2009) Task Force Report on Appropriate Therapeutic Responses to Sexual Orientation did not identify any such studies after 1981.  Even the bill’s authors had to rely on a 1994 report from the American Medical Association, a nearly 20-year-old document.

The linking of SOCE practitioners with aversive and shock treatments is a favorite smear of SOCE opponents, but it has not had any basis in fact for over 30 years. Moreover, NARTH is on record as not recommending these practices due to ethical and efficacy concerns (NARTH, 2010). That this factual inaccuracy is highlighted so prominently in SB 1172 certainly lends credence to the suspicion that the primary aim of the bill’s sponsors is to demonize SOCE and the clinicians who engage in this practice.

SB 1172: SOCE can be harmful or carry some risk of harm and SOCE practitioners deny this.

Fact: SOCE, as is the case with all forms of psychological care, carries some risk of harm.  No professional therapist engaged in SOCE would deny this. The question is whether SOCE carries an exceptionally greater risk than all other forms of psychological intervention, and the answer is that no studies exist that can truly speak to this issue.  The studies cited by the APA Task Force (2009) concerning harm are unable to be generalized beyond their specific samples, and the Task Force concluded, “Thus, we cannot conclude how likely it is that harm will occur from SOCE” (p. 42). Therefore, for the sponsors of SB 1172 to use this literature as a means of casting aspersions on all SOCE is an act of scientific dishonesty.

The most popularly cited study regarding harm from SOCE (Shidlo & Schroeder, 2002), specifically warns readers about generalizing from their research, which did not distinguish licensed professionals and religiously-based providers of SOCE in
their reports of harm. Furthermore, the authors of the study advertised for respondents with this notice: “Help Us Document the Harm.” To be able to know the exact prevalence of harm in SOCE and the significance of this prevalence rate, we would need to see prospective, longitudinal studies using representative samples, not personal anecdotes or samples that were advertised as being sought to “help” the researchers achieve a desired outcome. Such studies would need to track harm in other forms of psychological intervention for interpretive comparison (e.g., marital therapy). The fact that an intervention might be harmful in the absence of any scientific data that speak to the prevalence and significance of this harm is not a sufficient justification for banning or marginalizing an intervention. An ideologically based political activism rather than an objective scientific outlook appears to again be lurking in the background of SB 1172.

SB 1172: Claims this bill will protect minors from the potential, harmful effects associated with SOCE, including severe mental or emotional problems including suicide.

Fact: Notwithstanding the considerations regarding claims of harm noted above, there is reason to believe that this bill will likely increase harms to minors through its unintended consequences.

Here’s how I come to this very plausible conclusion. It would appear quite likely that the majority of parents who bring their children to therapists for SOCE are conservatively religious.  SB 1172 sponsors assume that with SOCE prohibited among licensed mental-health professionals, these parents would then bring their children to clinicians who would only provide care aimed at encouraging their children to embrace GLB identity and behavior.

I think the more likely scenario is that these parents, many of whom are already suspicious of the mental health professions, will simply pursue SOCE for their children with unlicensed, unregulated, and unaccountable religious counselors that do not fall under the jurisdiction of this bill. The vast majority of anecdotal accounts of harm to minors from SOCE seem attributable to these types of counselors and to religiously oriented programs. Parents who receive professional care by SOCE clinicians whom they sense are understanding of and sympathetic to their worldview will be receptive to their guidance, especially when their child is not interested in SOCE. It is highly unlikely that the average unlicensed conservatively religious counselor will be as sensitive to the contextual and motivational considerations licensed therapists must assess when determining if change-oriented intervention is appropriate for a minor client. This is a prescription for an increased risk of harm.  It would indeed be a tragic but foreseeable irony if the sponsor’s zeal to ban SOCE for minors via SB 1172 ends up actually increasing the harm these youths experience.

SB 1172 makes it clear that SOCE includes “…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” (Article 15. 865 (d); emphases added). This language seems to imply that psychotherapeutic intervention to reduce same-sex behaviors among minors is to be prohibited.  It is worth asking whether such broad language will have a chilling effect on even non-SOCE therapists who are asked to help minors reduce or manage their addictive or compulsive same-sex behaviors.  It seems quite conceivable that a minor at some later point could feel retrospectively slighted by this treatment and therefore be enticed by SB 1172 to file legal action against the therapist to the tune of up to $5,000.

So again, another unintended consequence of this bill could be to reduce the pool of non-SOCE therapists willing to wade into the incredibly murky clinical waters that SB 1172 would create, thus increasing harm by reducing the availability of any psychological services to LGB youth in California.

