Christopher H. Rosik, Ph.D., NARTH (National Association for Research & Therapy of Homosexuality) President, analysis:
California SB 1172 [SB-1172 Sexual orientation change efforts.(2011-2012)] 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 open proponents 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. The APA Task Force (2009) severely critiqued the SOCE research on these grounds, 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.
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.
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