Sexual orientation change efforts

Sexual orientation change efforts (SOCE) are methods that aim to change sexual orientation, used to try to convert homosexual and bisexual people to heterosexuality. They may include behavioral techniques, cognitive behavioral techniques (such as "reparative therapy"), psychoanalytic techniques, medical approaches, religious and spiritual approaches, and in some parts of the world acts of sexual violence ("corrective rape"). There are no studies of adequate scientific rigor to conclude whether or not SOCE work to change sexual orientation.

The longstanding consensus of the behavioral and social sciences and the health and mental health professions is that homosexuality and bisexuality are per se normal and positive variation of human sexual orientation. The research consistently failed to provide any empirical or scientific basis for regarding homosexuality as a disorder or abnormality. There is a large body of research evidence that indicates that being gay, lesbian or bisexual is compatible with normal mental health and social adjustment. Because of this, the major mental health professional organizations do not encourage individuals to try to change their sexual orientation from homosexual to heterosexual. Indeed, such interventions are ethically suspect because they can be harmful to the psychological well-being of those who attempt them; clinical observations and self-reports indicate that many individuals who unsuccessfully attempt to change their sexual orientation experience considerable psychological distress. For these reasons, no major mental health professional organization has sanctioned efforts to change sexual orientation and virtually all of them have adopted policy statements cautioning the profession and the public about treatments that purport to change sexual orientation. The Royal College of Psychiatrists shares the concern of both the American Psychiatric Association and the American Psychological Association that positions espoused by bodies like the National Association for Research & Therapy of Homosexuality (NARTH) in the United States are not supported by science and that so-called treatments of homosexuality as recommended by NARTH create a setting in which prejudice and discrimination can flourish.

SOCE has been controversial due to tensions between the values held by some right-wing faith-based organizations, on the one hand, and those held by LGBT rights organizations, human rights and civil rights organizations, and other faith-based organizations, as well as professional and scientific organizations, on the other. Some individuals and groups have, contrary to global scientific research and consensus, promoted the idea of homosexuality as symptomatic of developmental defects or spiritual and moral failings and have argued that SOCE, including psychotherapy and religious efforts, could alter homosexual feelings and behaviors. Such efforts are potentially harmful because they present the view that the sexual orientation of lesbian, gay, and bisexual youth is a mental illness or disorder, and they often frame the inability to change one’s sexual orientation as a personal and moral failure. Many of these individuals and groups appeared to be embedded within the larger context of conservative religious political movements that have supported the stigmatization of homosexuality on political or religious grounds. There is a population that undergoes sexual orientation change efforts (SOCE) and tends to have strongly conservative religious views that lead them to seek to change their sexual orientation. Co-founder and other former Exodus International leaders issued a public and formal apology for their work as ex-gay leaders and the harm they caused to those they tried to help.

History
Medical attempts to change homosexuality included surgical treatments such as hysterectomy, ovariectomy, clitoridectomy, castration, vasectomy, pudic nerve surgery, and lobotomy. Substance-based methods included hormone treatment, pharmacologic shock treatment, and treatment with sexual stimulants and sexual depressants. Other methods included aversion therapy, the reduction of aversion to heterosexuality, electroshock treatment, group therapy,    hypnosis,  and psychoanalysis.

Richard von Krafft-Ebing


Richard von Krafft-Ebing was a German-Austrian psychiatrist and one of the founders of scientific sexology. His first systematic work on sexual pathology was published in 1877 in a German psychiatric journal. His influential work, Psychopathia Sexualis was published in 1886. Numerous expanded German editions followed, and it was widely translated. Krafft-Ebing became a proponent of the sickness model of homosexuality.

