lebmashed

Hasan M. Abdessamad, MD, FRCSC, FACOG, and Omar Fattal, MD, MPH

Abstract

Lebanon is considered relatively liberal, but Lebanese lesbian, gay, bisexual, and transgender (LGBT) individuals continue to face social and legal challenges. Homophobia is common among health-care providers. Only 50% of physicians in a study were willing to “tend the medical needs” of homosexuals. Homosexuality is still perceived as a disease and the practice of reparative therapy is common. Programs focusing on sexual health are scarce, with only a few being LGBT-friendly. For Lebanese LGBT individuals, there remains a significant gap in access to health care. The Lebanese Medical Association for Sexual Health (LebMASH) was established to address this gap.

Introduction

In the past several years, we have noticed a trend in the West that depicts Lebanon as a gay-friendly destination. For example, The New York Times published an article in 2009 titled, “Beirut, the Provincetown of the Middle East.” In reality, even though Lebanon is more liberal than other Arab countries when it comes to lesbian, gay, bisexual, and transgender (LGBT) rights, Lebanese LGBT individuals face significant social and legal challenges.

Article 534 of the Lebanese penal code states: “Any sexual intercourse contrary to the order of nature is punished by imprisonment for up to one year.” This article has been widely used in recent years to criminalize a variety of consensual male and female homosexual relationships. It has also been widely used to blackmail and intimidate LGBT individuals.

Personal status and matters related to family law are under the jurisdiction of the religious court system. Christianity and Islam, the two biggest religions in Lebanon, have a large influence on the fabric of the society.

In general, homosexuality remains a social taboo, and in the past decade, Lebanon has witnessed a crackdown on the LGBT community. For instance, in July 2012, 36 individuals were arrested in a movie theater that caters to the clientele of men who have sex with men (MSM) in Beirut. In April 2013, a popular gay nightclub in a Beirut suburb was shut down by the local municipality. Several people were arrested and exposed to verbal, physical, and sexual abuse. Nude photographs of detainees were leaked to social media. In June 2013, Human Rights Watch (HRW) released a report detailing the ill treatment of vulnerable populations, including LGBT individuals, by Lebanese internal security forces.

These legal, social, and religious factors create a climate of fear and intimidation with several negative outcomes such as hindering LGBT individuals from coming out to friends and family as well as to their health-care providers.

Background on LGBT Health

The literature on LGBT health in Lebanon is very scarce. In a study that was conducted in 2010, 73% of surveyed physicians believed that homosexuality is a disease and only 50% were willing to “tend the medical needs” of a homosexual patient.

Forensic physicians are known to perform anal tests that involve the insertion of an egg-shaped object into the persons anus to ascertain if someone is homosexual.This practice came to light on a large scale after the movie theater arrests in 2012 when 36 detainees were subjected to the test. The incident stirred outrage from several human rights groups. HRW published a report in August 2012 titled, “Lebanon: Stop ‘Tests of Shame.’” This outrage resulted in the Lebanese Order of Physicians issuing a strong statement condemning this practice.

Furthermore, sexual orientation change efforts (SOCE) are still prevalent in Lebanon. There have been several verbal reports about the so-called Reparative or Conversion Therapy to Helem (Lebanons largest LGBT rights organization). Mental health professionals have spoken favorably about such practices publicly on TV.

The past decade has witnessed a few efforts to improve LGBT health, although catered more toward MSM. These efforts mainly represent the work done by Helem, Soins Infirmiers et Dèveloppement Communautaire, and the Ministry of Healths National AIDS Program to tackle HIV infection.11 In addition, Marsa was established in early 2011 as the first sexual health center in Lebanon. Marsa provides voluntary counseling and testing for HIV and comprehensive primary and secondary health-care services in an LGBT-affirmative environment.

