ArticlePDF Available

Abstract and Figures

Conversion therapies are any treatments, including individual talk therapy, behavioral (e.g. aversive stimuli), group therapy or milieu (e.g. “retreats or inpatient treatments” relying on all of the above methods) treatments, which attempt to change an individual’s sexual orientation from homosexual to heterosexual. However, these practices have been repudiated by major mental health organizations because of increasing evidence that they are ineffective and may cause harm to patients and their families who fail to change. At present, California, New Jersey, Oregon, Illinois, Vermont, Washington, DC, and the Canadian Province of Ontario have passed legislation banning conversion therapy for minors and an increasing number of US States are considering similar bans. In April 2015, the Obama administration also called for a ban on conversion therapies for minors. The growing trend toward banning conversion therapies creates challenges for licensing boards and ethics committees, most of which are unfamiliar with the issues raised by complaints against conversion therapists. This paper reviews the history of conversion therapy practices as well as clinical, ethical and research issues they raise. With this information, state licensing boards, ethics committees and other regulatory bodies will be better able to adjudicate complaints from members of the public who have been exposed to conversion therapies.
Content may be subject to copyright.
Journal of medical
Counting Physicians
in Specialties:
By What They Do
or How They Train?
State Board News
International News
The Growing Regulation
of Conversion Therapy
What State Medical Boards
Need to Know
JournalMedReg_Vol102_2 r2.indd 1 7/13/16 10:01 AM
Submit a manuscript to the Journal of Medical Regulation
For more information about how to submit a manuscript,
please see Information for Authors on page 28.
JournalMedReg_Vol102_2 r2.indd 2 7/13/16 10:01 AM
Journal of medical
Assessments of the peer-reviewed literature...have found
no evidence that conversion therapy treatments result
in changes in sexual orientation.”
From the article “The Growing Regulation of Conversion Therapy,” page 7.
VOLUME 102, Number 2, 2016
2 Publisher’s Information
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 Quoted | Note from the Editor
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 News & Notes
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 Message from the Chair
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 The Growing Regulation of
Conversion Therapy
Jack Drescher, MD; Alan Schwartz, MD; Flávio
Casoy, MD; Christopher A. McIntosh, MSc, MD;
Brian Hurley, MD, MBA; Kenneth Ashley, MD;
Mary Barber, MD; David Goldenberg, MD; Sarah
E. Herbert, MD, MSW; Lorraine E. Lothwell, MD;
Marlin R. Mattson, MD; Scot G. McAfee, MD;
Jack Pula, MD; Vernon Rosario, MD; D. Andrew
Tompkins, MD, MHS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13 Counting Physicians in Specialties:
By What They Do or How They Train?
Thomas C. Ricketts, PhD, MPH;
Erin P. Fraher, PhD, MPP; Julie C. Spero, MSPH
21 State Member Board Briefs
26 International Briefs
28 Information for Authors
JournalMedReg_Vol102_2 r2.indd 1 7/13/16 10:04 AM
Published Since 1913 | Volume 102, Number 2, 2016
All articles published, including editorials, letters and book reviews, represent the opinions of the authors and do
not necessarily reect the ofcial policy of the Federation of State Medical Boards (FSMB) of the United States
Inc. or the institutions or organizations with which the authors are afliated unless clearly specied.
Journal of medical
Ruth Horowitz, PhD
Editorial Committee
Carl F. Ameringer, PhD, JD
Mark Bechtel, MD
Richard Brantner, MD
C. Deborah Cross, MD
Eleanor Greene, MD
Rebecca J. Hafner-Fogarty,
Kathleen Haley, JD
Diane Hoffmann, JD
Heidi Koenig, MD
Wayne J. Reynolds, DO
E. Scott Sills, MD, PhD
Cheryl Graham Solomon, MA
Pascal Udekwu, MD, MBA
Jamie Wright, JD
Editor Emeritus
Dale G Breaden
© Copyright 2016
The Federation of
State Medical Boards
of the United States Inc.
Letters to the Editor
We welcome letters to the editor.
Letters should reference previously
published material in the Journal and
should not exceed 400 words and
4 references. Letters being considered
for publication will be shared with the
author(s) of the published material that
is referenced, and the author(s) will
have the opportunity to reply. Letters
to the editor must include the writer’s
address and phone number. Letters
may be edited and shortened for
space. To send a letter to the editor:
By email:
By regular mail:
Journal of Medical Regulation
Federation of State Medical Boards
400 Fuller Wiser Road, Suite 300
Euless, Texas 76039
FSMB Officers
Chair: Arthur S. Hengerer, MD
Chair-elect: Gregory B. Snyder, MD
Treasurer: Ralph C. Loomis, MD
President/Chief Executive Ofcer:
Humayun J. Chaudhry, DO, MS, MACP
Immediate Past Chair:
J. Daniel Gifford, MD, FACP
FSMB Board of Directors
Mark E. Bowden
Claudette E. Dalton, MD
Ana Z. Hayden, DO
Stephen E. Heretick, JD
Patricia A. King, MD, PhD, FACP
Jerry G. Landau, JD
Jean L. Rexford
Mari Robinson, JD
Scott Steingard, DO
Cheryl L. Walker-McGill, MD, MBA
Michael D. Zanolli, MD
FSMB Executive Staff
President/Chief Executive Ofcer:
Humayun J. Chaudhry, DO, MS,
The Journal of Medical Regulation
(ISSN 1547-48IX, publication number
189-120) is published quarterly by
the Federation of State Medical Boards
of the United States Inc.,
400 Fuller Wiser Rd., Suite 300,
Euless, TX 76039.
Telephone: (817) 868-4000
Fax: (817) 868-4098
Postmaster: Send address changes to
the Journal of Medical Regulation
400 Fuller Wiser Rd., Suite 300,
Euless, TX 76039.
Periodicals postage paid at Euless, Texas,
and additional mailing ofces.
