Title

Converting the Converters

Advocates in China Make the Case for LGBT-Affirming Mental Health Care

In an office tower in the western city of Xi’an, a lesbian woman in her 30s, who I’ll call “Xiu Ying,” sat in a conference room surrounded by psychological counselors peppering her with questions. What do your parents think? What is online dating like for lesbians? Can you explain the difference between sexual orientation and gender identity again?

The counselors weren’t subjecting Xiu to some strange therapy session. Rather, she had come to counsel the counselors.

As part of a two-day forum in July 2018 run by the Zhuangni LGBT Mental Health Center for LGBT-friendly counselors from across China, members of the country’s LGBT community facilitated small discussion groups, patiently answering questions from the dozens of curious (and mostly cisgender and straight) attendees. In an impressive display of commitment, the counselors paid their own way to Xi’an—perhaps driven by a sense of professional mission, or a chance to tap a new client stream, or both.

Concluding the session, Xiu reminded the counselors of the power they wield over the lives of their clients. “The voice of a psychological counselor is very authoritative. If you say being gay is a sickness, it’s a sickness. If you say it’s not a sickness, it’s not a sickness.” She was echoing a sentiment voiced by Dr. Damien Lu, an experienced advocate and therapist who had Skyped in from Los Angeles: “One sentence from us can change someone’s life—for the better or for the worse.”

Innumerable personal stories I have heard reflect the urgency of Xiu’s and Dr. Lu’s messages.

In Hangzhou, a gay acquaintance of mine’s mother pressured him into seeing a well-known psychiatrist. The psychiatrist ran a battery of tests, including a brain scan and a blood screening to analyze his hormone levels. The conclusion? The psychiatrist told his mother he was “pseudo-gay” (假性同性恋, jiaxing tongxinglian) and thus could lessen his attraction to men through, conveniently enough, an expensive treatment at the psychiatrist’s clinic. His mother demanded he get “treatment,” confiscated his ID card, and forbade him from returning to university, where she said he was “corrupted.” With the help of friends, he escaped and went back to university before the “treatment” commenced.

Compare this to a friend in Nanjing whose mother made her see a psychiatrist after she came out, but fortunately he did not pathologize her sexual orientation. “She’s very healthy,” the psychiatrist told her mother. “Above average, in fact!” It wasn’t like waving a magic wand, but it gave her mother pause; a long process of acceptance and reconciliation began.

Like anyone, LGBT individuals in China seek legitimate mental health services. And as elsewhere in the world, LGBT people in China experience much higher rates of anxiety, depression, and suicidality than their straight cisgender peers. Decades of research attributes this disparity to the greater social stigmatization LGBT people face, such as school bullying, family rejection, and workplace discrimination. A counselor unfamiliar with these challenges is less likely to provide competent care, while an LGBT-phobic counselor can seriously harm a client’s health.

Basing their work on this research, Chinese LGBT advocates have set out to convince China’s mental health field that being professionally competent means being LGBT-affirming (and for the already LGBT-friendly counselors, that mere friendliness is not enough—they also need to have well-developed counseling skills).

Over the past two years, as a Senior Fellow at Yale Law School’s Paul Tsai China Center, I have co-organized several seminars with scholars and advocates in China on LGBT-affirmative therapy, giving me a glimpse into their years-long uphill push to change China’s mental health field. In the rapidly shrinking space for civil society in China, their survival strategies have included building large networks of allies, offering solutions to challenges faced by mental health professionals, and reframing state agendas to include their advocacy goals. Their ability to persevere and progress shows what modes of bottom-up advocacy are still possible, even if precariously so.

Grassroots Advocacy for LGBT-Affirming Care

In one extreme conversion therapy case in 2012, Xin Ying, then a staff member of the Beijing LGBT Center and now its director, received a young lesbian woman’s cry for help through the Center’s social media account. The woman’s girlfriend’s parents had beaten her girlfriend and committed her to a mental hospital. LGBT advocates sent a lawyer to talk with the parents. The girlfriend eventually became so physically ill that she was moved to another hospital for care.