Section IV of Psychopathia Sexualis, “General Pathology“, discussed homosexuality in “Diagnosis, Prognosis and Therapy of Antipathic Sexual Instinct.” Krafft-Ebing believed that homosexuality could be either innate or acquired. In his view, it could sometimes be treated through prevention of masturbation and cure of the neuroses “arising out of the unhygienic conditions of sexual life”, but these methods would work only in rare cases “where acquired antipathic sexual instinct has not progressed far”, and would therefore usually be ineffective even when homosexuality was not inborn. Krafft-Ebing believed that hypnosis was therefore the "only means of salvation" in most cases. He stated that he knew of only a single case in which self-hypnosis had proven successful, and that hypnotic suggestion by another person was usually necessary to change homosexuality.

Krafft-Ebing wrote about this method that "... the object of post-hypnotic suggestion is to remove the impulse to masturbation and homosexual feelings, and to encourage heterosexual emotions with a sense of virility". Krafft-Ebing described three cases in which he believed it had proved satisfactory, writing that they "seem to afford a proof that even the gravest cases of congenital sexual inversion may be benefited by the application of hypnotism". He warned however that "only when hypnotism produces deep somnambulism decided and lasting results may be hoped for".

He rejected castration as a cure for homosexuality, and the internment of gay people in asylums, except in cases involving sex crimes. Krafft-Ebing cautioned that the success or failure of treatments for homosexuality proved nothing about its causes. He defended the right of patients to receive such treatment. Krafft-Ebing criticised several objections to medical treatment of homosexuality, including the charges that it was ineffective and that it gave an opportunity "to tainted individuals to propagate their perversions". In his view, physicians had a duty to provide such treatment if it was requested.

He concluded his discussion of methods of curing homosexuality by remarking that “in the majority of cases, the patient is quite satisfied when he becomes sexually neutral, and under these circumstances medical skill has rendered a great service to both society and the individual himself.” Later editions of Psychopathia Sexualis included an increased number of autobiographies by gay people who made it clear that they did not wish to change their sexual orientation.

Current status
In the last two decades of the 19th century, a different view began to predominate in medical and psychiatric circles, judging such behavior as indicative of a type of person with a defined and relatively stable sexual orientation. In the late 19th and 20th centuries, pathological models of homosexuality were standard.

In 1992, the World Health Organization replaced its categorization of homosexuality as a mental illness with the diagnosis of ego-dystonic homosexuality. The UK Government followed suit in 1994, followed by the Ministry of Health in Russian Federation in 1999 and the Chinese Society of Psychiatry in 2001. The trustees of the American Psychiatric Association (APA) had previously voted unanimously to remove homosexuality as a disorder from the Sexual Deviancy section of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-II in 1973. This decision was officially confirmed by 58% of the general APA membership in 1974, who voted to replace the diagnosis with a milder category of "sexual orientation disturbance", which was then replaced in the DSM-III with "ego-dystonic homosexuality" which, in 1986, was deleted from the DSM-III-R. The APA now classifies persistent and marked distress about one's sexual orientation under Sexual Disorders Not Otherwise Specified.

No major mental health professional organization has sanctioned efforts to change sexual orientation and virtually all of them have adopted policy statements cautioning the profession and the public about treatments that purport to change sexual orientation. These include the American Psychiatric Association, American Psychological Association, American Counseling Association, National Association of Social Workers in the USA, the Royal College of Psychiatrists, Australian Psychological Society, and the Pan American Health Organization.

Behavior therapy
Types of behavior therapy used to change sexual orientation include aversion therapy, covert sensitization and systematic desensitization. Aversion therapy associates negative stimuli with homoerotic pictures and positive stimuli with heteroerotic pictures. A series of 1966 experiments appeared promising, and the practice became popular, but when reports were shown to be flawed, it fell out of favour. Since 1994, the American Psychological Association has declared that aversion therapy is a dangerous practice that does not work, but it is still in use in some countries.

Bioenergetics
Bioenergetics is a therapeutic technique developed by Alexander Lowen and John Pierrakos, who were students of Wilhelm Reich. It has been used to attempt to convert gay people to heterosexuality by Richard Cohen, who has been called one of America's leading practitioners of conversion therapy. Cohen holds male patients in his lap with the patient curled into the fetal position, and also advocates methods involving shouting or slamming a pillow with a tennis racket.