Subscriptions and Correspondence
Subscribe online at:
Subscriptions and correspondence about
subscriptions should be addressed to
the Journal of Medical Regulation,
400 Fuller Wiser Rd., Suite 300,
Euless, TX 76039.
Subscriptions for individuals
are $70 per year; single copies are
$18 each. Subscriptions for libraries and
institutions are $140 per year; single
copies are $36 each. Notication of
change of address should be made at
least six weeks in advance. Enclose new
and old addresses, including ZIP code.
Authorization to Reproduce
For authorization to photocopy or
otherwise reproduce material under
circumstances not within fair use as
dened by United States Copyright Law,
contact the Federation of State Medical
Boards of the United States Inc. Such
photocopies may not be used for advertising
or promotional purposes, for creating
new collective works or for resale.
Manuscripts, letters to the editor and
other materials to be considered for
publication should be addressed to:
Journal of Medical Regulation
Federation of State Medical Boards
400 Fuller Wiser Rd.
Suite 300
Euless, TX 76039
Submit by email to:
AMA PRA Category 2 Credit™
The Journal of Medical Regulation
qualies as “authoritative medical
literature” and reading the Journal
is a valid activity for AMA PRA
Category 2 Credit™.
The opinions expressed by the authors
in the Journal of Medical Regulation
don’t necessarily reect the opinions
or policies of the Federation of State
Medical Boards.
JournalMedReg_Vol102_2 r2.indd 2 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 3
This taking the role of the other…is not something that just
happens but it is of importance in the development of cooperative
activity… [and] the control which the individual is able to
exercise over his own response.1
—George Herbert Mead
In my last issue as editor of JMR I would like to reiterate George Herbert Mead’s
central concept of “taking the role of the other.” I think we need to try to think about
what others’ concerns may be and we should not just assume their concerns are
the same as our own or that we can intuit what they are. It is necessary to work at
understanding their issues, to allow space for others’ views, and to discuss them.
In any situation in which diverse peoples are brought together whether medical
board deliberations, the doctor/patient relationship, or patient/healthcare team
interactions — it is imperative for each person to try to understand what the others’
concerns are. When we understand the positions of others, we can take them
into account in decision-making, thus potentially moderating our own actions and
working towards a consensus…The articles in this issue of JMR focus our attention
on thinking from multiple perspectives, as have many of the articles in the last
several years. If we want to assess how many additional providers patients may
need, for example, it may be better to count by the type of medical practice rather
than by board certication. In the article “Counting Physicians in Specialties: By
What They Do or How They Train?” (page 13) Dr. Thomas Ricketts and co-authors
nd that the availability of primary care providers looks very different when it is counted
by board certication rather than type of practice. In thinking about what state medical
boards should do about the use of “conversion therapy,” (“The Growing Regulation
of Conversion Therapy,” page 7) Dr. Jack Drescher and co-authors argue that we
need to think about what gays who are pushed or coerced to undergo such therapy
experience. How much do they and their families suffer from such treatment?
Broadening our own thinking to understand and incorporate the perspective of others
is a difcult task in a diverse society, but one that is essential to any democracy.
Ruth Horowitz, PhD
1 George H. Mead, Mind, Self and Society. 11934:254. University of Chicago Press.
JournalMedReg_Vol102_2 r2.indd 3 7/13/16 10:04 AM
4 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
Online Program Offers Information
about Rogue Internet Pharmacies
and Risks to Patient Safety
The Federation of State Medical Boards, in partner-
ship with the Alliance for Safe Online Pharmacies
(ASOP), is offering a free continuing education
program for physicians, pharmacists and other
health care providers that focuses on illegal
online drug sales.
The objective of the online educational activity,
titled “Internet Drug Sellers: What Providers Need
To Know,” is to provide education to health care
providers on the serious threat that illegal online drug
sellers pose to patient safety. Those participating
learn about the risks of purchasing drugs from
rogue internet pharmacies.
To learn more, visit
FSMB Elects New Officers
and Board Members
The Federation of State Medical Boards House of
Delegates elected new ofcers and board members
during its annual business meeting recently in
San Diego, Calif. The following individuals were
elected to the FSMB Board of Directors:
Arthur Hengerer, MD, assumed the position of
Chair of the FSMB Board of Directors. He has
served on the FSMB Board since 2011, as well as
on numerous FSMB committees, including chairing
the Ethics and Professionalism Committee. Dr.
Hengerer also was elected to the FSMB Foundation
Board of Directors in 2015. Appointed to the New
York State Board of Professional Medical Conduct
in 2002, he became Board Chair in 2012.
Gregory Snyder, MD, was elected FSMB Chair-elect.
Elected to a second term on the FSMB Board in
2015, Dr. Snyder has served on numerous FSMB
committees, including chairing the Workgroup
on Marijuana and Medical Regulation and the
Workgroup on International Collaboration. He
served on the Minnesota Board of Medical Practice
from 2006–2014, serving in many leadership
roles, including a term as President in 2014.
Anna Hayden, DO, was elected to a two-year term
on the Board of Directors. She has served on
several FSMB committees, including the Workgroup
on Education about Medical Regulation and the
Workgroup on Innovations in State-Based Licensure.
A member of the Florida Board of Osteopathic
Medicine, she has served two terms as the
Board’s Chair.
Scott Steingard, DO, was elected to a three-year
term on the FSMB Board of Directors. He previously
served on the FSMB Board from 2010–2013 and
served on numerous FSMB committees, including
chairing the FSMB Workgroup on Innovations in
State-Based Licensure. He has been active with
the Arizona Board of Osteopathic Examiners
in Medicine and Surgery for many years and has
served as the Board’s President since 2009.
Cheryl Walker-McGill, MD, MBA, was elected to
a three-year term on the FSMB Board of Directors.