One last observation that can provide further perspective: One wonders what the sponsors of SB 1172 would say about a widespread intervention for minors that carries the following warning: [This intervention] “… increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children, adolescents, and young adults with major depressive disorder (MDD) and other psychiatric disorders.”

This is the warning for the antidepressant Prozac. You can check out the potential side effects for other medications at www.pdf.net. It seems to me that if we are going to begin to ban certain types of psychological interventions on the basis of real (as opposed to uncertain) harms to minors, the sponsors of SB 1172 should be spending a lot more time focusing on the millions of youth (including GLB youth) currently being prescribed these powerful psychoactive medications (I say this as a therapist who thinks medications can have a place in treatment but are currently being over-prescribed).

SB 1172: Defines informed consent for adult clients as having to include four statements from mental health organizations about SOCE.

Fact: The statements used in SB 1172 are actual pronouncements but the lack of context is clearly meant to depict SOCE in deceptively unflattering terms.  The degree to which these four statements have been cherry-picked to provide an unduly negative picture of SOCE can be seen in their publication dates.  Three of the four were published between 1993 and 1997, which makes me wonder if these associations have said nothing in nearly 20 years that the sponsors of SB 1172 found sufficient for their purposes. Only the APA’s (2009) Task Force Report was recent in origin.  Unfortunately, the Task Force consisted only
of psychologists who were against SOCE from the start, and excluded several excellent scholars sympathetic to SOCE (Jones, Rosik, Williams, and Byrd, 2010).

This fact raises the curtain on the sociopolitical culture within the major professional mental-health associations.  While they do good work on many fronts, when it comes to social issues being debated in the culture, the APA and other associations are reliably left-of-center in their outlook.  One example will suffice here: In 2011, the APA council of representatives voted 157-0
to support gay marriage.  This is not a typographical error. Not a single vote in favor of the keeping the male-female definition as the social ideal.  This is a statistically impossible lack of diversity. Whatever one believes about this issue, it stretches incredulity to contend that such a vote does not reflect a mix of political activism and political correctness.  In a similar fashion, I believe that many of the pronouncements concerning SOCE cited in SB 1172 represent what occurs in professional mental health organizations when science is allowed to stagnate in the absence of support for viewpoint diversity.

Former APA President Dr. Nicholas Cummings observed that while unsuccessful attempts have been made in the APA to ban SOCE, the APA refused to take a stand on “rebirthing therapy,” which resulted in the suffocation death of one child when the birth process was simulated with tight blankets (Cummings, 2008).  Cummings then concluded, “If the APA rushes to judgment in the matter of sexual reorientation therapy while remaining derelict in its silence toward proven harmful techniques, therapists will be intimidated and patients will lose their right to choose their own treatment objectives. The APA, not the consumer, will become the de facto determiner of therapeutic goals” (p. 208). This sentiment is equally valid for SB 1172, only in this case California politicians, not the California consumer, will dictate which goals for psychological care are acceptable.

SB 1172: SOCE assumes that homosexual orientation is both pathological and freely chosen.

Fact: SB 1172 provides no documentation to support this claim.  In fact, NARTH represents many professional SOCE providers and is on the record as taking the position that same-sex attractions are usually not something people choose in some volitional manner (NARTH, 2010). Though historically many SOCE providers (not to mention most mental health professionals in general) viewed homosexuality as psychopathological, this is typically not the case today.  NARTH’s position is rather that same-sex attractions and behavior may reflect a developmental adaptation to certain biological and/or psychosocial environments, possibly in conjunction with a weak and indirect genetic predisposition. And while this adaptation may not constitute psychopathology per se, it does appear to place these individuals at greater risk for mental illness and physical disease, not all of which is likely to be attributable to social stigmatization.

In conclusion, this quick tour through some of the factual claims made by the sponsors of SB 1172 makes it clear that this legislation is playing fast and loose with its assertions about SOCE. It would be a travesty of immense proportions if the California legislature allows these falsehoods and inaccuracies to be enshrined into California law.  It would also constitute a corruption of the political process by activists that certainly would invite a legal challenge.

References:

American Psychological Association (2009). Report of the APA task force on appropriate therapeutic response to sexual orientation.  Retrieved from http://www.apa.org/pi/lgbt/resources/therapeutic-response.pdf

Cummings, N. A., & Donohue, W. T. (2008). Eleven blunders that cripple psychotherapy in America: A remedial unblundering. New York: Taylor & Francis Group.

