In Defence of ‘Conversion Therapy’

Under a law that the Government plans to introduce, the successful management of a sexually confused and anxious adolescent in 1978 that I’m about to describe could mean a large fine or even prison for doctors and psychologists taking the same approach next year. At that time, I was the psychiatrist attached to a university health service. It had very competent psychologists and I was only consulted about the more serious cases. One of those, involving a student who had made a nearly-fatal suicide attempt, was so unusual that I reported it in the British Medical Journal. The psychologists thought that anxiety about his sexuality was an important factor. He always made his excuses and left if actual sex with women looked imminent. That’s what had precipitated his suicide attempt, but since his masturbatory fantasies involved muscular men, the psychologists, very understandably, thought he was probably gay but repressing his inclinations. 

The student had had similar thoughts. Only a decade after the partial decriminalisation of homosexuality, guilt and repression were more common than they are today. When I delicately inquired about his sexual fantasies, he confirmed that they mainly involved men but when we got down to the sweaty details, it turned out that the men were never actually doing anything to him, or he to them. When clothed, he looked like a pretty average male student and he wasn’t short of friends of both sexes but he was scrawny and his body-image was very poor. The muscular men seemed to represent the sort of body that he wished he had and presumed that women also preferred.

Equally understandably, the management options we discussed included contact with gay groups but he didn’t seem very interested in gay sex. It was his fear of failure with women that had prevented him from ever taking that final practical test. In fiction and presumably in real life, some fathers take a hesitant and inexperienced son to see a ‘tart with a heart’ to be patiently introduced to sex. Today, the internet might easily locate one but this was 1978. Fortunately, the newly-described sexual surrogate therapy was available locally. Surrogates do much the same as the understanding tarts but are more formally therapeutic, less commercial and don’t have to rush things. Initially he opposed the idea, maintaining that sex couldn’t be separated from a ‘real’ relationship but agreed after another serious intimacy-related suicide attempt.

Over a period of four months, he had nine sessions (generously provided gratis by a married woman not long out of university herself) of which the first six involved only talking or varying degrees of petting, during which men faded out of his fantasies and women faded in. Eventually he had successful sexual intercourse on three occasions. A year later, I reported that “although he had not found ‘the right girl’, he was confident that when he did, there would be no sexual problem”. He needed no further help and made no more suicide attempts. I can resurrect his story without embarrassing him because after becoming a prominent novelist, he died several years ago. The obituaries recorded more than one long-term female partner.

I don’t believe that my management damaged his rights, his mental health or his prospects and it clearly removed his very high suicide risk. Ultimately, the choice was his, not mine. My main role was to present the management options and discuss their pros and cons. If he had been more sexually ambivalent, I might have suggested confidence-building in gay sex as well because in most areas of life, adaptability confers both social and Darwinian advantages. There are probably more bisexual men and women than exclusively gay ones but the proposed law may make conversations of this kind with sexually ambivalent patients too risky for most psychiatrists and psychologists to contemplate. Yet if I had simply ‘affirmed’ that initial apparent homosexuality, as organisations like Stonewall prefer, his obituaries indicate that I could have done him a serious disservice.

This story is relevant to The Great Trans Debate. Like most general adult psychiatrists, I saw a few transsexuals and never found them particularly difficult to deal with before referring them to specialist gender clinics. I’m also on nodding terms with a discreet trans-woman (biological male) who made a successful career in the arts but most of today’s would-be transsexuals are not what they used to be.  Until around 2000, the people who sought trans-surgery were mainly chromosomal males in their late teens, 20s or 30s. Like that classy transsexual Jan Morris, they often had no obvious major psychological concerns other than their unusual but overwhelming desire to change gender. Now, they are mostly pubescent or barely post-pubescent girls and most also have psychiatric problems like severe anorexia and autism. 

That new predominance of chromosomal females seems particularly significant because one of the most persistent psychiatric differences between men and women in nearly all cultures is the much greater female incidence of mass hysteria. The de-stigmatisation of mental illness means that the preferred term is now ‘mass psychogenic (or sociogenic) illness’ but its basic nature hasn’t changed. Epidemics typically occurred in single-sex female institutions like schools, nurses’ homes and nunneries, as in Ken Russell’s film The Devils. They are much rarer in the male equivalents but instead of nunneries, today’s typical aspiring young mutilées inhabit the seductive, mass hysteria-generating echo-chambers of social media. The mass-hysteria-like epidemic of transsexuality that I think we are seeing and which partly explains the Tavistock scandal is not like classic examples. They are usually short lived, rarely lasting more than a few weeks but it does look rather like the slow-burning varieties that have also been recorded. The psychogenic fits of the 18th century convulsionnaires of St Médard continued intermittently for over 50 years and the internet means that mass hysteria now spreads far beyond the walls of any single institution.

The campaign to destigmatise psychiatric diagnoses was well-meant but recent horrors like the Nottingham murders by Valdo Colocane can hardly have reduced public fear about patients with paranoid schizophrenia and other major psychoses – especially when the massive reduction in psychiatric beds since 1978 means that most of them now live among us instead of in psychiatric hospitals. Psychiatric diagnoses used to be labels that most people wished that they didn’t have and if they did have one, they usually kept quiet about it. They certainly weren’t proud of them, except perhaps for some classic manic-depressives because a little bit of mania can be very useful if it produces new ideas and the energy to pursue them. I was thanked by their support group for an article in the Times that described it as ‘the achiever’s insanity’ but that’s about the only exception. Severe autism is a serious handicap, frequently requiring long-term institutional care, and the milder and vaguer versions that burden schools and the NHS seem to have more potential for social friction than a touch of mania. I’m not suggesting a return to 1978 levels of shame and stigma. Just fewer demands for fashionable  psychiatric diagnoses and more awareness of  unfashionable ones like mass hysteria. Nobody ever flaunts that label.

Colin Brewer’s is a retired psychiatrist specialising in addictions whose latest book, The God Effect How Suggestion and Ritual Shape Religion and Medicine through Placebo Responses, is out now. Praise from Theodore Dalrymple: “Clear, incisive, witty, iconoclastic but without intolerance, disdain or bitterness, this book will open many people’s eyes to the power of placebo. It might even make then feel better.”