Dr. Walker-McGill has served on several FSMB
committees, including the Workgroup on Team-
Based Regulation. A member of the North Carolina
Medical Board, she served as Board President in
2015, chaired the Discipline and Policy committees,
and oversaw development of the Board’s 2015–18
strategic goals.
Michael Zanolli, MD, was re-elected to a three-year
term on the FSMB Board of Directors. He has
served on various FSMB committees, including
representing the FSMB to the Accreditation Council
for Continuing Medical Education. Dr. Zanolli has
been a member of the Tennessee Board of Medical
Examiners since 2004 and currently serves as
the Board’s President.
Mari Robinson, JD, Executive Director of the Texas
Medical Board, was elected to a two-year term
as an Associate Member of the Board of Directors.
Ms. Robinson joined the Texas board in 2001.
She has served on several FSMB committees,
including the Interstate Medical Licensure Compact
Planning Group, and has been an active member
of Administrators in Medicine.
JournalMedReg_Vol102_2 r2.indd 4 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 5
IN BRIEF Dr. Hengerer discusses new
pressures on physicians and how they are
contributing to an increasing incidence of
burnout and potential impacts on patient care.
As I begin my year as FSMB Chair, I would like
to share with JMR readers some thoughts
about an important and growing issue for the
medical community — physician burnout — and
a new initiative that the FSMB has launched in
response to it.
Over my career as a physician, I have witnessed
various behavioral issues among physicians that
concerned me, and when given the opportunity
to serve as a medical regulator in 2002, I gladly
accepted appointment to the New York State Board
of Professional Medical Conduct. I have served on
that Board since 2002 and was subsequently
appointed to be its Chair four years ago. My work
with the New York Board, and in more recent years,
with the FSMB, has presented never-ending insights
into issues that impact medical professionalism
and the ability of physicians to carry out their
responsibilities to patients.
Like many other physicians, I have been struck by
the growing incidence of occupational stress and
emotional exhaustion among my colleagues in
medicine leading to what for many has become
disillusionment with their profession.
From increasing regulations and oversight and
increased paperwork to mounting pressures to
see more patients in less time and rapid technical
and work-environment changes such as the use
of electronic health records (EHRs), physicians
commonly express feelings of frustration, over-
extension, a loss of self worth and lack of control.
They feel out of touch with the things that drew
them to the profession in the rst place, including
connection with their patients and a sense of
being able to help improve the lives of others.
While the impact of burnout on physicians’ sense
of well being is obvious, we may forget that
heightened feelings of anxiousness and stress
can’t help but impact the quality of care that
physicians are able to provide for patients. We
know that physicians in high-stress situations run
the risk of becoming depressed, and in turn, losing
cognitive function which can have devastating
consequences for patients. And we know, through
studies, that there is a correlation between work-
place stress, medication errors, and malpractice
claims. In short: An emotionally drained physician
is not an effective physician.
In that sense, our nation’s growing physician-burnout
problem becomes a patient-safety issue and
lands squarely in the court of medical regulators.
We simply can’t ignore the warning signs of this
issue and the implications for health care.
Unfortunately, the medical profession has been
slow to recognize the signicance of physician
burnout, and to create ways of mitigating the factors
that are leading to it.
We now know, for example, that many of the
stressors that lead to burnout begin at the earliest
stages of one’s medical career in medical school
and residency. Historically, physician trainees have
been taught to “tough it out” when the going gets
difcult and they can easily ignore warning signs of
over-extension and professional alienation.
Persistent traditions often get in the way of cultural
change, however and it is now incumbent upon
Message from the Chair
Addressing Physician Burnout:
A New Challenge for State Medical Boards
Arthur S. Hengerer, MD, FACS
Chair, Board of Directors
Federation of State Medical Boards
JournalMedReg_Vol102_2 r2.indd 5 7/13/16 10:04 AM
6 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
us to nurture a new dialogue about physician
wellness, starting from the earliest stages of
training. Helping medical students and residents
learn to recognize the warning signs of stress and
burnout is the rst step, followed by building a new
awareness of the importance of physician health
throughout one’s career.
As time goes by and careers mature, physicians need to
recognize the three primary characteristics of burnout:
emotional exhaustion, depersonalization toward
patients, and the loss of self-worth in their careers.
Physicians who feel drained after a day in the
clinic or being on call and are not able to recover
during their time off are on the road to emotional
exhaustion. Over time, their energy levels dissipate
more and more.
Those who nd themselves becoming negative or
cynical about their patients may be experiencing the
warning signs of depersonalization. They may feel
their patients are ungrateful and nd themselves
complaining about them and unable to show true
compassion toward them.
Those who become self-critical, increasingly
questioning their ability to provide quality care
in a challenging environment and feeling hopeless
and unmotivated, may be experiencing loss of
self-worth. The sense of accomplishment they
experienced when they rst became physicians
may be fading away.
Combined, these three factors can have a devastating
effect on a physician’s overall effectiveness. And
when they occur, physicians must either seek
help or change their career path.
The keys to turning the tide of physician burnout are
awareness-building, early warning, prevention, and
when necessary, intervention — and that’s where
state medical boards have a potential role to play.
It is in our best interests as regulators to help
physicians recognize the dangers of burnout and
take steps to either prevent it before it becomes a
major issue or to address it if it is starting to cause
more serious problems.
With this as a compelling factor, the FSMB has
launched an initiative on physician burnout that I
am committed to and will actively guide during my
year as Chair. I have appointed a formal workgroup
to study the issue and we will work with a broad
spectrum of stakeholders over the coming year as
we seek ideas, input and potential pathways for
state medical board leadership.
For success, state medical boards will need to
examine the requirements of questioning and
reporting mental health issues on the part of
physicians in order to remove stigma and the
reluctance to seek help.
We will need to involve our colleagues at the
Federation of State Physician Health Programs
(FSPHP) and other relevant organizations in this
effort as we explore new ways of working together,
synthesizing ideas and developing resources.