Jones, S. L., Rosik, C. H., Williams, R. N., & Byrd, A. D. (2010). A Scientific, Conceptual, and Ethical Critique of the Report of the APA Task Force on Sexual Orientation. The General Psychologist, 45(2), 7-18.  Retrieved May 31, 2011, from http://www.apa.org/divisions/div1/news/fall2010/Fall%202010%20TGP.pdf

NARTH Task Force on Practice Guidelines for the Treatment of Unwanted Same-Sex Attractions and Behavior (2010). Practice
Guidelines for the Treatment of Unwanted Same-Sex Attractions and Behavior, Journal of Human Sexuality, 2, 5-65.  Retrieved
from http://narth.com/2011/03/practice-guidelines-for-the-treatment-of-unwanted-same-sex-attractions-and-behaviors/

Shidlo, A., & Schroeder, M. (2002). Changing sexual orientation: A consumer’s report. Professional Psychology: Research and Practice, 33(3), 249-259.

_____________________________________________

California Senate Bill 1172: A Scientific and Legislative Travesty

A look at the bill’s misuse of science

Christopher H. Rosik, Ph.D.

California SB 1172 is a first-of-its-kind legislative effort to usurp the role of the professional mental-health associations and ban change-oriented psychological care to minors. This legislation assumes that sexual-orientation change efforts (SOCE) constitute a form of family rejection that will likely result in harm.

In reality, however, there is virtually no evidence to support this claim. In fact, the SOCE literature reporting harm among youth is extremely scarce and conducted only with non-representative samples.  A single study was used by the bill’s supporters to support their claim. But it is remarkable that the authors of SB 1172 could even conceive that this particular study had any relevance to their legislative aims.

Furthermore, NARTH clinicians have long been aware that parents with traditional values need not “reject” their child; they can be encouraged to love and accept their children, even when they disapprove of their child’s sexual lifestyle choices.

Secondarily, SB 1172 will also dictate the content of consent forms in SOCE therapy with adults and create the threat of legal action against therapists. Despite the existence of a substantial body of research evidence that some clients can change, and the lack of any research showing that harm is likely, clinicians will be required to tell their clients that the therapy they offer has no scientific validity and often results in harm.

While NARTH opposes this bill on many counts (see: http://narth.com/2012/04/narth-statement-on-californis-sb-1172-sexual-orientation-change-efforts/), this legislation is particularly worrisome in its use of scientific research.  The bill cites only one study to support its claims, presumably the most scientifically important research from the perspective of the sponsors of the bill (i.e., the group “California Equity”).  The citation of one single study to create new civil law can serve to clarify how activist agendas and politicians who are ignorant of research methods can work together to distort science and dictate a particular partisan outcome.

In the case of SB 1172, the specific aspect of the bill suited for this analysis is regarding the effects of SOCE on minors.

Claims of SB 1172

In section 1 of the bill, following a laundry list of quotes from professional organizations hand-picked to directly or indirectly suggest the discouragement of SOCE, the bill states in item (i):

Minors who experience family rejection based on their sexual orientation face especially serious health risks.  In one study, lesbian, gay, and bisexual young adults who reported high levels of family rejection during adolescence were 8.4 times more likely to report having attempted suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse compared with peers from families that reported no or low levels of family rejection.  This is documented by Caitlin Ryan, et al., in their article entitled Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual Young Adults (2009), 123, Pediatrics, 346.

This is followed by item (j):

California has a compelling interest in protecting the lives and health of lesbian, gay, and bisexual people.

Now clearly, NARTH is on record in our Practice Guidelines (http://narth.com/2011/12/narth-practice-guidelines/) as being very concerned that minors who engage in SOCE and the parents who bring them to treatment are provided with a high level of professional care. Such care extensively evaluates the clinical and motivational context of all parties to minimize any risk of harm.

In my own clinical work, I have told several parents upon initial evaluation that their teenage child is not invested in change at this time, and therefore their best path forward is to love their child and keep the lines of communication as open as possible. Yet SB-1172 appears to be engaging in a guilt-by-association argument, whereby SOCE with minors is by definition a marker of family rejection which endangers the lives and well-being of these youth.

The rhetoric coming from the office of the Senator who introduced this bill (Senator Lieu) certainly seems to confirm this assertion (see http://sd28.senate.ca.gov/news/2012-04-23-senate-panel-cracks-down-deceptive-sexual-orientation-conversion-%E2%80%98therapies). It asserts, among other things, that:

“[SOCE]….has resulted in much harm, including a number of lesbian, gay, bisexual and transgender youth committing suicide.”