Conversion therapy
The American Psychological Association defines conversion therapy or reparative therapy as therapy aimed at changing sexual orientation. The American Psychiatric Association states that conversion therapy or reparative therapy is a type of psychiatric treatment "based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that a patient should change his/her sexual homosexual orientation." Psychologist Douglas Haldeman writes that conversion therapy comprises efforts by mental health professionals and pastoral care providers to convert lesbians and gay men to heterosexuality, and that techniques include psychoanalysis, group therapy, aversive conditioning involving electric shock or nausea-inducing drugs, sex therapy, reparative therapy, and involvement in ex-gay ministries such as Exodus International.

The ethics guidelines of major U.S. mental health organizations vary from cautionary statements about the safety, effectiveness, and dangers of prejudice associated with conversion therapy (American Psychological Association) to recommending that ethical practitioners refrain from using conversion therapy (American Psychiatric Association) or referring patients to others who do (American Counseling Association). It may be harmful if the client is egosyntonic and does not wish to change their sexual orientation.

Ex-gay groups
A task force commissioned by the APA found that ex-gay groups act like support groups, in that they help counteract and buffer Minority Stress, marginalization, and isolation.

Most ex-gay groups focus on abstaining from homosexual relationships rather than a complete sexual orientation change from homosexual to heterosexual. Evergreen International teaches that it is unlikely therapy can erase all homosexual feelings, and does not advocate any particular form of therapy.

Marriage therapy
People with a sexual relationship disorder have difficulty forming or maintaining a relationship because of their sexual orientation. A significant number of men and women experience conflict surrounding homosexual expression within a mixed-orientation marriage. People may turn to a marriage therapist for help to change their sexual orientation. Although a strong homosexual identity was associated with difficulties in marital satisfaction, viewing the same-sex activities as compulsive facilitated commitment to the marriage and to monogamy.

Religious methods
Some people with unwanted homosexual attractions turn to their faith for help. Some conservative Christians believe that homosexuality is a result of a broken world and that faith can change sexual orientation. Some report that their sexual orientation has been changed through the atonement of Jesus Christ.

Syntonic therapy
Syntonic therapy, a method developed by Robert Kronemeyer, was based partly on the work of Wilhelm Reich.

Kronemeyer agreed with Arthur Janov that, "...the homosexual act is not essentially a sexual one but is based upon the denial of real sexuality; it is, through sex, the acting out symbolically of a need for love." However, Kronemeyer criticised Janov's methods for over-relying upon catharsis, stating that it was not the only important part of therapy. Kronemeyer also stated that patients should be allowed to continue in their neurotic crutches until their defenses were strong enough for them to abandon them voluntarily since not doing so was inhumane, that primal therapy was excessively expensive, and that many of the patients who screamed did so only to please their therapists. Kronemeyer contrasted his idea of cure with Janov's, stating that while Janov regarded it as the emergence of a primal person, he regarded it as the integration of all aspects of a person, including body, emotions, mind, and spirit.

Kronemeyer rejected some earlier methods that were used in attempts to change homosexuality, including lobotomy, electroshock treatment, and Aesthetic Realism.

Reasons why people seek to change sexual orientation
A majority of people who attempt to change their sexual orientation come from conservative religious backgrounds. A study by Spitzer found that 79% of 200 men and women who said they changed their sexual orientation were motivated by religion, with 93% indicating that religion is "extremely" or "very" important. Others indicated their desire came from moral or social values, which may be independent of their religion. Many people also say they wish to remain faithful to a spouse, or wish to enter into an opposite-sex marriage. Spitzer's study indicated that 67% of the men and 35% of women listed this as a reason.

Many people may seek to change their sexual orientation as a way to avoid behaviors which they perceive as being associated with homosexuality, such non-monogamy. Some men perceive that men who have sex with men are at higher risk for HIV infection and other sexually transmitted diseases, and seek to change their sexual orientation to avoid what they see as risky sexual behavior.