In my time as a medical regulator, I have become
increasingly interested in the idea that our regulatory
system — and health care overall — would function
better if state medical boards were less threatening
and more supportive of physicians. The physician
burnout issue provides an excellent opportunity to
work with physicians in new, constructive ways that
could arguably lead to improved outcomes and
enhanced patient safety.
With all of these steps combined, we have the
opportunity as a professional community to make
a signicant difference on a fast-emerging issue.
During my year as Chair I will of course also
continue to support the many FSMB workgroups
that are completing important other tasks for
example, developing new ideas for regulation in
team-based medical practice and new educational
programs about medical regulation for medical
students and state board members. I am committed
to working closely with the leaders of every one of
our state and territorial boards to ensure quality,
member knowledge and consistent disciplinary
decision-making. I am very proud of the steady
growth in the stature of the FSMB, as well as
the respect exhibited by allied groups and federal
government ofcials as we have become a more
visible and impactful participant in health care
I look forward to working with our dedicated FSMB
leadership, and the fellows of the FSMB, over the
year to come. I know we can succeed in nding
solutions, not just to the problem of physician
burnout, but to the many other issues and challenges
before us. n
JournalMedReg_Vol102_2 r2.indd 6 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 12| 7
On April 8, 2015, the Obama administration called
for an end to conversion therapies that seek to
change a person’s sexual orientation or gender
identity. The White House issued a statement saying,
“As part of our dedication to protecting America’s
youth, this Administration supports effor ts to ban
the use of conversion therapy for minors.1 This
unprecedented announcement occurs at a time when
California, New Jersey, Oregon, Illinois, Vermont,
Washington, D.C., and the Canadian province of
Ontario, have banned such therapies undertaken by
licensed professionals for minors. In addition, 17
states have seen bills introduced into their legislatures
also seeking to ban these therapies. Unlicensed
practitioners of conversion therapy have been
successfully sued in New Jersey using consumer fraud
legislation; however, most states do not regulate
“therapy” provided by unlicensed practitioners.
This growing trend toward banning conversion
therapies creates novel challenges for licensing
boards and ethics committees, most of which are
unfamiliar with the issues raised by complaints
against conversion therapists. In an effort to close
that knowledge gap, this paper outlines the state
of current research and ethical considerations
surrounding conversion therapy.
Karl Maria Kertbeny, a Hungarian writer, and
Richard von Krafft-Ebing, a psychiatrist, rst used
the terms “homosexual” and “homosexuality” in
the 19th century, though they disagreed on the
term’s moral implications.2,3 Their early differences
presages an ongoing argument that continued into
the middle of the 20th century, where two major
competing theoretical views of homosexuality
predominated: that of psychoanalysis, a eld
dominated by psychiatric physicians, and that of
academic sexology research.
Sigmund Freud, the father of psychoanalysis, offered
a view of homosexuality as a developmental arrest, a
form of “immaturity,” in which normal sexual instincts
ABSTRACT: Conversion therapies are any treatments, including individual talk therapy, behavioral
(e.g. aversive stimuli), group therapy or milieu (e.g. “retreats or inpatient treatments” relying on all of the
above methods) treatments, which attempt to change an individual’s sexual orientation from homosexual
to heterosexual. However, these practices have been repudiated by major mental health organizations
because of increasing evidence that they are ineffective and may cause harm to patients and their families
who fail to change. At present, California, New Jersey, Oregon, Illinois, Vermont, Washington, D.C., and the
Canadian Province of Ontario have passed legislation banning conversion therapy for minors and an
increasing number of U.S. States are considering similar bans. In April 2015, the Obama administration
also called for a ban on conversion therapies for minors.
The growing trend toward banning conversion therapies creates challenges for licensing boards and ethics
committees, most of which are unfamiliar with the issues raised by complaints against conversion therapists.
This paper reviews the history of conversion therapy practices as well as clinical, ethical and research
issues they raise. With this information, state licensing boards, ethics committees and other regulatory
bodies will be better able to adjudicate complaints from members of the public who have been exposed
to conversion therapies.
The Growing Regulation of Conversion Therapy
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Jack Drescher, MD; Alan Schwartz, MD; Flávio Casoy, MD; Christopher A. McIntosh, MSc, MD;
Brian Hurley, MD, MBA; Kenneth Ashley, MD; Mary Barber, MD; David Goldenberg, MD;
Sarah E. Herbert, MD, MSW; Lorraine E. Lothwell, MD; Marlin R. Mattson, MD;
Scot G. McAfee, MD; Jack Pula, MD; Vernon Rosario, MD; D. Andrew Tompkins, MD, MHS
JournalMedReg_Vol102_2 r2.indd 7 7/13/16 10:04 AM
8 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
1990, the World Health Organization removed
homosexuality from the International Classication
of Diseases (ICD-10).15
Despite these changes in scientic thinking in the
last two decades, social and religious conservatives
have advanced their own illness/behavior model
of homosexuality.16 These individuals believe that
if homosexual behavior can be changed in just
one person, homosexuality cannot possibly be
an inborn trait, like race.17 They maintain that
homosexuality is not inborn and that variations
of long disproven psychoanalytic theories of
homosexuality’s etiology can serve as a basis
for offering conversion therapies.16,17,18,19
Research, Clinical and Ethical Issues
The position that a homosexual orientation can
change received a great deal of media attention
in 2001 when Robert L. Spitzer, MD, presented
his study of 200 individuals who claimed to have
undergone such changes.20,21 According to Spitzer,
a majority of the study’s subjects reported some
change from a “predominantly or exclusively”
homosexual orientation to a “predominantly or
exclusively” heterosexual orientation. Many scholars
made methodological criticisms of the study, which
was published without conventional peer review.20
Instead, reviewer commentaries most of them
negative and urging the journal not to publish
accompanied the study’s publication. In 2012,
Spitzer repudiated his own study, writing, “There
was no way to judge the credibility of subject
reports of change in sexual orientation.”22
Assessments of the peer-reviewed literature from
multiple professional organizations, including the
American Psychiatric Association, the American
Psychological Association, and the American Academy
of Child and Adolescent Psychiatrists, have found
no evidence that conversion therapy treatments
result in changes in sexual orientation.23,24,25 There
is no formal training available on how to conduct
conversion therapy. Moreover, the evidence,
suggests these treatments are harmful.26,27,28,29
of childhood persist into adulthood.4 However,
psychoanalysts after Freud, until the last decade of
the twentieth century,5 , 6 based their views on the
work of Sandor Rado, who believed there was no
such thing as normal bisexuality.7 Rado dened
adult homosexuality as a phobic avoidance of
heterosexuality caused by inadequate early parenting.