Lebanese Medical Association for Sexual Health

Despite these efforts, the gap in access to health care for LGBT individuals in Lebanon remains very large. A group of Lebanese health-care professionals came together in September 2012 to create the Lebanese Medical Association for Sexual Health (LebMASH). LebMASHs mission is to advance health care for LGBT individuals and sexual health for all individuals in Lebanon. LebMASH has the following objectives:

	• Spreading awareness and knowledge, as well as influencing attitudes and behaviors of health-care providers and the general public regarding LGBT health and sexual health
	• Influencing and changing policies and legislations in professional organizations, including schools, hospitals, and governmental agencies, to protect the health rights and well-being of LGBT individuals and sexual health of the general public
	• Advancing research regarding LGBT and sexual health
	• Supporting other organizations that provide health care to LGBT individuals and sexual health care

In the past year, LebMASH had several activities that fall under the following categories:

	• Raising awareness
	• Education
	• Advancing research
	• Advocacy
	• Encouraging professional development

Under the category of raising awareness, LebMASH has been vigilant in monitoring the Lebanese media for any appearances or reports that present inaccurate information on sexual or LGBT health. In June 2013, LebMASH published a reply to a pseudopsychologist who appeared in an interview on a major TV station and was noted to give wrong information on homosexuality.

LebMASH also published a position statement on SOCE on May 17, 2013, to correct misconceptions regarding homosexuality.The statement urged “health care providers in Lebanon to refrain from this [SOCE] unethical and potentially harmful practice,” and called on “health care organizations to take a strong position against such practices.”

Under the category of education, one LebMASH board member gave a lecture about LGBT health to second-year medical students at the American University of Beirut in late 2012. This was the first time medical students receive such a lecture. The same author gave a Q&A Skype session about transgender health with 11th-grade students at the Dubai British School in February 2013.

Under research activities, LebMASH actively seeks funding to examine trauma in LGBT refugees in Lebanon. Currently, LebMASH is working on translating to Arabic a landmark study that was published by Shidlo and Schroeder in 2002 on reparative therapy. This activity falls under LebMASHs commitment to making more scientific literature available in Arabic. LebMASH established the annual “Break the Silence” research award for students. The 2013 award went to a medical student who wrote an article on hymenoplasty. LebMASH has served as a consultant on a research project on perception of discrimination by LGBT people in the health-care system in Lebanon.

Under the category of advocacy, LebMASH worked closely with the Lebanese Psychiatric Society and the Lebanese Psychological Association to come out with historic position statements about homosexuality in May 2013.These statements, the first of their kind in the Arab world, reaffirmed that homosexuality is not a disease and does not require any treatment. The statements also stressed the health risks of SOCE. These statements were widely discussed in national and international media.

Under the category of professional development, LebMASH sponsored a medical student in 2012 and another one in 2013 to travel to the United States to attend the annual conference of the Gay and Lesbian Medical Association: Health Professionals Advancing LGBT Equality. Attending such meetings brings international experience to students in Lebanon and diversifies their training and exposure.

In its first year of existence, LebMASH has faced several challenges. The first challenge was related to language. Arabic is the official language in Lebanon, which necessitates making all content available in or translated to Arabic to reach the general public. In addition, medical schools in Lebanon use either English or French language solely; therefore, it is important to provide all content in these two languages as well for a wider reach within the medical community. Using three languages is time-consuming and costly.

Second, LebMASHs executive board has members who are based in Lebanon, the United States, and Canada. Even though this can be viewed as an asset especially when it comes to networking, resources, international reach, and experience, it presents a burden when board meetings or events need to be arranged. Finally, the political instability in the region makes people less concerned about health in general and sexual health in particular, and more concerned with issues of security.

Moving forward, LebMASH will continue to strengthen and expand its activities in the major areas outlined above: awareness, education, research, advocacy, and professional development. Also, LebMASH aspires to represent Lebanon at the international level on issues relating to LGBT and sexual health.

Conclusion

The past decade in Lebanon has witnessed some advances on the legal and social fronts for LGBT individuals; however, the health front has seen only minimal advances. LGBT individuals continue to face major barriers on multiple levels, and the gap in LGBT health remains very significant. LebMASH was established to address this gap, and during its first year of existence, it has proven to be a promising model for advancing LGBT health in difficult environments in which LGBT individuals lack civil protections.