An APA task force found that people often sought out SOCE due to (a) a lack of other sources of social support; (b) a desire for active coping and (c) access to methods of sexual orientation identity exploration and reconstruction. The American Psychological Association states that harassment and abuse, as well as pressure from family, peers, and religious groups ignorant about and prejudiced against homosexuality, may cause high levels of emotional stress for LGB people. These pressures may lead people to feel forced into attempting to change their sexual orientation. Other researchers have found that social pressure plays a key role in a person's desire to change his or her sexuality.

Effects of SOCE
The American Psychological Association appointed the Task Force on Appropriate Therapeutic Responses to Sexual Orientation to review the available research. The Task Force reached in the following findings:

Recent studies of participants in Sexual Orientation Change Efforts (SOCE) identify a population of individuals who experience serious distress related to same sex sexual attractions. Most of these participants are Caucasian males who report that their religion is extremely important to them (Beckstead & Morrow, 2004; Nicolosi, Byrd, & Potts, 2000; Schaeffer, Hyde, Kroencke, McCormick, & Nottebaum, 2000; Shidlo & Schroeder, 2002, Spitzer, 2003). These individuals report having pursued a variety of religious and secular efforts intended to help them to change their sexual orientation. To date, the research has not fully addressed age, gender, gender identity, race, ethnicity, culture, national origin, disability, language, and socioeconomic status in the population of distressed individuals.

There are no studies of adequate scientific rigor to conclude whether or not recent SOCE do or do not work to change a person’s sexual orientation. Scientifically rigorous older work in this area (e.g., Birk, Huddleston, Miller, & Cohler, 1971; James, 1978; McConaghy, 1969, 1976; McConaghy, Proctor, & Barr, 1972; Tanner, 1974, 1975) found that sexual orientation (i.e., erotic attractions and sexual arousal oriented to one sex or the other, or both) was unlikely to change due to efforts designed for this purpose. Some individuals appeared to learn how to ignore or limit their attractions. However, this was much less likely to be true for people whose sexual attractions were initially limited to people of the same sex.

Although sound data on the safety of SOCE are extremely limited, some individuals reported being harmed by SOCE. Distress and depression were exacerbated. Belief in the hope of sexual orientation change followed by the failure of the treatment was identified as a significant cause of distress and negative self-image (Beckstead & Morrow, 2004; Shidlo & Schroeder, 2002).

Although there is insufficient evidence to support the use of psychological interventions to change sexual orientation, some individuals modified their sexual orientation identity (i.e., group membership and affiliation), behavior, and values (Nicolosi, Byrd, & Potts, 2000). They did so in a variety of ways and with varied and unpredictable outcomes, some of which were temporary (Beckstead & Morrow, 2004; Shidlo & Schroeder, 2002). Based on the available data, additional claims about the meaning of those outcomes are scientifically unsupported.

Position of professional organizations on SOCE
The World Health Organization's ICD-10, which is widely used internationally outside of North America (where DSM-IV-TR is used), states that "sexual orientation by itself is not to be regarded as a disorder". It lists ego-dystonic sexual orientation as a disorder instead, the diagnosis for which is when "the gender identity or sexual preference (heterosexual, homosexual, bisexual, or prepubertal) is not in doubt, but the individual wishes it were different because of associated psychological and behavioural disorders, and may seek treatment in order to change it."

In 2012, the Pan American Health Organization (the North and South American branch of the World Health Organization) released a statement cautioning against "services that purport to 'cure' people with non-heterosexual sexual orientations" as they "lack medical justification and represent a serious threat to the health and well-being of affected people", and noted that "there is a professional consensus that homosexuality is a normal and natural variation of human sexuality and cannot be regarded as a pathological condition". The organization further called "on governments, academic institutions, professional associations and the media to expose these practices and to promote respect for diversity." They further noted that adolescents have sometimes been forced to attend these therapies involuntarily, being deprived of their liberty and sometimes kept in isolation for several months, and that these findings were reported by several United Nations bodies. Additionally, the organization recommended that such malpractices be denounced and subject to sanctions and penalties under national legislation, as they constitute a violation of the ethical principles of health care and violate human rights that are protected by international and regional agreements.