His views were highly inuential in the pathological
models of psychiatrists of the mid-20th century who
theorized about homosexuality from a self-selected
group of patients seeking treatment and from
prison populations.8,9
Sexology researchers of the mid-twentieth century
tried to make sense of human sexual behavior by
studying general populations. They did eld
research, recruiting large numbers of non-patient
subjects for study. The work of Alfred Kinsey and
Evelyn Hooker lent support to a growing scientic
view that homosexuality, like heterosexuality, is a
normal variation of human sexual expression.10,11,12
American psychiatry at that time, under the sway of
psychoanalytic theory, mostly ignored this research
and its normalizing conclusions.
In 1970, sexology research was brought forcefully to
the attention of the American Psychiatric Association
(APA). Organized gay and lesbian activists, convinced
that psychiatry’s pathologizing attitudes about homo-
sexuality were a major contributor to social stigma,
disrupted the 1970 and 1971 annual APA meetings.
As a result, APA embarked upon a process of studying
the scientic question of whether homosexuality
should be considered a psychiatric disorder. After an
extensive review of the literature, the APAs Board of
Trustees voted to remove homosexuality from the
DSM-II in December 1973.13,14
The removal of the diagnosis from the DSM contributed
to changes in cultural attitudes about homosex-
uality in the U.S. and other countries. Those who
accepted scientic authority on such matters
gradually came to accept the view that homosexuality
is a normal variant of human sexual expression.
Similar shifts gradually took place in the interna-
tional mental health community as well. In
JournalMedReg_Vol102_2 r2.indd 8 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 9
Harm can occur when patients blame themselves
for their failure to change, questioning their faith or
level of motivation. This may lead to depression,
anxiety, and suicidal ideation. Some individuals are
encouraged to marry during a course of conversion
therapy and may have spouses and children by the
time they accept that change has not happened.
These families may break apart. In cases where
religious beliefs discourage divorce, mixed orientation
couples often stay living together in tragic circum-
stances. Also, years of trying fruitlessly to change
one’s sexual orientation can delay the decision to
come out as gay or lesbian. When the individual
does come out, the experience of conversion therapy,
which can be likened to a concentrated dose of
anti-homosexual stereotyping, may create intimacy
and sexual problems. Haldeman refers to this as
a “spoiled” gay identity.28
Furthermore, while it is difcult to capture empirically
the rates of depression, suicide, and other negative
health outcomes caused by conversion therapy, there
is strong evidence showing that social and family
rejection of gay or lesbian identity are strongly
correlated with negative health outcomes. Ryan and
others show that lesbian, gay, and bisexual young
adults who reported high levels of family rejection were
8.4 times more likely to have attempted suicide, 5.9
times more likely to report depression, and 3.4 times
more likely to have tried illegal drugs when compared
to individuals who did not feel rejected. Instead of
protecting individuals who experience this rejection,
conversion therapy can potentially increase this risk by
deepening the rejection of the patient’s identity.32
Conversion therapists have at times defended their
actions by claiming their clients should be able to
choose to take part in these therapies. We disagree
and suggest that a parallel proscribed behavior that
regulatory bodies can consider while assessing how to
respond to these complaints is sexual contact between
therapists and patients. Sexual contact, even when
consensual, has been shown to be very detrimental to
the patient and has no place in the clinical setting.
In the past, professional organizations regarded
conversion therapies as private agreements
between individual patients and therapists. Many
believed that efforts to eradicate homosexuality
were a reasonable and harmless undertaking.16
In recent years, however, complaints about poor
outcomes have led to greater scrutiny. An emerging
clinical focus developed on individuals who after
attempting and failing conversion therapy — later
adopted a gay or lesbian identity. Referring to
themselves as “ex-gay survivors,” these individuals
have begun organizing themselves.30 An accumulation
of patient reports paints a disturbing picture:
therapists may be doing psychological damage to
patients who fail to change and eventually come out
as gay or lesbian — and to their families, as well.
Ethical violations in these treatments include:
Telling patients that homosexuality is a mental
disorder because of practitioner beliefs when
there is no evidence that this is the case.
Breaches of condentiality, i.e., counselors in
religious schools informing administration ofcials
about a patient’s sexual behavior discussed in
therapy, sometimes leading to expulsion.
Improper pressure placed on patients, i.e., threatening
to end treatment if the patients do not submit to
the therapist’s authority.
Abandoning patients who eventually decide to
come out as gay or lesbian, i.e., unwillingness
to refer a patient to a gay or lesbian afrmative
therapist when conversion therapy fails.
Indiscriminate use of treatment, i.e., regardless of
the probability of success, conversion therapists
will recommend their treatments to anyone.
When patients are not able to change their sexual
orientation, conversion therapists often blame the
patient, rather than the therapy.29,31 This can lead
to shameful internalizations that may induce or
worsen depression.
These troubling ethical practices have raised alarm
in major mental health professions, particularly
because of the harm to patients. Further, all of
these factors raise another ethical issue: Even if
the questionable claims of conversion therapy’s
effectiveness are valid, should the conversion of
some “homosexuals” to heterosexuality condone
the iatrogenic harm done to other patients who later
come out as gay or lesbian?16 In other words, should
it not matter how many gay or lesbian people are
hurt in the process of creating a few heterosexuals?