This harrowing experience made Xin determined to effect change. “I wanted us to transform the whole mental health industry,” she said. “At the time, it felt very ambitious. People would say, ‘How can you do that? You are not experts.’ But this kind of battle is not initiated by experts.”

The Beijing LGBT Center started finding allies in the mental health field—including a small group of already-out counselors—to train mental health counselors in working with LGBT clients. For the Center’s first training, staff invited every counselor they could find in Beijing. Only about 20 showed up. Before the training, half of the participating therapists said they supported conversion therapy, but by the time the training ended they had all changed their minds. Xin felt like the Center was onto something.

Dozens of events and years of painstaking work later, the Center has trained more than 600 counselors. “The level of enthusiasm and acceptance is greater and greater,” said Liu Xin, an openly gay mental health counselor at the Center who also manages its engagement with the mental health profession. Other Chinese organizations such as the Gay and Lesbian Campus Association of China, Wuhan Tongxing, and the Zhuangni LGBT Mental Health Center (whose founder, Li Chunjian, spearheaded the Beijing LGBT Center’s mental health service programs before creating his own organization) conduct similar activities, adding to the burgeoning community of LGBT-friendly counselors. “We have improved the overall atmosphere somewhat,” said Liu, “but we still don’t have enough people who qualify as adequately trained LGBT-affirmative counselors.” As a next step, the Center wants to move from organizing standalone trainings to creating a rigorous weeks-long online course to ensure trainees don’t just self-identify as LGBT-friendly, but are truly competent in serving LGBT clients.

Understaffed and strapped for cash, the Beijing LGBT Center’s staff members recognize that even with online courses they wouldn’t come close to meeting the needs of China’s estimated 70 million LGBT people. Realizing Xin’s goal of changing the mental health profession will require convincing decision makers—in universities, in professional associations, and, ultimately, in the government—that LGBT-affirmative therapy belongs in curricula and in professional guidelines. “It is still very hard to reach the higher levels,” said Liu. A host of prejudices against LGBT people remain embedded in official institutions, and hostility towards civil society and insistence on ideological conformity have been intensifying. However, the Center and other LGBT advocates think they can gain traction by appealing to policymakers’ interest in professionalizing China’s fast-growing but disorderly and fraud-filled mental health sector, of which conversion therapy is just one of many worrying trends. Their argument is that if China is going to have an ethical, competent, and evidence-based mental health profession up to international standards, it will need to clear out stigmatizing and pseudoscientific beliefs and practices regarding LGBT people—including conversion therapy. But in such a perilous political environment, can LGBT advocates press their case without triggering a crackdown?

Entrenched Prejudice in the Government and Mental Health Profession

In January, performance artists drove three red trucks up China’s east coast, parking them outside conversion therapy clinics in protest. Giant messages inscribed on the trucks read in exasperation, “Treating an illness that doesn’t exist,” “The Chinese Classification of Mental Disorders still includes ‘sexual orientation disorder,’” “It’s been 19 years. Why?”

Their frustration is understandable. The Chinese Psychiatric Association stopped classifying homosexuality as a mental disorder in 2001, but change on the ground has been plodding, if not grudging. In 2015, the Beijing LGBT Center surveyed nearly one thousand mental health professionals: roughly one-third said that being gay is a form of mental illness and that conversion therapy is effective. These numbers are much higher for non-professionals. At a 2019 national conference of the Chinese Psychological Society (CPS), one of China’s most influential professional associations in the mental health field, leading scholar and China Central Normal Psychology Professor Jiang Guangrong presented survey results showing up to two-thirds of the general public still think being gay is a mental illness. Reports continue to emerge of practitioners using electroshock, drugs, hypnosis, acupuncture, and even “renaming” clients in accordance with the ancient text the Yi Jing to change a client’s sexual orientation. These practices are not just limited to quacks: In 2015, a clinic at the large and government-run Beijing National Olympic Psychological Hospital made a young woman hold a metal rod that was hooked up to an unidentifiable machine to analyze her “48 chromosomes” to determine whether she was “innately” lesbian. In 2017, at the elite Zhejiang University, researchers sprayed oxytocin up the noses of gay men to see if it would change their sexual orientation. Advocates have compiled a list of at least 204 LGBT-phobic clinics and practitioners.