The American Psychiatric Association "affirms that same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality regardless of sexual orientation identity; reaffirms its position that homosexuality per se is not a mental disorder and opposes portrayals of sexual minority youths and adults as mentally ill due to their sexual orientation; concludes that there is insufficient evidence to support the use of psychological interventions to change sexual orientation; encourages mental health professionals to avoid misrepresenting the efficacy of sexual orientation change efforts by promoting or promising change in sexual orientation when providing assistance to individuals distressed by their own or others’ sexual orientation; concludes that the benefits reported by participants in sexual orientation change efforts can be gained through approaches that do not attempt to change sexual orientation; concludes that the emerging knowledge on affirmative multiculturally competent treatment provides a foundation for an appropriate evidence-based practice with children, adolescents and adults who are distressed by or seek to change their sexual orientation; advises parents, guardians, young people, and their families to avoid sexual orientation change efforts that portray homosexuality as a mental illness or developmental disorder and to seek psychotherapy, social support and educational services that provide accurate information on sexual orientation and sexuality, increase family and school support, and reduce rejection of sexual minority youth; encourages practitioners to consider the ethical concerns outlined in the 1997 APA Resolution on Appropriate Therapeutic Response to Sexual Orientation, in particular the following standards and principles: scientific bases for professional judgments, benefit and harm, justice, and respect for people’s rights and dignity; encourages practitioners to be aware that age, gender, gender identity, race, ethnicity, culture, national origin, religion, disability, language, and socioeconomic status may interact with sexual stigma, and contribute to variations in sexual orientation identity development, expression, and experience; opposes the distortion and selective use of scientific data about homosexuality by individuals and organizations seeking to influence public policy and public opinion and will take a leadership role in responding to such distortions; supports the dissemination of accurate scientific and professional information about sexual orientation in order to counteract bias that is based in lack of knowledge about sexual orientation; and encourages advocacy groups, elected officials, mental health professionals, policy makers, religious professionals and organizations, and other organizations to seek areas of collaboration that may promote the wellbeing of sexual minorities."

The American Psychiatric Association states: "It is possible to evaluate the theories which rationalize the conduct of "reparative" and conversion therapies. Firstly, they are at odds with the scientific position of the American Psychiatric Association which has maintained, since 1973, that homosexuality per se, is not a mental disorder.  The theories of "reparative" therapists define homosexuality as either a developmental arrest, a severe form of psychopathology, or some combination of both.  In recent years, noted practitioners of "reparative" therapy have openly integrated older psychoanalytic theories that pathologize homosexuality with traditional religious beliefs condemning homosexuality. The earliest scientific criticisms of the early theories and religious beliefs informing "reparative" or conversion therapies came primarily from sexology researchers.  Later, criticisms emerged from psychoanalytic sources as well. There has also been an increasing body of religious thought arguing against traditional, biblical interpretations that condemn homosexuality and which underlie religious types of "reparative" therapy."

Mainstream health organizations critical of attempts to change sexual orientation include the American Medical Association, American Psychiatric Association, the American Psychological Association, the American Counseling Association, the National Association of Social Workers, the American Academy of Pediatrics, the American Association of School Administrators, the American Federation of Teachers, the National Association of School Psychologists, the American Academy of Physician Assistants, and the National Education Association.

In the United Kingdom, the Royal College of Psychiatrists states: "The Royal College shares the concern of both the American Psychiatric Association and the American Psychological Association that positions espoused by bodies like the National Association for Research and Therapy of Homosexuality (NARTH) in the United States are not supported by science. There is no sound scientific evidence that sexual orientation can be changed. Furthermore so-called treatments of homosexuality as recommended by NARTH create a setting in which prejudice and discrimination can flourish. The Royal College of Psychiatrists holds the view that lesbian, gay and bisexual people should be regarded as valued members of society who have exactly similar rights and responsibilities as all other citizens."