References

1. P Healy: Beirut, the Provincetown of the Middle East. The New York Times. July 29, 2009. Available at http://travel.nytimes.com/2009/08/02/travel/02gaybeirut.html (last accessed on Nov. 11, 2013).
2. N Saghiyeh, W Al-Farchich: Homosexual relations in the penal codes: General study regarding the laws in the Arab countries with a report on Lebanon and Tunisia. Helem. October 2009. Available at http://helem.net/node/53 (last accessed on Nov. 11, 2013).
3. A Awadalla: Lebanon—inflammatory TV show leads to arrests of gay men. The Global Voices. August 1, 2012. Available at http://globalvoicesonline.org/2012/08/01/lebanon-inflammatory-tv-show-leads-to-arrests-of-gay-men (last accessed on Nov. 11, 2013).
4. J Ayoub: Lebanese police arrest four during gay club raid. The Global Voices. May 8, 2013. Available athttp://globalvoicesonline.org/2013/05/08/lebanon-scandal-breaks-out-over-homophobic-raid-in-dekwaneh(last accessed on Nov. 11, 2013).
5. Human Rights Watch: Lebanon—police torturing vulnerable people. June 26, 2013. Available atwww.hrw.org/news/2013/06/26/lebanon-police-torturing-vulnerable-people (last accessed on Nov. 11, 2013).
6. F Elkak: Homophobia in clinical services in Lebanon, a physician survey. Helem. February 8, 2010. Available at http://helem.net/sites/default/files/HELEMStudies_MroueKak_0.pdf (last accessed on Nov. 11, 2013).
7. BBC World News: Outraged Lebanese demand end to anal exams on gay men. August 7, 2012. Available atwww.bbc.co.uk/news/world-middle-east-19166156 (last accessed on Nov. 11, 2013).
8. Human Rights Watch: Lebanon: Stop “tests of shame.” August 10, 2012. Available atwww.hrw.org/news/2012/08/10/lebanon-stop-tests-shame (last accessed on Nov. 11, 2013).
9. Russia Times: Test of shame! Lebanese protest against anal probe for suspected gays. August 11, 2012. Available at http://rt.com/news/homosexuality-anal-test-protest-lebanon-445 (last accessed on Nov. 11, 2013).
10. Lebanese Medical Association for Sexual Health: Response to Dr. Khourys interview about homosexuality. June 24, 2013. Available at http://lebmash.wordpress.com/2013/06/24/pr2-en (last accessed on Nov. 11, 2013).
11. J Tohme: MSM in Lebanon: A look at current HIV prevention and sexual health initiatives. The Global Forum on MSM & HIV. November 4, 2013. Available at http://msmgf-blog.blogspot.ca/2013/11/a-look-at-hiv-prevention-and-sexual.html (last accessed on Nov. 11, 2013).
12. Marsa Sexual Health Center website. Available at http://marsa.me (last accessed on Nov. 11, 2013).
13. Lebanese Medical Association for Sexual Health: Position statement on sexual orientation change efforts (SOCE). May 17, 2013. Available at http://lebmash.wordpress.com/2013/05/17/ps1-en (last accessed on Nov. 11, 2013).
14. A Shidlo, M Schroeder: Changing sexual orientation: A consumers report. Prof Psychol Res Pract2002;33:249–259.
15. Lebanese Medical Association for Sexual Health: Lebanese Psychiatric Society: Homosexuality is not a disease. July 12, 2013. Available at http://lebmash.wordpress.com/2013/07/12/lps-en (last accessed on Nov. 11, 2013).
16. Lebanese Medical Association for Sexual Health. Third Lebanese Medical Group to denounce conversion therapy. July 18, 2013. Available at http://lebmash.wordpress.com/2013/07/18/lpa-en (last accessed on Nov. 11, 2013).
17. Lebanese Medical Association for Sexual Health: LebMASH sponsors medical students trip to Denver USA. July 17, 2013. Available at http://lebmash.wordpress.com/2013/07/17/bts-en (retrieved on Nov. 11, 2013).

