The following is an interview with the American Public Health Association’s Ethics Section with Fordham University Center for Ethics Education Director Dr. Celia B. Fisher who served as an advisor for a White House panel on conversion therapy.
In April of this year, President Barack Obama announced his support for state efforts to pass Leelah’s laws. Such laws seek to ban conversion therapy, a practice which claims to change individuals with LGBTQ identities to a heterosexual identity and is named for an American transgender girl who committed suicide after undergoing conversion therapy. Celia B. Fisher is the Marie Ward Doty University Chair in Ethics and Director of the Center for Ethics Education at Fordham University and an Ethics Section member. She served as an advisor for a White House report released last fall, Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth.
She joins us this month for a Q & A, sharing her insights into one area of contemporary public health ethics in practice:
Q: What are the highlights Ethics Section members should know about the report Ending Conversion Therapy?
A: The report was commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA) with the assistance of the American Psychological Association (APA) under the auspices of White House interest. The goal of the SAMHSA-APA committee was to investigate the empirical case supporting, and not supporting, the use of conversion therapy. And so, a committee was brought together, the majority of members were researchers in the field of child development, pediatric physicians and mental health practitioners, or those who study gender identity formation. There were also experts across the spectrum from conservative and progressive political views on this issue.
We reviewed all the literature out there. We poured over the few empirical studies that had been cited as supporting conversion therapy, and when we looked at them, they were not scientifically rigorous; much of such research that appears to support conversion therapy lacks the standard features of research design. For example, sometimes there were no outcomes reported, just a perspective of a physician sharing anecdotal reports–no random assignment or control groups, no pre- and post-measurements, and/or no follow-up. Compared to the research that demonstrated no efficacy and some harm, there really was no doubt as to what the empirical data was saying.
The data spoke to a total lack of effectiveness. Moreover, the issue here was whether there were procedures that were actually harmful and iatrogenic, and there were. The evidence indicated that conversion therapy is damaging and the use of “pseudoscience” to conduct such therapies can lead to malpractice.
As therapy, conversion therapy comes under the professional–the medical, the public health–umbrella. And the report has been taken up at both the national and state, for example a recent proposal put forth by several congressional representatives calls for changing FTC policy. Such calls push for Medicare not to cover this form of “treatment.” Other legislation is taking place in the states, for example in New York State, conversion therapy cannot be conducted in any government medical institution. In some states, medical professionals can have their medical licenses revoked.
Q: Did the report offer any recommendations for what mental health professionals ought to do, not just which practices to avoid?
A: We also looked at the extent to which sexual orientation and gender identity was or was not a mental health issue. We looked at all the research and writings and clinical work in that area and in agreement with all the major medical and psychiatric associations, found no evidence that lesbian, gay or bisexual orientation or gender “nonconforming” identity is deviant, or pathological, or a mental health disorder; rather different sexual orientations and gender identities represent a continuum of natural variation of child adolescent and young adult development.
The report provides information for policymakers, medical professionals, and for parents who really want to do the best for their child. For example, when parents bring a gender nonconforming child to see a practitioner, the goal should not be to encourage “fixing” a young person’s gender identity toward any particular direction when a child or young adult is still developing, but rather allow for a normal path to discovering whatever that child is going to be, as they grow up, learn more about themselves, and begin to enter puberty. A goal of any kind of treatment is not to encourage or discourage a certain orientation or identity, but to help the child unfold in the direction that is best for them.
Q: Conversion therapy exemplifies the dangers of policy based on pseudoscience. Can your experience offer lessons for other areas of public health communication?
A: Health literacy is extremely important for public health to be achievable. The public has to have a certain health literacy that includes an understanding of what is scientific and what is not scientific. When the media publishes a report about “A study was done…” reporters are not necessarily looking at peer review standards, and therefore you can have a misinformed public. One of the challenges for public health officials and practitioners is how to complement or facilitate reporting by the media to ensure that the way that the public is being educated does have a scientific and valid basis. This goes far beyond conversion therapy–such challenges were seen in the Ebola crisis, with parents’ concerns about vaccinations, and it has to do now with what is happening around the Zika virus.
I think there was an underlying view among professionals in public health and in medicine and the behavioral sciences that conversion therapy didn’t work, but I don’t think they wanted to get into the political fire that would emerge from taking a stance. And so, in being silent we in fact encouraged the propagation of this kind of very damaging therapy. The medical and public health establishment may be too wary of political repercussions when science is being reported, and maybe APHA as an organization and perhaps the Ethics Section can begin to grapple with these barriers to ethical health policymaking. What is the role of professions in speaking to untruth? What is their role in standing up to a supposed “balanced” media that “balances” truths and untruths as if they are equal?
Q: You are also currently serving as chair of the APHA Ethics Code Task Force. Is there a possibility that the task force might help public health professionals articulate such an understanding of professional integrity?
A: On the SAHMSA-APA report, we also worked really hard to establish the ethical foundation guiding our deliberation, and we concluded that the report spoke to a need for a human rights health agenda for sexual and gender minority development. The report articulates the view that each of us has a right to develop and determine our own sexual orientation and gender identity, and the right to treatment in support of this development, rather than interventions that stymie our growth.
We are still in the drafting stages of the code of public health ethics. The goal of our ethics code is not to be regulatory, or to result in punitive action. Rather the goal is to articulate what the values are of the field, and there are many values we are considering. Health justice and equity are important values and their relationship to evidence-based policy is something we have been talking a lot about. We have also concluded that the process of identifying appropriate public health goals and alternatives is an essential part of an ethical process that must include consideration of empirical data, as well as the historical, cultural, legal, and social contexts in which public health has to operate, and the moral claims of stakeholders. Our goal is to develop an ethics code that will reflect the values and merit the trust public health practitioners, organizations, and the communities they serve.
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RELAY – Research and Education for LGBT and Allied Youth is a project of the Fordham University Center for Ethics Education which looks to advance the conversation about health for lesbian, gay, bisexual, and especially trans youth.