In Australia, the Australian Psychological Society states: "Even though homosexual orientation is not a mental illness and there is no scientific reason to attempt conversion of lesbians or gays to heterosexual orientation, some individuals may want to change their own sexual orientation or that of another individual (for example, parents seeking therapy for their child). Some therapists who undertake this kind of therapy report that they have changed their client's sexual orientation (from homosexual to heterosexual) in treatment. Close scrutiny of these reports shows that many of the claims come from organisations with an ideological perspective on sexual orientation rather than from mental health researchers. Also, the treatments and their outcomes are poorly documented and the length of time that clients are followed up after the treatment is sometimes too short to be a true reflection of the outcome. In other cases it has been shown that individuals can be assisted to live a heterosexual lifestyle, but that their sexual orientation remains unchanged. In other words, their pattern of arousal to members of the same sex does not alter. The Australian Psychological Society acknowledges the lack of scientific evidence for the usefulness of conversion therapy, and notes that it can in fact be harmful for the individual."

In China, Western psychiatry and psychology were imported during a "Westernization Movement" in the late 19th century. At that time, the West viewed homosexuality as a mental disorder, and that became the prevailing view in China as well. During this period, homosexual sexual behavior was grounds for persecution, a marked change from the attitude of general (but not total) acceptance found in pre-19th-century China. These views lasted throughout the 1970s, despite changed theoretical models of sexuality orientation in the West, during a period when the Chinese government held a "closed-door" policy on information about human sexuality. After 1980, information became more available, and views began to change. In 2000 and under pressure from both the APAs and the ACA, the Chinese Classification of Mental Disorders (CCMD-III) declassified homosexuality, but added a diagnosis resembling ego-dystonic sexual orientation. Attempts to change sexual orientation are rare in China.

In India, psychiatry and psychology scholars have "preserved an almost complete silence on the subject of homosexuality". One paper discusses behavior modification methods used to treat the sexual orientation of thirteen gay patients. They use the WHO classification of egodystonic sexual orientation, but the People's Union for Civil Liberties reports that doctors will often diagnosis the patient as egodystonic even if the patient really is egosyntonic.

In Italy, little research has been conducted in the mental health community on homosexuality. Early work tended to describe homosexuality as a pathology or a developmental arrest. More recently, attitudes have begun to change: "with a lag of about ten years, Italy has followed ... the attitudes of American mental health professions toward homosexuality".

In Germany, the psychiatry, psychology, and sexology establishment from the early 20th century viewed homosexuality as pathological. However, following the increased visibility of the homosexual community during the AIDS epidemic of the late 1980s and the declassification of homosexuality as a mental disorder in the ICD-10, non-pathological, rather than pathological, models of homosexuality became mainstream.

Japan's psychiatric body removed homosexuality from its list of psychiatric disorders in 1995.

In Norway, a country known for its strong LGBT rights legislation, the shift from a pathological to non-pathological understanding of homosexuality began in the 1970s, following the APA's declassification in 1973. In 2000, the General Assembly of the Norwegian Psychiatric Association overwhelmingly voted for the following position statement on sexual orientation change therapy: Homosexuality is no disorder or illness, and can therefore not be subject to treatment. A ‘treatment’ with the only aim of changing sexual orientation from homosexual to heterosexual must be regarded as ethical malpractice, and has no place in the health system.

Debate
Changing sexuality has become highly politicized, and the ensuing debates "have obscured the scientific data by calling into question the motives and even the character of individuals on both sides of the issue." The ethics, efficacy, benefits, and potential for harm of SOCE are under extensive debate, both in the professional literature and the popular media. Concerns have been expressed about forcing people to undergo SOCE against their will, blocking people who are seeking to change their sexual orientation from attempting to do so, and concern over the way SOCE is being promoted affects LGB rights.

The American Psychoanalytic Association says psychoanalytic SOCE often causes psychological pain by reinforcing internalized homophobia.