I would like to share with you this piece about Sexual Orientation Change Effort published by two friends of mine: Dr. Omar Fattal, a psychiatrist in New York and Dr. Hossam Mahmoud, a psychiatrist in Chicago. Both are also current board members of the Lebanese Medical Association for Sexual Health. It was published in Mind Matters, a newsletter by the Illinois Psychiatric Society.

This comes few months after the Lebanese Medical Association for Sexual Health, the Lebanese Psychiatric Society and the Lebanese Psychological Association all released statements against Sexual Orientation Change Efforts (SOCE), as SOCE might be hazardous and lead to gravid risks for no proven benefit. The three Lebanese health organization reiterated the internationally known medical fact that homosexuality is not a disease and thus requires no treatment.

“Reparative Therapy,’ a Non-Cure for a Non-Malady.” Mind Matters, Issue 25, October 2013

By: Omar Fattal, MD MPH and Hossam Mahmoud, MD MPH

Introduction:

Reparative therapy” is a term that has called for much attention and controversy in the media and among mental health care professionals and nonprofessionals. It has been a controversial issue and has become a polarizing topic, in which issues of politics, religion, civil rights and mental health intersect.

Reparative therapy, also known as “conversion therapy” is an approach that has been undertaken by some groups and mental health providers as a way to help “cure” homosexuals of the “disease” of homosexuality. In the opinion of such groups and providers homosexuality or homosexual tendencies are considered a malady, an illness, which requires treatment. However, given that there is no substantiated evidence that reparative therapy is effective as a treatment, and to be in accordance with the terms used by scientifically-sound literature on this topic, the authors prefer to use the term “Sexual Orientation Change Efforts” (SOCE).

The last couple of years have been pivotal with regard to changes that have taken place on the issue of SOCE, across different sectors both in the United States and abroad. The following are just some of the changes we have seen in the past two years:

• In April 2012, Robert Spitzer, MD, issued an apology directed to the gay community, especially those affected by SOCE, regarding his controversial study (1), which had been misinterpreted as evidence that “highly motivated homosexuals” can change their sexual orientation. (2, 3) Unfortunately, this study has been repeatedly misused as evidence for efficacy of SOCE.
• In June 2013, Exodus International, an “ex-gay” organization, whose mission for decades was to help “cure” gay Christians of homosexuality and “help” them turn straight, issued an apology to the gay community (4). It also closed down its “cure ministry.” (5) At this time, it appears that Exodus International has abandoned its attempts of “treat” homosexual tendencies.
• SOCE has made headlines over the past few months in different parts of the country. In several states, including California, Massachusetts, New York and New Jersey, bills banning SOCE for minors have either been introduced or passed, with much controversy (6, 7, 8). The bill which passed in California banning SOCE for minors has been appealed on the grounds that it may constitute an “unjustified infringement on free speech.” (6) At the time this article was written, the case was still pending.
• On a more global level, SOCE have gained attention worldwide, including in Lebanon. In 2013, three Lebanese health groups spoke out against SOCE. In May, the Lebanese Medical Association for Sexual Health (LebMASH) released a strongly-worded position statement emphasizing that homosexuality is not an illness; furthermore, the statement emphasized that SOCE are not based on sound medical evidence, and that such attempts can be harmful (9). This position statement was followed in July by two announcements from the Lebanese Psychiatric Society (LPS) and Lebanese Psychological Association (LPA) arguing that homosexuality is not an illness and, therefore, does not require treatment. (10) This has been the first time in the Arab World that a professional medical association and a professional psychological association have spoken out against SOCE and asserted that homosexuality is not an illness.

Homosexuality Is Not a Disease:

Before we discuss the ramifications of SOCE, it’s important to examine the “disease” that this “therapy” is claiming it can cure. Homosexuality is not a mental illness.

