MAY 27 — During the debate on the Mental Health (Amendment) Bill in parliament earlier this week, Perikatan Nasional MPs Jamaluddin Yahya and Halimah Ali suggested that the LGBT community should be classified as having mental health issues. Halimah also acknowledged that mental health disorders are a major problem in Malaysia right now — further propagating the institutional notion that psychological disorders and trauma contribute towards the ‘proliferation’ of the LGBT ‘lifestyle’.
This stance runs afoul of the World Health Organisation’s (WHO) 2019 resolution to remove “gender identity disorder” from its global manual of diagnoses. The health agency has also emphasised the importance of appropriate regulations to prevent poor mental health interventions and to ensure effective care. Left unregulated, certain forms of treatment can lead to damaging effects on patients, including lifelong mental and physical injuries.
Thus, in an era where more people than ever, including Malaysians, are seeking mental health treatments, the question of safeguards for patients becomes vital. And acceptable standards and regulations are needed not only for conventional mental health treatments such as psychotherapy and counselling, but also for alternative forms such as faith-based practices.
Any attempts to cement the notion of ‘treating’ the LGBT community as people having mental health disorders — including those that claim to be scientific treatments at large — should therefore be subjected to scrutiny in line with the principle of ‘do no harm’. In doing so, I take a look at conversion therapy — a pseudoscientific practice aiming to ‘treat’ LGBTs.
Varying regulatory safeguards for mental health treatments globally
According to the WHO, the quality of mental health treatments should be ensured based on the following regulatory pillars: (i) sufficient research backing the treatments (ii) competency of the mental health practitioners and (iii) the delivery process of the treatments. Some countries have attempted to put in place regulatory frameworks that address these components, to varying levels of breadth and depth.
Countries that have established regulatory frameworks for mental health treatments include the US, UK, Germany, Sweden and India among others. These countries generally have licensing boards and self-regulating professional bodies to oversee mental health service providers to varying extents. The licensing boards’ function is generally to register competent practitioners and outline ethical practices; self-regulating bodies operate similarly but on a voluntary basis. In some jurisdictions there are over-arching entities that regulate mental health services; for instance, each US state that receives a mental health grant from the federal government is required to establish a Mental Health Planning & Advisory Council. These councils monitor, review, and evaluate mental health services in their respective states.
The regulations themselves, however, are not without inconsistencies and gaps. For example, while professional bodies such as the American Psychological Association (APA) recommend research-backed treatments for mental disorders, attempts at amending US laws towards this direction have resulted in little change. In 1999, a Bill was proposed in the state of Arizona to establish a committee to review the use of unsubstantiated mental health treatments. However, the Bill was rejected by the state governor as well as local psychologists.
Meanwhile in the UK, it is prohibited by law for anyone without the necessary qualifications to claim professional titles that are listed on the register of the Health and Care Professions Council (HCPC). But not all professional titles are listed on that register; while “practitioner psychologists“ are on the list, psychotherapists and counsellors are not. Moreover, though organisations such as the British Association for Counselling and Psychotherapy (BACP) have established themselves as self-regulating professional bodies, they are not put under statutory oversight. The UK government’s preference is instead for therapists and counsellors to register their practices voluntarily with such bodies.
Requirements for registration into self-regulating bodies may range widely. In Singapore for instance, anyone with a Master’s degree in psychology can voluntarily register themselves as a psychologist with the Singapore Psychological Society after fulfilling 400 supervised clinical hours, but the government does not regulate their services. A similar situation can be observed in Japan; as there are no regulations in place for practitioners, they register themselves with professional bodies such as the Society of Certified Clinical Psychologists or the Federation for Psychotherapy.
Meanwhile, there are a variety of examples of avenues for redress in cases of bad process or treatment delivery. In the UK, a disciplinary panel of the Health and Care Professionals Tribunal Service suspended a psychologist in June this year after complaints were lodged against her for discussing her own troubles during therapy sessions. Although the psychologist claimed that her methods had therapeutic benefits, the disciplinary panel found that she breached professional boundaries of a practitioner. In Canada, the New Brunswick College of Psychologists took action to suspend a psychologist earlier this year for “using experimental and non-evidence-based interventions” on her client, among other charges of professional misconduct.
Malaysia: Too Much Self-Regulation?
Malaysia’s regulatory framework for mental health treatments and practitioners are governed by three key pieces of legislation: the Counsellor Act 1998, the Allied Health Professions Act 2016, and the Traditional and Complementary Medicine Act 2016.
Each provides for a board or council (see note 1) to register, oversee, and regulate professionals who practise in the country. All three Acts also stipulate fines and jail terms for unregistered individuals found guilty of forging qualifications, impersonating as a registered practitioner, or for misconduct as a practitioner (upon investigation of such complaints).