Chuck Bright wrote that refusing to endorse a procedure that "has been deemed unethical and potentially harmful by most medical and nearly every professional psychotherapy regulating body cannot be justifiably identified as prohibiting client self-determination." Some commentators, recommending a hard stand against the practice, have found therapy inconsistent with a psychologist's ethical duties because "it is more ethical to let a client continue to struggle honestly with her or his identity than to collude, even peripherally, with a practice that is discriminatory, oppressive, and ultimately ineffective in its own stated ends." They argue that clients who request it do so out of social pressure and internalized homophobia, pointing to evidence that rates of depression, anxiety, alcohol and drug abuse and suicidal feelings are roughly doubled in those who undergo therapy.

Forced SOCE
Until the 1970s, homosexuality was considered a mental illness and homosexuals were forced by the government to undergo treatment. Famous cases include Alan Turing. This practice is outlawed in most of the world, but human right groups have complained that in some parts of the world, treatment is still being forced upon unwilling patients.

In one of the few published U.S. cases dealing with conversion therapy, the Ninth Circuit addressed the topic in the context of an asylum application. A Russian citizen "had been apprehended by the Russian militia, registered at a clinic as a 'suspected lesbian,' and forced to undergo treatment for lesbianism, such as 'sedative drugs' and hypnosis." The Ninth Circuit held that the conversion treatments to which Pitcherskaia had been subjected constituted mental and physical torture. The court rejected the argument that the treatments to which Pitcherskaia had been subjected did not constitute persecution because they had been intended to help her, not harm her, stating that "human rights laws cannot be sidestepped by simply couching actions that torture mentally or physically in benevolent terms such as 'curing' or 'treating' the victims."

There have been few, if any, medical malpractice lawsuits filed on the basis of conversion therapy. Laura A. Gans suggested in an article published in The Boston University Public Interest Law Journal that this is due to an "historic reluctance of consumers of mental health services to sue their care givers" and "the difficulty associated with establishing the elements of... causation and harm... given the intangible nature of psychological matters." Gans also suggested that a tort cause of action for intentional infliction of emotional distress might be sustainable against therapists who use conversion therapy on patients who specifically say that his or her anxiety does not arise from his or her sexuality.

Another concern is unwilling patients, particularly children, being forced into SOCE. Children experience significant pressure to conform with sexual norms, particularly from their peers, and often lack adequate legal protection from coercive treatment.

In 2005, Love In Action, an ex-gay ministry based in Memphis, was investigated by the Tennessee Department of Health and the Tennessee Department of Mental Health and Developmental Disabilities for providing counseling and mental health care without a license, and for treating adolescents without their consent. There have been reports that teenagers have been forcibly treated with conversion therapy on other occasions. Several legal researchers argue that parents who force their children into aggressive conversion therapy programs are committing child abuse under various state statutes.

Some advocates of SOCE (including NARTH ) have spoken in favor of a patient's right to reject SOCE and embrace a lesbian, gay or bisexual identity. Richard A. Cohen, an advocate of conversion therapy, has said, "If someone wants to live a gay life, that needs to be respected. If someone wants to change and come out straight, that too needs to be respected. Let us practice true tolerance, real diversity, and equality for all."

Voluntary SOCE
Gregory M. Herek, a professor of psychology at the University of California, Davis, wrote: "Few would dispute that some people’s sexual orientation changes during their lifetime. Indeed, many lesbians and gay men report living as a heterosexual before recognizing or developing their homosexual orientation. The question at issue is not whether sexual orientation can change but whether interventions can be designed to bring about such change."

Position of SOCE advocates
Positive Alternatives to Homosexuality, a coalition of ex-gay groups, supports the right for individuals to pursue a non-homosexual identity if they so choose, the right to know information the coalition provides to make informed decisions, and the right of those conflicted by their homosexual attraction to self-determine their own goals in therapy. They advocate compassion and respect specifically for ex-homosexuals and those on that path, and policy neutrality in creating laws that would inhibit freedom of speech to discuss SOCE. They claim equal access to public forums to state their viewpoint, share their experiences, and to raise awareness of ways to reject a gay identity.

