Experts weigh in on conversion therapy

November 12, 2015

In the first ever consensus statement on conversion therapy for LGBTQ children, an expert panel cautions against the practice, calling it both ineffective and harmful.

Conversion therapy for lesbian, gay, bisexual, transgender, and queer (LGBTQ) children is not an appropriate, evidence-based intervention, and should be avoided, according a new report outlining the first published consensus statement on conversion therapy and the role of pediatricians in effecting change to the LGBTQ treatment regimen.

“Pediatricians can play a critically productive role in helping families understand appropriate therapeutic and support approaches when dealing with LGBTQ children,” says Elliot Kennedy, special expert for Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Policy Liaison Branch. “Pediatricians are very often the first health professionals families turn to when they need help addressing issues that have arisen because their child is, or is perceived to be, LGBTQ.”

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The report, “Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth,” was released in October by the SAMHSA to provide a comprehensive review of conversion therapy. The consensus was reached by an expert panel convened by the American Psychological Association in July 2015. The panel found that variations in sexual orientation and gender identity are normal, and conversion strategies are both harmful and ineffective.

The expert panel noted that gender development begins in infancy, and gender diversity or dysphoria can emerge as early as the preschool years and as late as adolescence. In some cases, gender dysphoria will be replaced in adolescence or adulthood with cisgender, and a majority of these children will identify as lesbian, gay, or bisexual as adults. For those who don’t fall into these categories, gender dysphoria will persist and usually worsen with the physical changes brought on by adolescence, according to the report, and these children will eventually identify as transgender in most cases. Gender dysphoria may also emerge after puberty without any childhood history, the report notes.

The physical effects of puberty in children with gender dysphoria can be difficult for these children to process, and they may suffer from depression, anxiety, or other behavioral issues, the report notes. These problems can be caused or exacerbated by social attitudes or judgments, putting these children at an increased risk of victimization, violence, suicide attempts and ideation, and homelessness.

“Being a sexual or gender minority, or identifying as LGBTQ, is not a mental disorder,” the report states. “Variations in sexual orientation, gender identity, and gender expression are normal. Sexual and gender minority children have unique health and behavioral health needs, and may experience distress related to their sexual orientation or gender, as well as others’ responses to their current, future, or perceived sexual orientation, gender expression, or gender identity. In addition, gender minority youth may experience distress caused by the incongruence between their gender identity and physical body.”

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With conversion therapy off the table, the expert panel offers appropriate therapeutic guidance based on current evidence and research that includes providing the children with accurate information on sexual orientation and gender development, providing family and school support, and focusing on reducing social rejection. Treatments should focus on providing a comprehensive evaluation and providing the child with support in their identity exploration without establishing a fixed goal of a particular gender or sexual orientation, the report notes. These interventions, however, will not make the journey to a child finding acceptance necessarily easy.

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“Eliminating the practice of conversion therapy 
with sexual and gender minority minors is
 an important step, but it will not alleviate the myriad of stressors they experience as a result of interpersonal, institutional, and societal bias and discrimination against sexual and gender minorities,” the report states. “[The] LGBTQ youth still need additional support to promote positive development in the face of such stressors. Supportive family, community, school, and healthcare environments have been shown to have great positive impacts on both the short- and long-term health and well-being of LGBTQ youth. Families and others working with LGBTQ children and adolescents can benefit from guidance and resources to increase support for sexual and gender minority minors and to help facilitate the best possible outcomes for these youth.”

Pediatricians are in a unique role to assist LGBTQ children and their families, since they have established, and usually long-standing relationships already in place. For this reason, the report suggests that pediatricians keep up-to-date on therapeutic interventions for LGTBQ children, and maintain a roster of professionals to whom they can refer families for additional support.

A number of resources are available to help pediatricians navigate this process, including a set of competencies compiled by the Association of American Medical Colleges in 2014, and practice parameters set out by the American Academy of Child and Adolescent Psychiatry that deals with the importance of addressing family dynamics when working with families with LGBTQ children.

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Key principles of these recommendations include providing families with accurate information about what is means to be LGBTQ, paying particular attention to family and parent questions about the healthiness or normality of their child’s behaviors.

“This can be particularly important for transgender and gender nonconforming youth, who may be seeking medical interventions to help mitigate the effects of untreated gender dysphoria, as some parents might hold the belief that their youth’s gender identity is inherently pathological,” the report states. “In fact, it is the associated gender identity-sex anatomy discrepancy that characterizes gender dysphoria, and which is the treatable phenomena, not the gender identity itself.”

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Lesbian, gay, bisexual, transgender, and queer children who come from families that highly reject their gender identity or sexual preferences are 9 times more likely to engage in suicidal attempts or behaviors, according to the report, and pediatricians should be on the lookout for signs of these family reactions and provide appropriate support and counseling.

Pediatricians should also work to ensure that their practice fosters a climate that provides comfort and acceptance to LBGTQ children. This can be accomplished by adjusting intake forms to include both gender identity and sex assigned at birth, training frontline staff to ask for pronoun and name preferences, and to form relationships with LGBTQ community organizations that can provide additional support to patients.

In terms of medical care, pediatricians should also note when it is appropriate-as in cases of gender dysphoria-to offer medical interventions such as pubertal suppression or cross-gender hormone therapy, according to the report. This may require collaboration with a behavioral health provider, endocrinologist, or surgeon.

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The American Academy of Pediatrics and American College of Physicians also offer specific guidance on treating LGBTQ children, as the appropriateness of medical interventions vary by the age of the child and their particular situation. The report notes that no medical interventions are currently recommended for children who have not yet reached puberty, and are most effective in young adolescents with gender dysphoria. Not all children with gender dysphoria necessarily want to live permanently or completely as the other gender, the report cautions, and thorough evaluations and counseling should be undertaken prior to the initiation of any medical therapies.

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“Youth should realize that medical intervention or a complement of hormone therapy and gender affirming surgeries are not the only treatment option to solve gender dysphoria, and should realize that gender dysphoria may exist in many forms and intensities,” the report notes.

Additionally, even when medical interventions are occurred, continued psychological support remains important

“Continued mental health treatment should be offered when an adolescents’ gender incongruence requires further exploration and/or when other psychological, psychiatric, or family problems exist,” according to the report. “Adolescents receiving medical intervention without these additional concerns may also benefit from continued psychological treatment; given that pubertal suppression or administration of hormone therapy occurs over many years during important developmental periods, the need for psychological treatment may change with time as new questions arise.”

Suppression of puberty remains and controversial treatment, according to the report, yet current research supports the intervention as “promising,” as well as fully reversible.