JournalMedReg_Vol102_2 r2.indd 9 7/13/16 10:04 AM
10 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
As it is likely that more states will be banning
conversion therapies for minors, regulatory bodies
should create easily accessible mechanisms for
the public to register complaints about them.
Regulatory bodies whose members do not have
expert knowledge about conversion therapies
should seek out expert consultation when managing
complaints about them.
Regulatory bodies should develop appropriate
guidelines on how to sanction licensed practitioners
of conversion therapies. n
About the Authors
The authors comprise the LGBT Committee of the Group for the
Advancement of Psychiatry.
Kenneth Ashley, MD, is Assistant Professor of Psychiatry-
Clinician/Educator Track, Icahn School of Medicine at Mount
Sinai, New York.
Mary Barber, MD, is Clinical Director, Rockland Psychiatric
Center-Ofce of Mental Health, and Associate Clinical Professor
of Psychiatry, Columbia University College of Physicians
and Surgeons.
Flávio Casoy, MD, is Medical Director of Admissions, Rockland
Psychiatric Center-Ofce of Mental Health, and Clinical Instructor
in Psychiatry, Columbia University.
Jack Drescher, MD, is Clinical Professor of Psychiatry, New York
Medical College, and Adjunct Professor, New York University.
David Goldenberg, MD, is Assistant Professor of Clinical
Psychiatry, Weill Cornell Medical College, and Faculty, New York
Psychoanalytic Institute.
Sarah E. Herbert, MD, MSW, is Clinical Associate Professor,
Department of Psychiatry and Behavioral Sciences, Morehouse
School of Medicine.
Brian Hurley, MD, MBA, is Robert Wood Johnson Foundation
Clinical Scholar, David Geffen School of Medicine of the University
of California, Los Angeles.
Lorraine E. Lothwell, MD, is Medical Director, Child & Adolescent
Psychiatry Outpatient Clinic, Harlem Hospital, and Assistant
Clinical Professor of Psychiatry, Columbia University Department
of Psychiatry.
Marlin R. Mattson, MD, is Professor Emeritus of Clinical
Psychiatry, Weill Cornell Medical College.
Scot G. McAfee, MD, is Interim Chair and Residency Training
Director, Psychiatry, Maimonides Medical Center, and Assistant
Professor of Clinical Psychiatry, New York Medical College.
Christopher A. McIntosh, MSc, MD, FRCPC, is Head, Adult Gender
Identity Clinic, Centre for Addiction and Mental Health, and
Assistant Professor, University of Toronto.
Jack Pula, MD, is Assistant Clinical Professor of Psychiatry,
Columbia University College of Physicians and Surgeons.
Vernon Rosario, MD, is Associate Clinical Professor, University
of California, Los Angeles.
Alan Schwartz, MD, is Supervisor of Psychotherapy, William
Alanson White Institute, New York.
D. Andrew Tompkins, MD, MHS, is Assistant Professor,
Department of Psychiatry and Behavioral Sciences, Johns
Hopkins University School of Medicine.
Current Legislation
As of this writing, ve states (California, New
Jersey, Oregon, Illinois, Vermont), the District of
Columbia and the Canadian province of Ontario
have passed legislation outlawing the practice of
conversion therapy by licensed mental health
professionals for patients less than 18 years of
age (Table 1). In addition, New Mexico has passed
legislation forming a state task force to study the
practice of conversion therapy and bring recommen-
dations back to the legislature.
Nineteen additional states have introduced legislation
outlawing conversion therapy for minors for the
current legislative session. In February 2016, New
York Governor Cuomo issued an executive order
that barred New York insurers from paying for con-
version therapy to minors, prohibited New York
Medicaid from covering
conversion therapy, and
forbid the New York State Ofce
of Mental Health
facilities from providing conversion therapy to
minors. Overall, this level of legislative action points
to the importance of state licensing boards familiar-
izing themselves with what constitutes conversion
therapy in order to adjudicate possible complaints.
As of this writing, to our knowledge, there have
been no formal actions by a regulatory body against
a provider for engaging in conversion therapy.
However, major mental health organizations have
rejected conversion therapy as a treatment modality
given that there is no rigorous scientic evidence
to support the claim that sexual orientation can be
changed and there is evidence that these treatments
can cause harm to patients. Furthermore, there is
likely to be more legislation banning the practice in
the coming years. Regulatory bodies must take
these issues into consideration when evaluating
claims regarding these treatments.
While existing legislation only bans conversion
therapy for minors, regulatory bodies should develop
guidelines to deal with complaints from adults who
have been harmed by conversion therapies.
JournalMedReg_Vol102_2 r2.indd 10 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 11
Table 1
Status of Laws Banning Conversion Therapy
Passed Pending Failed Bill/Resolution
Bill/Resolution Title
Date of Last Action
on Bill/Resolution
AZ xSB1464 Sexual orientation change efforts; prohibition. 02/03/2016
CA xSB 1172 Sexual orientation change efforts. 09/19/2012
CO xHB1210 A bill for an act concerning a prohibition on conversion
therapy by a licensed mental health provider.
CT xHB5530 An act concerning health care services relating to a
minor child’s sexual orientation.
DC xB 20-0501 Conversion Therapy for Minors Prohibition Amendment
Act of 2014
FL xS 0258/H 0137 An act relating to sexual orientation change efforts. 03/11/2016
GA xHB716 An act prohibiting sexual orientation conversion therapy
to people under 18 year old.
HI xSB2615
Prohibits sexual orientation conversion therapy for minors.
IL x
Creates the Youth Mental Health Protection Act. 08/20/2015
IA xHF276/SF334 A bill for an act relating to sexual orientation change
efforts and making penalties applicable.