“Some individuals perceived that they had benefited from sexual orientation change therapy, but the vast majority of participants perceived that they had been harmed.”

“Sexual orientation change therapies….are the types of sham therapies that California law does not protect against for minors.”

“These bogus [SOCE] efforts have led in some cases to patients later committing suicide, as well as severe mental and physical anguish.  This is junk science and it must stop.”

These quotes, not to mention the content of the bill, make painfully obvious that for the sponsors of this legislation, licensed clinicians who engage in SOCE are placing significant numbers of their minor clients in serious physical and psychological danger.

To bolster their case with research, the sponsors cite a study by Ryan, Huebner, Diaz, and Sanchez (2009) in the respected journal Pediatrics that provides the genuinely sobering statistics noted above.  But does this study really support the bill’s implication that SOCE constitutes a form of family rejection that results in such increased risk of negative health outcomes for minors?  To answer this question, we must take a closer look at the actual research.

-

Methodological Analysis of Ryan, et al. (2009)

In order to provide a certain degree of objectivity to this analysis, I will refer to the standards for conducting research outlined in the Report of the on American Psychological Association Task Force Appropriate therapeutic responses to sexual orientation (2009). Keep in mind that these are the standards that the APA used in their report to justify the nearly complete dismissal of the vast body of research literature supporting the effectiveness of SOCE.  Thus, it is appropriate and highly relevant to examine the Ryan, et al. (2009) study through the APA’s own analytical lens, since in this instance research is being cited not to support, but rather to ban, SOCE.

Sampling issues. The Ryan, et al. (2009) study described its sample procedure as one of “participatory research” whereby the researchers “…advised at all stages…the population of interest (LGB adolescents, young adults, and family members), as well as health care providers, teachers, and advocates” (p. 347).  However, as the APA’s Task Force (2009) noted, “Knowing that one is being studied and what the experimenter hopes to find can heighten people’s tendencies to self-report in socially desirable ways and in ways that please the experimenter” (p. 32).

This very same standard of avoiding potential demand characteristics was clearly violated in the Ryan, et al., study where, “Providers, youth, and family members met regularly with the research team to provide guidance on all aspects of the research, including methods, recruitment, instrumentation, analysis, coding, materials development, and dissemination and application of findings” (p.347).

Recruitment issues. Ryan, et al. (2009) described their procedure for recruitment of participants as follows:

Participants were recruited conveniently from 249 LGB venues within 100 miles from our office.  Half of the sites were community and social organizations that serve LGB young adults, and half were from clubs and bars serving this group. Bilingual recruiters conducted venue-based recruitment from bars and clubs and contacted each agency to access all young adults who use their services. (p. 347)

A main methodological critique of the SOCE literature offered by the APA Task Force (2009) had to do with the limitations of convenience sampling.  The Task Force warned that, “Additionally, study respondents are often invited to participate in these studies by [therapists] who are proponents of SOCE, introducing unknown selection biases into the recruitment process”  (p.34). Futhermore, the APA observed that since “…study recruiters were openproponents of the techniques under scrutiny; it cannot be assumed that the recruiters sought to encourage the participation of those individuals whose experiences ran counter to their own view of the value of these approaches” (p. 34).

Although the Ryan, et al. (2009) study had an admittedly different focus than the APA Task Force (family rejection of LGB young adults versus outcomes of SOCE), the APA’s warnings are relevant here, in that selection bias in recruitment is certainly a plausible risk.  While it no doubt appears probable that LGB youth face higher risks of family rejection which can contribute to negative health consequences, Ryan, et. al.’s recruitment methods make their findings unreliable for generalization to LGB
youth as a whole, and provide no scientifically relevant information for assessing perceptions of family rejection among SOCE minor clients.  In fact, SOCE-related family rejection experiences were not even assessed in Ryan, et al.’s study.

Generalization difficulties are also created by the sample composition of Ryan, et al. (2009).  The sample is limited to young adult non-Latino and Latino LGB persons. The APA Task Force (2009) noted that research on SOCE has “…limited applicability to non-Whites, youth, or women” (p. 33) and, “No investigations are of children and adolescents exclusively, although adolescents are included in a very few samples” (p. 33). This means that even had Ryan and colleagues assessed for SOCE backgrounds among participants, it would be inappropriate to generalize their findings in a manner that would cast aspersions on all SOCE experiences of minors, which again is precisely what AB 1172 is determined to do.