Conversion therapy—and the medical pathologization of sexual and gender minorities—originated in the West. In the United States, it was only after decades of research and advocacy inside and outside the mental health profession that the American Psychiatric Association declassified homosexuality as a mental illness in 1973; it took several more decades before a majority of professional associations condemned conversion therapy as ineffective and harmful. Now, most professional ethic codes require counselors to provide competent and non-discriminating care to LGBT clients, and knowledge of LGBT issues is considered an integral part of multicultural competency, a mandatory component of counseling education for most accredited programs. But serious problems remain. Tens of thousands of LGBT adolescents in the United States will likely be subjected to conversion therapy before they reach adulthood, and only 18 U.S. states and Washington, D.C. ban conversion therapy for minors, though this number has rapidly increased recently due to activist efforts.

For China’s LGBT advocates, heavy state repression has made challenging the profession’s status quo far tougher. The government frequently shuts down LGBT events and organizations, censors media, and has detained LGBT advocates. Political sensitivity and social taboos discourage many individuals from speaking up, even if they are supportive in private. Colleagues, advisors, or “the relevant departments” often discourage or expressly prohibit faculty, graduate students, and practitioners from focusing on LGBT issues. Sometimes they are ostracized for even trying. With so many barriers to advocacy and open scientific discourse, outdated, stigmatizing, and pseudoscientific views remain entrenched.

In a 2014 survey, the Gay and Lesbian Campus Association of China found that 40 percent of textbooks published after its declassification in 2001 still pathologize homosexuality. In a 2010 journal article, faculty of medicine in Guangxi describe making clients look at sexually arousing photos of people of the same sex and then had them flick a rubber band on their wrists to “cause severe pain.” In a 2005 article, a Xi’an professor who was also the director of her college’s mental health counseling center recommended electric shocks to cure “pseudo-gays.” Test prep materials for the recently-defunct state-run mental health counselors licensing examination categorized homosexuality and bisexuality as “perversions” (性变态, xìngbiàntài). Approximately 1.5 million people passed the licensing examination between 2002 and its termination in 2017.

The official Chinese Classification of Mental Disorders (CCMD-3) continues to include “ego-dystonic homosexuality” (“自我不和谐同性恋,” “zìwǒ bù héxié tóngxìngliàn”), which posits that feeling distress about one’s sexual orientation is a disorder (the U.S.’s Diagnostic and Statistical Manual of Mental Disorders removed an analogous entry in 1987). But instead of addressing the self-rejection that social stigma causes, many practitioners believe certain people are “pseudo gays” who, because they do not want to be gay, can be “cured.”

Several leading figures who help dictate the field’s conventional wisdom and shape the next generation also continue to spread misinformation. A lesbian college student in Tianjin said that her male therapist, who often appears on television, told her that only heterosexual intercourse can give women sexual pleasure (he charges 5,000 renminbi, or about U.S.$700, an hour). At the 2017 CPS national conference in Beijing, I attended a seminar where Dr. Cong Zhong, a celebrity psychiatrist from the reputable Peking University Number Six Hospital, recycled old baseless theories about how boys become gay because of overbearing mothers and distant fathers. He said he would tell parents their gay child would have a chance of changing “just to give them a little hope.” The audience was rapt.