MA xH.97 An act relative to abusive practices to change sexual
orientation and gender identity in minors.
MN xHF1620/
Conversion therapy with children or vulnerable adults
prohibited, and medical assistance coverage for
conversion therapy prohibited.
NV xSB353 Enacts provisions relating to sexual orientation
conversion therapy.
NH xHB1661 Relative to conversion therapy seeking to change
a person’s sexual orientation.
NJ xA 3371/S 2278 An act concerning the protection of minors
from attempts to change sexual orientation and
supplementing Title 45 of the Revised Statutes.
NY xA04958/
Designates as professional misconduct, engaging in
sexual orientation change efforts by mental health care
professionals upon patients under 18 years of age.
OH xSB74 To enact sections 4723.93, 4731.96, 4732.34,
4743.09, and 4757.46 of the Revised Code to prohibit
certain health care professionals from engaging in sexual
orientation change efforts when treating minor patients.
ON xBill 77/S.O.
2015 C.18
Afrming Sexual Orientation and Gender Identity Act. 06/04/2015
OR xHB2307 Relating to efforts to change an individual’s orientation
and declaring an emergency.
PA xHB935/SB45 An act prohibiting mental health professionals from
engaging in conversion therapy with an individual under
18 years of age.
RI xS2827 Prevention of conversion therapy for children. 05/26/2016
TX xHB3495 An act relating to unprofessional conduct by mental
health providers who attempt to change sexual
orientation of a child.
VT xS0132 An act relating to the prohibition of conversion therapy
on minors.
VA xSB262/HB427 Sexual orientation change-efforts prohibited. 02/16/2016
WA xHB 1972/
Prohibiting the use of aversion therapy in the treatment
of minors.
WV xHB4343 The Youth Mental Health Protection Act. 02/01/2016
xHB 2450/
SR 184
Therapeutic Fraud Prevention Act/Stop Harming Our
Kids Resolution of 2015.
JournalMedReg_Vol102_2 r2.indd 11 7/22/16 2:50 PM
12 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
20. Drescher J, Zucker KJ. (Eds.). Ex-Gay Research: Analyzing the
Spitzer Study and Its Relation to Science, Religion, Politics,
and Culture. New York: Harrington Park Press. 2006.
21. Spitzer RL. Can Some Gay Men and Lesbians Change Their
Sexual Orientation?: 200 Subjects Reporting a Change from
Homosexual to Heterosexual Orientation. Arch Sex Behav.
2003; 32(5), 403-417.
22. Spitzer RL. Spitzer Reassesses His 2003 Study of Reparative
Therapy of Homosexuality. Arch Sex Behav. 2012; 41(4), 757.
23. 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; 51(9): 957-974.
24. American Psychological Association Task Force on the
Appropriate Therapeutic Response to Sexual Orientation.
Report of the Task Force on the Appropriate Therapeutic
Response to Sexual Orientation. Washington, DC: American
Psychological Association. 2009.
25. American Psychiatric Association Commision on Psychotherapy
by Psychiatrists. Position Statement on Therapies Focused
on Attempts to Change Sexual Orientation (Reparative or
Conversion Therapies). Am J Psychiatry. 2000; 157(10):
26. Beckstead AL. Can We Change Sexual Orientation? Arch
Sex Behav. 2012; 41(1), 121-134.
27. Beckstead AL & Morrow SL. Mormon Clients’ Experience
of Conversion Therapy: The Need for a New Treatment
Approach. Couns Psychol. 2004; 32(5), 651-690.
28. Haldeman DC. Therapeutic Antidotes: Helping Gay and
Bisexual Men Recover from Conversion Therapies. J Gay &
Lesb Psychother. 2002; 5(3/4), 117-130.
29. Shidlo A. & Schroeder M. Changing Sexual Orientation: A
Consumers’ Report. Prof Psychol Res Pr. 2002; 33(3), 249-259.
30. Beyond Ex-Gay: An Online Community For Those Who Have
Survived Ex-Gay Experiences. Retrieved from http://www. Accessed on November 13, 2015.
31. Salzer A & Salomon A. (Writers). Abomination: Homosexuality
and the Ex-Gay Movement: Frameline. 2006.
32. Ryan C., Huebner D., Diaz R. and Sanchez J. Family Rejection
as a Predictor of Negative Health Outcomes in White and
Latino Lesbian, Gay, and Bisexual Young Adults. Pediatrics.
2009; 123(1), 346-352.
33. #BornPerfect: Laws & Legislation by State. 2015; Retrieved
by-state. Accessed on November 13, 2015.
34. Washington State Legislature. 2015. Retrieved from http://
Accessed on November 13, 2015.
35. Library of Congress. 2015. Retrieved from http://thomas. Accessed on November 13, 2015.
36. Legislative Assembly of Ontario. 2015. Retrieved from
&BillID=3197&detailPage=bills_detail_status. Accessed on
November 13, 2015.
1. Jarrett V. Response to Your Petition on Conversion Therapy.
2015. Retrieved from
Accessed on November 13, 2015.
2. Bullough VL. Homosexuality: A Histor y. New York:
Meridian. 1979.
3. Krafft-Ebing R. Psychopathia Sexualis (H. Wedeck, Trans.).
New York: Putnam. 1965.
4. Freud S. Three Essays on the Theory of Sexuality, Standard
Edition of the Complete Psychological Works of Sigmund
Freud (Vol. 7, pp. 123-246). London: Hogarth Press. 1957.
5. American Psychoanalytic Association. Position Statement on
Attempts to Change Sexual Orientation, Gender Identity, or
Gender Expression. 2012. Retrieved from http://www.apsa.
pdf. Accessed on November 13, 2015.
6. American Psychoanalytic Association. Position Statement on
Sexual Orientation, Gender Identity, and Civil Rights. 2012.
Retrieved from
20Civil%20Rights.pdf. Accessed on November 13, 2015.