These laws appear to mostly address practitioners’ competence, and are largely silent or uneven on the need for scientific or evidentiary backing as well as ensuring best practice in treatment delivery. Even with such limited scope, the extent of these Acts’ enforcement has been called into question. For example, criticism has been raised over the lack of action by the Board of Counsellors (LKM) in tackling the existence of unregistered counsellors, as well as misconduct complaints lodged against registered counsellors.
Though there are laws in place, it is still possible for intermediaries, including government agencies, to set their own requirements as to who qualifies as a mental health practitioner. Jakim and the Department of Social Welfare, under whom “counsellors” are employed, are two examples. Jakim provides its own course and certificate in counselling, while the Department of Social Welfare’s website stated that a Bachelor’s in Counselling is expected of its counsellors. Although these counsellors are empowered to provide mental health help, it is unclear if they are registered to LKM and are beholden to any of the existing laws. Providing services without being registered seems to be a violation of the Counsellor Act, where it states that one would have to register with LKM before branding themselves as a counsellor in Malaysia.
While statutory boards do provide their own codes of ethics and, in the case of LKM, enact its own Investigation and Disciplinary Committees, the language used in the codes sounds more advisory than mandatory. There has yet to be strict oversight over the ethical practices of all counsellors in Malaysia.
Nonetheless, the biggest regulatory gap for mental health treatment in Malaysia remains the lack of requirement for scientific backing or forms of evidence regarding safety and effectiveness. The Ministry of Health (MOH) has issued operational policies and clinical practice guidelines for providing research-backed and ethical mental health treatments, but these remain guidelines; there is no force of law to ensure compliance.
Moreover, policies and guidelines notwithstanding, what constitutes as valid or even non-harmful treatments seems to be left up to practitioners’ interpretation; the Ministry’s operational policy document, for instance, lists recommended treatments such as person-centred therapy and cognitive behaviour therapy as valid interventions for psychological disorders. However, at the same time, it states that “any other (psychological) therapies that are not stated and found to be beneficial for improving a patient’s functioning are highly recommended”. The document does not mention how the therapies should be shown to be beneficial and who should counter check its safety and effectiveness.
It is in this environment that questionable treatments, unqualified practitioners, and unbridled delivery of questionable treatments can thrive. The harm that arises from the gaps in oversight can result in aggravating rather than helping the conditions of people already grappling with mental health issues. I look to the practice of conversion therapy as an example.
Deep dive: Conversion therapy
Conversion or reparative therapy refers to interventions aimed at changing an individual’s gender identity or sexual orientation. The premise underlying most conversion therapy is to address sexual orientation or gender identity as a mental illness that can be cured. This therapy began as a series of hypnosis sessions conducted by Albert von Schrenck-Notzing, a German psychiatrist in 1899, before evolving into various types of psychological, physical, and spiritual interventions over the next century. Some conversion therapies have been known to employ controversial techniques including chemically-induced nausea, hypnosis, electric shock, and more.
There are widely differing stances across the world on conversion therapy, reflecting the tension between values and beliefs on one hand and medical-scientific stipulations on the other. Some countries have officially banned conversion therapy due to reported adverse mental health effects, some countries allow conversion therapy to be run privately while in countries such as China and Iran, conversion therapy is sponsored by the state.
In Malaysia, conversion therapy is conducted by both state agencies as well as privately. State-sponsored conversion therapy is mainly carried out by religious authorities: Jakim at the federal level and by the religious departments at the state level. In the private or civil arena, entities such as churches and complementary medicine practitioners run their own versions of the therapy.
State-sponsored conversion therapy in Malaysia
Jakim has its own conversion therapy programme, Mukhayyam, which is funded through the federal budget while state religious departments fund conversion therapy programmes run by third parties. All state religious departments have a budget allocation for programmes addressing the LGBT community.
Since the programmes claim to address sexual orientation and gender identity as a curable mental illness, the principle of ‘do no harm’ should be upheld and the aforementioned three regulatory pillars proposed by WHO should be applied. Unfortunately there are deficiencies on all counts.
Firstly, programme content or treatment are not as yet backed by evidence of its effects on participants’ mental health. For instance, Jakim's Mukhayyam provides religious and rigorous physical activities that have been branded as treatments, despite research showing that such treatment methods are not supported by science. It is unclear whether evidence of programme impact — impact not only on the stated aims of curing participants but also on participants’ general mental health — is a criteria in programme design in the case of JAKIM, or in appointing third-party programme providers in the case of state religious departments.