It has been 40 years since the American Psychiatric Association (APA) removed homosexuality from its list of conditions considered to be mental disorders. As a district branch of the APA, IPS holds the same position with regards to this issue since it was changed in 1973. On a more global scale, in 1990 The World Health Organization (WHO) removed homosexuality from its list of disorders, known as the International Statistical Classification of Diseases and Related Health Problems (ICD) (11) As per the Pan American Health Organization (PAHO) which is the Regional Office of WHO, “In none of its individual manifestations does homosexuality constitute a disorder or an illness and therefore it requires no cure.” (12)

Unfortunately, to this date, some people still criticize the APA’s decision to remove homosexuality from the list of mental illnesses and dismiss this decision as being based on politics and not science. It is true that the APA – like all major associations – has several interest groups within its membership that may influence its policies, and the Association may respond to external lobbying as well.

In the same way that there were groups in the years preceding 1973 asking the APA to remove homosexuality from the list of mental illnesses, there were other groups asking the APA to keep homosexuality on the list of mental illnesses. Simply because a decision was made partially due to pressure from certain groups does not mean that the decision itself was not a valid or that the APA did not incorporate scientifically sound studies as a basis for developing the DSM. The APA made its decision to remove homosexuality from the list of mental illnesses in the context of strong evidence that was supportive of the fact that homosexuality was not uncommon and that homosexuals did not have mental illnesses due to homosexuality itself. Researchers like Kinsey, Clellan Ford and Frank Beach, and Evelyn Hooker were among several researchers that contributed significantly to this field and helped change people’s view of homosexuality. (13)

Forty years have passed since the APA’s decision to remove homosexuality from the list of mental illnesses, and the DSM has been revised several times since then. These four decades would have given anyone plenty of time to prove that homosexuality in itself is a disorder; however, this has not happened.

SOCE Are Not Effective:

Since 2000, the APA’s position urging mental health care providers against SOCE has been clear. In addition, over the last decade, several other major professional organizations released statements regarding SOCE. To name a few, the American Psychological Association (apa), the American Academy of Child and Adolescent Psychiatry (AACAP), and the American Academy of Pediatrics (AAP) emphasized, in statements they issued on this issue, the lack of evidence proving that this kind of therapy can actually change one’s sexual orientation (13, 14, 15).

The apa formed a task force that reviewed the literature related to SOCE. The task force reviewed 83 studies published between 1960 and 2007. They found major methodological issues with these studies. Some of these issues included failure to control for confounding factors, lack of control subjects, and being qualitative. They concluded that “Given the limited amount of methodologically sound research, claims that recent SOCE is effective are not supported.” (13)

Even in his apology to the gay community, Robert Spitzer stated: “I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some “highly motivated” individuals.” (3)

SOCE Can Be Harmful

As it is, research has consistently shown that Lesbian, Gay, Bisexual, and Transgender (LGBT) people are at higher risk of developing psychiatric conditions such as depression, anxiety, and substance abuse. It’s widely believed that these disorders are not due to the LGBT people’s sexual orientation itself but rather due to the pressures that LGBT people face in their homes and communities. (16) It would be considered unethical to promote practices that can bring further harm to LGBT people.

Unfortunately, SOCE continues to be practiced in many parts of the world, causing further harm to this population. Evidence of the harm that such practices can cause has been well documented. In 2002, Ariel Shidlo and Michael Schroeder published a landmark study where they interviewed 202 individuals who had undergone SOCE. Many of these individuals reported that they experienced psychological, social and interpersonal, as well as spiritual harm, as a result of this type of therapy. (17) More recently, in their review of the literature related to SOCE, the APA task force found evidence that SOCE resulted in harm. “These negative side effects included loss of sexual feeling, depression, suicidality, and anxiety”. (13)

Even prior to these studies, there was enough evidence of the harm that can result from SOCE, that the APA recommended that “ethical practitioners refrain from attempts to change individuals’ sexual orientation, keeping in mind the medical dictum to First, do no harm” (18)

Several other professional and well respected organizations concur with the APA’s position. AACAP and AAP emphasize that SOCE can be harmful to individuals undergoing this kind of therapy. (14, 15). According to the statement by AAP, individuals undergoing SOCE can experience feelings of anxiety and guilt as a result of it. (15)

In May 2012, PAHO released a statement that echoed the statements mentioned above and affirmed that reparative or conversion therapies “represent a severe threat to the health and human rights of the affected persons.” Furthermore, PAHO states that “Repression of sexual orientation has been associated with feelings of guilt and shame, depression, anxiety, and even suicide” (12)

Conclusion:

Given the controversy associated with SOCE currently, the authors felt it important to emphasize the facts that have been clearly established, prior to expressing an opinion or making any recommendations.

