The case to end sexual orientation change efforts in Lebanon

First do no harm

Homosexuality is part of the natural spectrum of human identity and is not a disease, a disorder, or an illness to be treated or “fixed.” However, there is a plethora of evidence documenting the challenges that lesbian, gay, bisexual, and transgender (LGBT) people experience daily as a result of discrimination, rejection, and stigma.

Sexual orientation change efforts (SOCE) are increasingly regarded as harmful. These practices attempt to change a person’s sexual orientation through counseling, psychotherapy, or other means. Historically, SOCE have included some extreme measures, such as forced institutionalization, forced medication, and electroconvulsive shock therapy. These efforts are the product of a lack of respect for normal human differences and have been proven ineffective. Most importantly, these practices have harmful effects on the mental and physical health of the individuals being pressured into them.

In the United States, it was estimated in a 2010 study that approximately 20,000 youths between the ages of 13 to 17 who do not identify as heterosexual or straight would be exposed to SOCE by the age of 18.

In Lebanon, people who belong to sexual and gender minorities lack protection and support from societal and family-based discrimination. Policies to protect LGBT people in schools, universities, and workplaces do not exist. Also, misconceptions about sexual rights, sexual orientation, and gender identity are widespread. A national study in 2015 showed that 79 percent of respondents thought homosexuality was a hormonal sickness and 72 percent viewed it as a mental disorder. Around 80 percent of the respondents agreed that homosexual people should be taken in for psychological or hormonal treatment.

In 2018, the Lebanese Medical Association for Sexual Health (LebMASH), of which we are both board members, collaborated with Helem, an LGBT rights organization, to conduct a pilot study in order to better understand SOCE in Lebanon. The study involved interviews with gay and lesbian people who were subjected to SOCE, mental health providers whose patients have discussed being subjected to SOCE, and providers who practice SOCE. The team also reviewed television interviews that aired from 2010-2016 with healthcare professionals that dealt with SOCE.

This pilot study revealed that in Lebanon, SOCE is most commonly initiated by parents, who take their gay or lesbian children for a consultation, typically at the suggestion of a school nurse or teacher. Health providers, urologists, and clerics are all represented in the SOCE industry. SOCE appear to be fueled by religious beliefs and cultural values, but more importantly, demand for it is based on defunct theories about homosexuality—with some believing that such sexual orientations are the result of trauma, the absence of a father figure, or other factors related to upbringing. It is important to note that attempts to conform to heteronormative expectations also affect bisexual and transgender people, but our study was solely focused on gay and lesbian people.

Our findings showed that most SOCE practices include psychological pressure and suggestive counseling, involving shaming or pushing the person to behave in a way that contradicts how they would act if left to their own volition. Examples of this pressure under the guise of encouraging “normal behavior” would be to suggest to a homosexual man that he should force himself to have sex with a woman. Other practices included prescribing hormones or medications typically used for erectile dysfunction, without a clinical indication for their use. One provider talked about performing electroshock “therapy” on patients as they watched gay pornography, though the study team was unable to find any individuals who had been subjected to this. Individuals who were subjected to various kinds of SOCE reported increased feelings of shame, depression, anxiety, and even suicidal thoughts.

Legal and medical perspectives are changing

Due to SOCE’s harmful effects, leading medical and mental health organizations in the US, such as the American Psychiatric Association and the American Psychological Association, have condemned SOCE. The Pan American Health Organization (PAHO), which is the WHO’s regional body in the Americas, has strongly condemned SOCE. Furthermore, in the US, as of July 2018, 14 states have laws banning SOCE for minors, and 21 other states have pending bills addressing the same issue. In 2016, Malta was the first country in Europe to ban SOCE, with a law against trying to change, repress, or eliminate a person’s sexual orientation. The European Parliament also condemned SOCE earlier this year and encouraged its member states to issue bans on SOCE. The United Kingdom is currently considering a bill in parliament that would ban SOCE, after Prime Minister Theresa May vowed to do so earlier this year. In Lebanon, the Lebanese Psychiatric Society (LPS) and the Lebanese Psychological Association (LPA) each issued strong statements in 2013 affirming that homosexuality was not a disease and condemning SOCE.

As healthcare professionals, we have two fundamental beliefs: Everyone has an equal right to the highest quality of care regardless of their personal attributes—such as age, sex, socioeconomic status, religion, sexual orientation, or gender identity—and that healthcare professionals are bound by a duty to do no harm. Therefore, to eliminate SOCE practices we strongly advocate to first raise awareness that:

(1) Homosexuality is not a choice. Whether homosexual, bisexual, or heterosexual, individuals are not able to choose their sexual orientation.

(2) Homosexuality is not a disease. Homosexuality is a normal variation of human sexuality. Homosexual people are equal to heterosexual people in their ability to achieve normal psychological, social, and professional functioning. Homosexuality is not related to a hormonal imbalance.

(3) Homosexuality is not related to certain factors during upbringing and cannot be explained by other similar theories. These theories are defunct and have no scientific backing.

We, secondly, call for all practitioners in the field of sexual counseling, and all mental health providers, to receive further training on working with sexual minorities and emphasize that those who practice SOCE are not following the appropriate guidelines or current standards of care.

As members of LebMASH, we further recommend that all people involved in sexual orientation and gender identity discussions with family, friends, and school personnel consult with competent healthcare providers, such as those listed under LebGUIDE—our list of providers that have been screened for their attitudes and behaviors toward LGBT people through a self-reported survey and interviews, and that have met our criteria for inclusion. We, finally, call on the Lebanese government to institute a ban on SOCE, especially its application on minors.

Allowing healthcare providers to engage in harmful SOCE punishes LGBT people simply for being who they are. SOCE do not have scientific validity, are ineffective in their stated goal, and come with great risks. Exposure to SOCE puts LGBT people, particularly LGBT youths, at a greater risk of mental health problems such as anxiety, depression, and even suicide. SOCE must be banned.

Omar Fattal is a psychiatrist, co-founder, and board member of LebMASH.

Suha Ballout has a doctorate in nursing and is a board member of LebMASH.

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