Secondly, though these programmes deal directly with the mental health issues of their targeted groups and individuals, those involved in administering the programmes may lack the license, training and competency to provide mental health support and care. For example, the Consultation Officers or Pegawai Rundingcara of Jakim's Keluarga, Sosial dan Komuniti (KSK) Care Centres — tasked with guiding and counselling those with personal and/or family issues — are encouraged to approach LGBT individuals to promote the state-funded corrective programmes administered by them. However, it may only take a Bachelor’s degree in Islamic Studies to qualify for the role, and Jakim's own counselling programme seems optional for the officers. This is very different from the requirements set by the Public Services Commission (SPA) for the hiring of psychological officers in the federal civil service, which include Bachelor’s degrees in either psychology, clinical psychology, or counselling.
Finally, oversight on the delivery of such programmes, often provided together with religious counselling, also remains unclear as they appear not to fall under current laws on mental health treatments even though the participant’s or patient’s mental state is clearly the centre of focus. There is a code of ethics for the Consultation Officers, for instance, but it is unknown to what extent the code is legally enforceable. It is also unclear what avenues for legal redress exist if physical or psychological damage is done as a result of the treatment.
Privately run conversion therapy in Malaysia
Faith-based practitioners are one of the main private or civil actors involved in delivering conversion therapy, with groups such as the Real Love Ministry and Gabungan Perawat Muslim Malaysia. Much like state-sponsored conversion therapy, privately run ones also fall short of all three regulatory pillars proposed by WHO.
Firstly, all treatments that come under the ambit of conversion therapy in the private sector do not need to provide scientific backing or evidence of non-harmful impact to any regulatory body. There is a huge range of therapies done in the private sector, some of which questionable and possibly harmful to mental health — reports include aversion therapy practices such as hitting the client and spraying pepper into the client’s eyes (ostensibly to rid them of jins (*See note 2)).
Moreover, practitioners in the private sector administering conversion therapy may also lack the competency in dealing with the mental health of LGBTs. Take the case of practitioners employing the aforementioned methods, for instance; those “treatment centres” allow non-medically trained individuals to “treat” patients with methods such as caning and hitting.
As with state-sponsored conversion therapy programmes, there is also a lack of oversight on the delivery of privately run ones. As mentioned above, practitioners employing questionable methods have been able to continue their operations despite explicit prohibition of them in current policies. There are also codes of ethics provided to private practitioners, including faith-based ones, but it remains unclear how they are enforced in practice.
Far cry from ‘do no harm’
Any treatment that attempts to target some aspect of a patient’s mental health (which includes gender identity and sexual orientation) needs to be checked against WHO’s three regulatory pillars mentioned above or it could risk harming rather than helping the patient. To gauge the impact of unchecked treatments on patients’ or participants’ mental health, I conducted a brief study in 2021 comprising a quantitative survey as well as one-to-one interviews with people who had undergone conversion therapy.
Due to the sensitivity of the issue and heightened fears around confidentiality, I was not able to gather a meaningful number of respondents for the quantitative survey and the qualitative interviews (less than 15 for the former and less than 10 for the latter). Nevertheless, the depth of negative experiences described by the respondents, each with experiences of different practitioners and methods, was eye-opening.
Respondents revealed that the impact conversion therapy had on their mental health was significant. Common descriptions of the experience include “unpleasant”, “uncomfortable”, and even “horrifying”.
“It made me feel wrong and disgusted. I didn’t feel like me, I felt like a shell of a human.” Respondent A
“Humiliated, confused, scarred were the after-effects of conversion therapy I experienced.” — Respondent B
Half of the respondents we interviewed also did not feel safe during the conversion therapy sessions. Three-quarters of respondents said that they were not assessed for their mental health state before and/or after receiving the conversion therapy treatment, showing a lack of adherence to the Ministry of Health’s guidelines on mental health treatment delivery. It is unsurprising that many LGBTs feel discouraged about seeking help for mental health issues — fear of being referred to conversion therapy is a factor.
Clear regulations to safeguard patients
At the core of the issue here is ensuring that patients are not harmed in any way during or as a result of mental health treatments. As the debate on the Mental Health (Amendment) Bill goes on, it is high time for new standards as well as better enforcement of current laws and guidelines for all mental health treatments in Malaysia.
*Note 1: They are, respectively, the Board of Counsellors (LKM), the Allied Health Professions Council, and the Traditional and Complementary Medicine Council.
*Note 2: Despite an explicit prohibition of “claims of being able to capture and dispose of jins” in the Ministry of Health’s National Traditional and Complementary Medicine (T&CM) Policy, practitioners who employ such methods have managed to continue marketing themselves as “treatment centres”.
* This is the personal opinion of the writer or publication and does not necessarily represent the views of Malay Mail.