The government has done little to change these views and, in many ways, has reinforced them. Numerous government health officials have expressed in private and in public a fear that greater tolerance would make being gay “fashionable” or would increase the amount of youth “coaxed” into being gay—and, thus, in their logic, increase the spread of HIV. A Center for Disease Control (CDC) in Yuncheng, Shanxi province placed a poster outside a high school in 2017 that read, “Choose friends rationally. Say NO to GAY.” In 2019, a poster in a Guangxi high school described gays as “violating the laws of nature” and as a threat to “normal” people. Both posters were removed after advocates complained.

Censorship rules categorize homosexuality as “abnormal” alongside “perversions” and sexual assault. Social media and e-commerce platforms try to comply by conducting sweeping, though irregular, purges of LGBT content. In April, one resulted in the deletion of Sina Weibo posts with the hashtag #les (short for “lesbian”), which had been used to create a mega discussion forum for lesbian issues. In 2017, advocates filmed a day of lectures on LGBT-affirmative therapy with an online education video platform, but the platform never published the videos because of newly issued censorship rules for video streaming sites. Beijing LGBT Center Director Xin also thinks the tightening media controls have impacted the Center’s engagement work more generally. “Because of the increase in censorship, mental health experts feel working with us is unsafe,” she said.

Encounters with security forces also indicate the existence of severe prejudice. When nine LGBT advocates were arrested in 2014, one of the police officers told them, “Homosexuals need to be reformed. It is like for people who are coprophiles. If we don't help them to change the habit of eating feces, how can our society progress?”

Changing Attitudes and a Changing Mental Health Profession

Examples of discrimination and repression abound, but neither the government nor the mental health profession are uniformly LGBT-phobic. Many local Centers for Disease Control have constructive (though not always smooth) relationships with grassroots gay men’s organizations to work on HIV prevention. Some CDC officials have even publicly argued that good public health policy requires eliminating gay-related stigma. China’s central CDC partners with Blued, China’s largest gay men’s dating app, on public health education and research (state media can be skittish about using the word “gay” and instead uses euphemisms for Blued like “interest-based social network”). In a 2014 court case that sent chills through the conversion therapy industry, a judge declared that since homosexuality is not a mental illness, it is fraudulent to claim that one can “cure” it.

At the United Nations, Chinese government delegates have made a series of cautiously circumscribed but generally supportive statements on LGBT equality. In March, delegates to the U.N. committed China to passing LGBT-inclusive anti-discrimination laws. Empty words of diplomats perhaps, but domestic LGBT advocates believe they can use such statements to change public opinion and engage other government officials.

Despite the government’s continued censorship and repression, it has left some space for LGBT civil society. At Shanghai Pride, a weeks-long multi-event festival now in its 11th year, one can meet grassroots groups from every corner of the country. When millions of netizens protested online against Weibo’s 2018 gay content ban, Weibo quickly backed down, a move some state media outlets supported. Even the Chinese language edition of the Global Times published in 2018 a glowing profile of PFLAG China (short for Parents, Family, and Friends of Lesbians and Gays)—an NGO dedicated to helping parents accept and embrace their LGBT children—for its “positive energy” and promotion of family harmony. In addition to suing conversion therapists, advocates have brought suits against the Ministry of Education for allowing homophobic textbooks in university curricula. The Ministry of Education prevailed on procedural grounds, but the plaintiff later convinced Renmin University Press and other publishers to revise their textbooks.

Some prominent members of CPS, like Professor Jiang, mentioned above, and of other influential institutions like the Chinese Academy of Sciences Institute of Psychology, have conducted research and activities on LGBT issues with local NGOs and with international trailblazers like Armand Cerbone, the co-author of the American Psychological Association’s first Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients. At CPS’s 2017 and 2019 national conferences, several presenters openly raised LGBT-related issues and the need to provide greater support. Since 2007, the CPS code of ethics has prohibited discrimination based on sexual orientation, but that code only applies to the roughly one thousand elite psychologists officially recognized by CPS, and few mental health practitioners I’ve met are aware of this antidiscrimination clause.