Here are the basic facts:

• Homosexuality is not a mental illness and, therefore, requires no treatment.
• SOCE lack sound scientific evidence supporting its effectiveness.
• SOCE can be harmful.

PAHO calls, in its 2012 statements, on professional associations to “disseminate documents and resolutions by national and international institutions and agencies that call for the de-psychopathologization of sexual diversity and the prevention of interventions aimed at changing sexual orientation.” (12)

In this country, the APA has taken many positive steps in this direction. However, given that the United States allows for individual states to regulate licensure, professions and practices, we urge the IPS and IPS members to take more proactive measures in support of evidence-based practices, in the state of Illinois against SOCE and its harmful effects. As physicians, it is our duty to advocate for our patients, and first, do no harm, which is where it starts.

References

1. Can some gay men and lesbians change their sexual orientation? 200 participants reporting a change from homosexual to heterosexual orientation. Arch Sex Behav. 2003 Oct; 32(5):403-17; Spitzer RL.

2. Psychiatry Giant Sorry for Backing Gay ‘Cure’. The New York Times.http://www.nytimes.com/2012/05/19/health/dr-robert-l-spitzer-noted-psychiatrist-apologizes-for-study-on-gay-cure.html

3. Dr. Robert Spitzer Apologizes to Gay Community for Infamous ‘Ex-Gay’ Study.http://www.truthwinsout.org/news/2012/04/24542

4. I Am Sorry. Exodus International. http://www.exodusinternational.org/2013/06/i-am-sorry

5. Group apologizes to gay community, shuts down ‘cure’ ministry. CNN.http://www.cnn.com/2013/06/20/us/exodus-international-shutdown

6. Court Hears Gay ‘Conversion Therapy’ Arguments. The New York Times.http://www.nytimes.com/2013/04/18/us/day-in-court-for-california-law-banning-conversion-therapy.html

7. Openly Gay State Senator Introduces Bill To Ban Conversion Therapy For People Under 18. The NY Daily News http://www.nydailynews.com/new-york/bill-seeks-ban-gay-conversion-therapy-minors-article-1.1328889

8. New Jersey Bans Gay Conversion Therapy. Chicago Tribune. http://articles.chicagotribune.com/2013-08-19/news/sns-rt-us-usagaytherapy-newjersey-20130819_1_california-based-exodus-international-christian-group-championing-conversion-therapy

9. Lebanese Medical Association for Sexual Health http://lebmash.wordpress.com/2013/05/17/ps1-en

10. Lebanese Medical Association for Sexual Health http://lebmash.wordpress.com/2013/07/18/lpa-en

11. International Statistical Classification of Diseases and Related Health Problems (10th Revision). World Health Organization (1994). Geneva, Switzerland. http://apps.who.int/classifications/icd10/browse/2010/en

12. “Cures” for an illness that does not exist. 2012 May 17. The Pan American Health Organization/World Health Organization PAHO/WHO Position Statement. http://new.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=17703&Itemid

13. Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. http://www.apa.org/pi/lgbt/resources/therapeutic-response.pdf

14. Adelson SL; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2012 Sep;51(9):957-74

15. Committee on Adolescence – American Academy of Pediatrics. Homosexuality and Adolescence. Pediatrics 1993 Oct; 92(4):631-34. http://pediatrics.aappublications.org/content/92/4/631.full.pdf

16. Adelson SL; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2012 Sep; 51 (9):957-74.

17. Ariel Shidlo and Michael Schroeder. 2002. Changing Sexual Orientation: A Consumers’ report. Professional Psychology: Research and Practice. Vol 33 (3): pp249-259

18. APA Commission on Psychotherapy by Psychiatrists. Position statement on therapies focused on attempts to change sexual orientation (reparative or conversion therapies). Am J Psychiatry. 2000 Oct;157(10):1719-21