Promotion of SOCE
The American Psychological Association and the Royal College of Psychiatrists expressed concerns that the positions espoused by NARTH and Focus on the Family are not supported by the science and create an environment in which prejudice and discrimination can flourish. The Just the Facts Coalition, consisting of the American Academy of Pediatrics, American Association of School Administrators, American Counseling Association, American Federation of Teachers, American Psychological Association, American School Counselor Association, American School Health Association, Interfaith Alliance Foundation, National Association of School Psychologists, National Association of Secondary School Principals, National Association of Social Workers, National Education Association, and the School Social Work Association of America, in 2008 released Just the Facts About Sexual Orientation and Youth. In it, they expressed concern that the advancement of SOCE may cause social harm by disseminating inaccurate views about sexual orientation.

The National Gay and Lesbian Task Force has described the recent support for sexual orientation change efforts as "the Christian Right repackag[ing] its anti-gay campaign in kinder, gentler terms. Instead of simply denouncing homosexuals as morally and socially corrupt, the Christian Right has now shifted to a strategy of emphasizing ... the ex-gay movement. Behind this mask of compassion, however, the goal remains the same: to roll back legal protections for lesbian, gay, bisexual and transgender people ..."

Psychologist John Gonsiorek said the way in which the Christian right promoted SOCE was hypocritical. He wrote "some conservative Christian institutions actively foster social conditions to maximize distress for such clients about their sexual orientations, and these institutions simultaneously promote conversion therapy as the solution to this distress." Prominent ex-gay Joe Dallas, while opposing homosexual sex, called Christians to repent of their hostility toward homosexuals and reach out to them: "I find to this day that there is a certain wrath Christians often express towards this sin that they do not express towards other sins – both sexual and non-sexual. And that's a problem. It's an imbalance."

Ecuador
In November 2011, an Ecuadorean activist group, called Fundación Causana, began a petition on Change.org to entreat the Ecuadorean minister of health to close down more than 200 illegal "ex-gay clinics". The group claimed that the clinics abuse and torture patients in an effort to "cure homosexuality".

The clinics primarily targeted lesbians and operated under the guise of being drug rehabilitation centers. At least one pair of parents discovered the abuse and asked for the clinic to release their daughter, Paola Ziritti, but were denied. Ziritti was eventually released after two years of confinement and was the first to press a formal complaint against the clinics.

Activists consequently called on the government to close down the clinics, but as of August 2011, only 27 had been closed while a reported 207 clinics remained open.

On 23 January 2012, the Change.org petition was closed and marked as a success with 113,761 international signatures. The petition also was updated with a statement from Fundacion Causana reading, "After ten years of outcry, the nation of Ecuador - through the Ministry of Public Health - has entered into a commitment with civic organizations and society in general to deconstruct the belief that homosexuality is an illness and root out the use of torture in these clinics. We extend our thanks to all the men and women who signed our petition. It has been invaluable to have this support in starting to change this reality."

Carina Vance Mafla's ministry of health shortly thereafter raided three clinics in the vicinity of Quito and rescued dozens of women.

United Kingdom
In 2013, several LGBT organizations and a number of members of Parliament called on the government to ban gay conversion therapy.

United States
In August 2012, the California State Legislature approved SB 1172 prohibiting mental health providers from engaging in sexual orientation change efforts with minors, which Governor Jerry Brown signed into law on September 29, 2012. Opponents challenged the law in federal court, and on December 21, 2012, hearing Pickup v. Brown, the Ninth Circuit issued an emergency injunction barring enforcement.

In June 2013, the New Jersey Legislature passed A3371 which would make it illegal to engage in sexual orientation change efforts on minors. It now awaits Governor Chris Christie's signature.

As of July 2013, the Massachusetts General Court is considering a similar bill that would protect minors from sexual orientation and/or gender identity change efforts.