Indeed, China’s mental health sector is highly unregulated, even unruly. 2018 exposés in the newspaper Southern Weekend showed how myriad pseudoscientific treatments proliferate, including psychologists who offer cancer cures through semi-mystical methods. In response, three influential psychological professional associations, including CPS, issued a joint statement condemning the fraudulent treatments and called on practitioners to respect professional ethics. Strong words, but they have no means of disciplining violators. Complicating matters, the government scrapped the psychological counselor licensing examination in 2017 for being a poor measure of aptitude—many likened it to the written portion of a driver’s license test—but has not replaced it. As it stands, the profession cannot meaningfully perform gatekeeping or housekeeping.

Reform is coming, but how and when is unclear. The government has issued a flurry of policies to support the restructuring and development of the mental health sector to serve an increasingly atomized and high-pressure society that has undergone dizzying change. Currently, different professional associations and government departments are jockeying to be the sector’s main regulator with no clear winner in sight. One public WeChat account likened the chaotic competition to the classical novel Romance of the Three Kingdoms. Whoever winds up on top will have power over professional standards, ethics, guidelines, and possibly the prize of charging tuition for continuing education courses. LGBT advocates see this tumultuous transition as a chance to help shape the sector’s future rules and institutions to make them more LGBT-inclusive. They are striving to be heard above the din.

Grassroots Advocacy Reaching Out and Up

“I am bisexual. What about me?” At the 2017 CPS conference, Cai Yao, a staff member of the Beijing LGBT Center, challenged the celebrity psychiatrist’s theories about how boys become gay because of their relationship with their parents or the types of toys with which they played. It was a gutsy move in a classroom of roughly a hundred people, many of whom started murmuring audibly. The psychiatrist seemed taken aback. He deflected Cai’s line of questioning and tried to move on. By speaking up, Cai shed doubt on his authority that had gone undisputed the whole lecture and reminded the audience that LGBT people were not just alien objects of discussion, but living breathing people present in the room.

When Beijing LGBT Center staff first started going to major conferences in China several years ago, it was by pretending to be psychologists and sneaking in. “It wasn’t very polite,” Xin recalled. They would hand out pamphlets, and take pictures at the venue brandishing rainbow flags and banners calling on counselors to oppose discrimination against LGBT people. “That didn’t allow us to build any real connections to those experts, though,” she said. “We needed to have real dialogue with them, so we changed strategies.” The Center began reaching out privately to experts to pitch research collaborations and convince them of the need to help the LGBT community. Now, with the contacts they have cultivated and the expertise they have gained, they get on the agendas of major conferences—and they still call out stigmatizing pseudoscience when they see it.

At the 2017 CPS conference, the Beijing LGBT Center, in conjunction with researchers from the Chinese Academy of Sciences Institute of Psychology, Yale Law School’s Paul Tsai China Center, and Dr. Ilan Meyer of the University of California, Los Angeles, conducted a seminar with 60 counselors from across China to discuss the unique pressures LGBT people face and how to provide care to LGBT clients. A researcher from the Chinese Academy of Sciences Institute of Psychology shared research she conducted with the Beijing LGBT Center about the disproportionately high levels of depression and anxiety among LGBT people in China. Dr. Meyer shared his groundbreaking work from the United States demonstrating social stigma’s negative impact on the mental health of LGBT people. In a breakout session at the 2019 CPS conference, co-organized by the Tsai Center, 90 mental health counselors crammed into a seminar room to learn about LGBT-related issues from Zhuangni LGBT Mental Health Center founder Li Chunjian and professors from Wuhan and Hong Kong who shared their research and experiences about how greater support leads to better mental health outcomes for LGBT people.

