Conversion therapy for homosexuality: serious violation of ethics

Across the world, homosexuality is gaining legitimacy; stigma and discrimination are gradually giving way to equality and inclusion. The situation in India is in stark contrast to these trends. In this country, homosexuality is an offence as per Section 377 of the IPC. The homosexual community is fighting for its rights and continues to suffer from intense stigma and discrimination. Their healthcare needs are not at all attended to; their sexual orientation is conceptualised as a socially deviant mental disease that needs psychiatric treatment (1).

Mr T, a 20-year-old male, was taken to a psychiatrist by his parents with the request that he be “treated” for his homosexual orientation. They viewed his sexual orientation as abnormal and deviant, and felt that it was a “disease” which should be “cured”. They sought a complete medical evaluation of their son, followed by conversion therapy.

“I want my son to become a successful engineer rather than suffer on the streets like hijras,” were the words of his father. He claimed that psychiatrists “treat” these “erring males” and reconvert them into normal males through hormone therapy and electroconvulsive therapy. He insisted that his son be provided with these correctional therapies.

Mr T was in the third year of his graduate engineering course. He had a very lively campus life – he was good at academics and was an active member of the dramatics club. He enjoyed directing plays and had represented his college in inter-college meets. He had become aware of his sexual orientation during his stay in hostel, when he had felt attracted to his room-mate. He would find guys attractive and was surprised to find that he had never felt attracted towards any girl. He reported that he had fantasies and dreams about sexual encounters with only males. He had once had a brief affair with a girl, but it ended because he did not feel physically attracted to her. He also revealed that he had had anal intercourse with his room-mate and said he had thoroughly enjoyed it. He was distressed when his room-mate refused to continue with the relationship.

He felt comfortable about his sexuality, but was finding it difficult to gain peer acceptance. He was ridiculed for not being straight, and was at times mocked about being feminine. He had started feeling distressed due to this social ostracism and had started contemplating changing his sexual orientation.

This index case mirrors the unmet needs of homosexual people in India. The mounting societal pressure makes the sexual orientation extremely distressing as society views homosexuals as sinners/criminals. The verbal and physical abuse often results in a deep sense of internalised stigma, which has adverse consequences on mental health. Further compounding the pressure is the repeated pestering by parents and relatives to undergo conversion/reparative/reorientation therapy. The American Psychological Association has proscribed against conversion therapy, stating that its harms far outweigh its benefits (2). Nonetheless, psychiatrists continue practising it in some form or the other. These forms range from counselling, psychotherapy, conditioning, hormone replacement to electroconvulsive therapy (3).

Homosexuality is currently understood as a variant of normal human sexual orientation (4). The sexual orientation of a person is currently understood to be determined by a complex interplay of biological, psychological, cultural and social factors, and to a great extent, is innate and immutable. India has yet to formulate guidelines for the management of people with a homosexual orientation. The basic principles of biomedical ethics cannot be ignored while providing any form of psychiatric treatment. Conversion therapy violates all four basic principles of biomedical ethics. Trying to change the sexual orientation of people against their wishes is a serious breach of their autonomy as homosexuality per se does not cause any life-threatening risk to justify overriding the principle of autonomy.

Coming to the issue of non-maleficence, conversion therapy is known to adversely affect mental health in terms of generating feelings of shame, which can further aggravate negative affective states such as depression and anxiety (2). Since conversion therapy is not an evidence-based therapy and does not provide any benefit to the person, either in terms of providing success in change in sexual orientation or any other psychological benefit, it does not fulfil the principle of beneficence (2).

The use of conversion therapy further enhances stigma in people with a homosexual orientation and compounds their perception of discrimination. Hence, the forceful application of therapies for change in sexual orientation violates the principle of justice.

While the law in India is still taking time to provide this marginalised section of the population with its due rights, it is the duty of psychiatrists to provide homosexuals with support and care with a view to enhance their acceptance of their sexual identity and engender positive coping skills. If the treating psychiatrist adopts an approach of unconditional acceptance rather than setting the goal of changing sexual orientation, it can go a long way towards enhancing the selfdetermination and adaptive coping and strengthen the self-identity of the hapless person (2).