The SOCE literature pertaining to harm among youth is extremely scarce and conducted only with non-representative samples, and I am unaware of any studies assessing specifically for family rejection among SOCE with minors.  This may be why the authors of SB 1172 had to set aside all pretensions of scientific restraint in their citation of Ryan, et al.

Measurement issues. Finally, the inapplicability of Ryan, et al. (2009) as demonstrable support for SB 1172 can be questioned on measurement grounds as well. unds, observing that, “…overreliance on self-report measures and/or measures of unknown validity and reliability is common” (p. 31).  Even more to the point, “People find it difficult to recall and report accurately on feelings, behaviors, and occurrences from long ago, and with the passage of time, will often distort the frequency, intensity, and salience of things they are asked to recall” (p. 29).

It appears that these cautions could equally apply to the Ryan, et al. (2009) study, in that participants averaged just under 23 years of age, meaning that they were recalling experiences that occurred on average 3 to 10 years ago.  Furthermore, psychometric information on reliability and validity was not provided by Ryan, et al., for some of the measures they developed (i.e., substance use and abuse, sexual risk behavior).

In addition, Ryan, et al. (2009) acknowledge that “…given the cross-sectional nature of this study, we caution against making cause-effect interpretations from these findings” (p. 351).  Presumably, this caution alone should have been enough to prevent the authors of SB 1172 from employing the Ryan study.  Even had the study findings been generalizable, they would have not been able to indicate whether SOCE caused the negative health outcomes or if youth with negative health markers disproportionately sought SOCE.

Other problematic aspects of Ryan, et al.’s construct development include the dangers of losing important interpretive information by dichotomizing continuous variables, the limitations of using perceptions of family rejection (e.g., being blamed by a parent) versus objectively verifiable variables (e.g., registration at a homeless shelter), and the lack of a measure of impression management.

The question is not why the designers of SB 1172 failed to report such limitations of the Ryan study; rather, it is how the authors could even conceive that this research had relevance to their legislative aims.

-

SB 1172: A Legislative Solution in Search of a Clinical Problem

This analysis of the science behind SB 1172’s intention to ban SOCE to minors should in no way be construed to imply that psychological injury does not occur from family rejection for some GLB youth.  NARTH clinicians share a concern for the welfare of GLB youth and therefore take great care to determine if coercive influences are implicated when minors present for SOCE.  While some opponents no doubt view SOCE with minors by definition as reflecting family rejection, there is no data to back up this claim, and the experience of NARTH professionals is that parents can be assisted to love and accept their child without having to sacrifice their traditional values regarding sexual expression.

My intent in this brief investigation of the Ryan, et al. (2009) study through the lens of the APA Task Force’s (2009)methodological standards is simply to demonstrate how science appears to have been hijacked in the service of concocting an authoritative-sounding link between SOCE, family rejection, and negative health outcomes.

Based on this analysis, there appears to be no scientific grounds for referencing the Ryan study as justification for a ban on SOCE to minors.  The study’s findings, while likely reflecting some underlying connection between family rejection and mental health outcomes, are not reliable and have no scientific justification for being generalized to minors who engage in SOCE with licensed therapists. It is troubling that SB 1172 would utilize Ryan, et al.’s work when the internal and external validity limitations of the study make such claims profoundly misguided, as underscored by the APA Task Force.

SB 1172 therefore supports its attempt to ban SOCE for minors with a study that cannot be generalized, and it cherry-picked citations from several mental health associations, none of which have banned SOCE with minors.

By way of conclusion, it needs to be pointed out that an unmistakable implication of SB 1172 is that the California licensing agencies and mental health associations are so derelict in their protection of GLB youth that politicians must step in and do their work for them.  How else should we understand the complete absence of licensure revocations or membership suspensions among California therapists who provide SOCE when suicides and severe mental and physical anguish are so presumably widespread among GLB youth and attributable to this form of psychological care?

Either these agencies and professional associations are incredibly negligent and inept, or SB 1172 is an ideological agenda masquerading as a legislative solution to a clinical problem that simply does not exist. Citing research that cannot be generalized and professional pronouncements in the absence of censorious actions against SOCE professionals cannot, by any reasonable measure, provide sufficient justification for the ban on SOCE with minors that SB 1172 sponsors seek.

References

American Psychological Association (2009). Report of the APA task force on appropriate therapeutic response to sexual orientation.  Retrieved from http://www.apa.org/pi/lgbt/resources/therapeutic-response.pdf

Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123, 346-352.