The advocates’ heavy emphasis on empiricism at the CPS conferences contrasted sharply with the baseless conjecture of the celebrity psychiatrist’s lecture. The Beijing LGBT Center has made it a strategy to produce and cite authoritative research to show the need for promoting LGBT-affirmative therapy—a strategy that dovetails with the profession’s leaders’ overall push towards evidence-based practice. Also, even though the political environment is increasingly restrictive and government officials, academics, and professional associations are prioritizing toeing the ideological line, many still speak in the language of pragmatic governance. Advocates are hoping that if they can, for example, use evidence to argue that LGBT-affirming counseling at schools would benefit student mental health (or, framed more bluntly, would decrease student suicides, a sensitive issue of government concern especially given several recent incidents), people with power just might listen.

Attendees at the CPS conferences, many of whom were counselors at school mental health centers, discussed just how real this need is. They expressed wanting to improve their ability to serve LGBT clients, but not necessarily knowing how. One counselor started crying when talking about a gay student client who was potentially suicidal because of intense family rejection. “I have to do something,” she said. “Because this is a life.”

Moments of catharsis are common at activities like this. Attendees who might usually feel uncomfortable discussing LGBT issues with colleagues get a chance to share pent-up feelings with likeminded individuals. Afterwards, counselors stay in touch through WeChat groups, sharing articles and photos of putting up a rainbow flag in their office or of them discussing sexuality and gender issues with groups of students. They go from being isolated to having a community of support.

It’s a step forward, but attending one seminar isn’t a sufficient amount of training. Liu hopes the Beijing LGBT Center can create an online curriculum that one of the professional associations would officially recognize. They’ve been met with lots of dismissals. Last year, one influential scholar told them official support would likely not materialize because the government does not want to be seen “approving of” LGBT people. Even fellow advocates have their doubts, and some have sympathy for professional associations’ leaders because of political pressures. The Beijing LGBT Center is fine-tuning its message to be more inviting to the profession’s stakeholders. “We know LGBT issues are still sensitive,” said Xin, “so we are doing the work in the name of improving multicultural competency and professionalism.”

Headway is being made in ever-so-slight steps, both because of advocate efforts and scholars and practitioners joining the cause on their own initiative. Between the 2017 and 2019 CPS conferences, I noticed an uptick in the number of times expert presenters raised LGBT issues—whether with regard to stopping school bullying or including LGBT awareness in multicultural competency training. University counseling centers and private counselor networks are starting to become more visibly supportive. Some clearly state “LGBT-friendly” in counselor bios, put pamphlets about LGBT issues in waiting rooms, and facilitate support groups of LGBT students. At Peking University, which hosts the CPS Registration System, a counselor at the mental health center set up a weeks-long workshop focused on exploring one’s gender and sexuality. Beijing Normal University, home to China’s top psychology program, has started a course on multicultural competency that includes LGBT issues. Professors from other cities have dispatched grad students to the Beijing LGBT Center to learn and collect resource materials.

Since many leaders of the professional associations are professors, mainstreaming LGBT issues in the academy can have ripple effects throughout the field. Universities also teach future counselors, and the younger generation’s attitudes toward sexuality and gender are already much different from their predecessors. “The acceptance level of young counselors gives me the most hope,” Liu said.

The creation of hope is perhaps what is most powerful about the Beijing LGBT Center and other LGBT NGOs’ activities. Counselors are inspired to take small concrete actions, such as changing the binary gender choice on intake forms, or putting up a small rainbow sticker. Next might be writing an article, pursuing a research project, or teaching a course. The hope is, in accumulation, these actions will change the profession over time.

The infusion of galvanizing optimism is palpable. After a November 2018 training by the Beijing LGBT Center, the Tsai Center, Beijing Normal University, and the Chinese Academy of Sciences, one attendee wrote in a feedback form, “Before this, I was skeptical about what an individual could do. Now I know I am like one of innumerable snowflakes in an avalanche.” When one counselor expressed hopelessness at the prospect of the profession’s leaders ever acting on LGBT issues, another responded to encourage her: “History is advanced by the people.”