7. Rado S. A Critical Examination of the Concept of Bisexuality.
Psychosomatic Medicine. 1940; 2, 459-467.
8. Bieber I, Dain HJ, Dince PR, Drellich MG, Grand HG, Gundlach
RR, . . . Bieber TB. Homosexuality: A Psychoanalytic Study
of Male Homosexuals. New York: Basic Books. 1962.
9. Socarides CW. The Overt Homosexual. New York: Grune &
Stratton. 1968.
10. Kinsey AC, Pomeroy WB, Martin, CE. Sexual Behavior in the
Human Male. Philadelphia: W.B. Saunders. 1948.
11. Kinsey AC, Pomeroy WB, Martin CE, Gebhard PH. Sexual
Behavior in the Human Female. Philadelphia: Saunders.
12. Hooker EA. The Adjustment of the Male Overt Homosexual.
J Proj Tech 1957; 21, 18-31. 1957.
13. Bayer R. Homosexuality and American Psychiatry: The
Politics of Diagnosis. New York: Basic Books. 1981.
14. Drescher J, Merlino JP. (Eds.). American Psychiatr y and Homo-
sexuality: An Oral History. New York: Haworth Press. 2007.
15. Cochran, SD, Drescher J, Kismodi E, Giami A, García-Moreno
C, Reed GM. Proposed Declassication of Disease Categories
Related to Sexual Orientation in ICD-11: Rationale and
Evidence From the Working Group on Sexual Disorders and
Sexual Health. B World Health Organ. 2014; 92, 672-679.
Retrieved from
16. Drescher J. Ethical Issues in Treating Gay and Lesbian
Patients. Psychiatr Clin North Am. 2002; 25(3), 605-621.
17. Drescher J. The Spitzer Study and the Culture Wars. Arch
Sex Behav. 2003; 32(5), 431-432.
18. Drescher J. I’m Your Handyman: A History of Reparative
Therapies. J Homosex. 1998; 36(1), 19-42.
19. Drescher J. Can Sexual Orientation be Changed? J Gay &
Lesb Ment Health. 2015; 19(1), 84-93.
JournalMedReg_Vol102_2 r2.indd 12 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 12| 13
The balance of physician supply to needs in the
United States has been a longstanding policy
concern. Claims of growing shortages of physicians
as well as severe maldistribution between rural
and urban areas and among the specialties are
common.1,2 The balance between the supply of
primary care physicians and population is presented
as a par ticularly important measure of access
to care, affecting the ability of the system to deliver
on the promise of public health insurance programs
such as Medicare, Medicaid and Veterans’ health
care.3 State policymakers are especially sensitive
to the local supply of primary care practitioners,
as many have invested in programs and incentives
to produce and distribute physicians into under-
served areas.4,5
The question of the adequacy of the supply of
primary care physicians is a public policy issue in
North Carolina.6 To measure physician supply, data
have been collected and reported annually by the
North Carolina Health Professions Data System
(HPDS) at the University of North Carolina to the
state legislature since 1979. Physician data are
collected from license les provided by the North
Carolina Medical Board (NCMB). In 2011, North
Carolina’s annual summary report of its supply of
actively practicing physicians noted that the number
of primary care physicians practicing in the state
dropped from 9,017 in 2010 to 7,520 in 2011.7 As
the report explained, the decline was due not to a
real drop in the number of physicians, but rather
was the result of a change in the way the data were
collected. The NCMB had implemented a “redesign”
of the online registration system that asked
physicians to identify their “area of practice.” The
goal of this change was to capture better data on
the specialty practice area in which the physicians
are actively engaged as opposed to the specialty
in which they were trained and/or practiced in the
past. This article describes the concept of “areas
of practice” using data North Carolina physicians
reported on their license and re-registration forms
and compares those designations to the physicians’
specialty training. While using current specialty
practice area to categorize physicians may provide
a more accurate description of what physicians
do, it disrupts the analysis of trends in physician
supply by specialty in North Carolina. The disruption
is especially problematic for primary care, as
new roles and classications are being applied to
generalists. The North Carolina case may presage
a change in specialty classication systems and
ABSTRACT: The number of actively practicing physicians in the United States is not precisely known,
nor do we know the total number of physicians required to meet population needs. The possible gap
between these two numbers is a controversial issue, especially for primary care physicians. Primary care
physicians can be counted in more than one way, either by their “area of practice” (in other words, what
they do) or by the specialty in which they train. Regulatory agencies and other health organizations see
the area of practice as more relevant to understanding physician supply. In North Carolina, the counts
of primary care physicians were historically based on specialty of training. In 2010, the way physicians
were counted was changed from denition by specialty of training to denition by area of practice, which
resulted in an apparent drop in the number of primary care physicians by more than 16% in a single year.
When terms such as “hospitalist,” “urgent care,” “student health,” and “integrative medicine” were added
to describe additional practice areas of physicians, most of the loss was accounted for. Researchers,
regulators and policy makers need to be aware of the effects of a shift in how physicians are counted
and assigned to specialties to understand the extent of pending shortages.
Counting Physicians in Specialties:
By What They Do or How They Train?
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thomas C. Ricketts, PhD, MPH; Erin P. Fraher, PhD, MPP; Julie C. Spero, MSPH
JournalMedReg_Vol102_2 r2.indd 13 7/13/16 10:04 AM
14 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
This issue has been the focus recently of a variety
of reports, projections, and models that use a wide
range of data and arrive at different conclusions. Part
of the problem is the lack of a single, authoritative
and comprehensive source indicating the number of
physicians practicing in the United States, and their
practice specialties.13 Because we are unsure of
the numbers of practitioners, we are unable to
answer the question of balance, i.e., do we train
physicians in specialties that meet the needs of
patients and the system? Traditionally, we have
considered physician supply as a combination of
specialists and generalists trained in residencies
and fellowships after their medical school training.
We have classied them by their specialty training,
identifying them as family physicians, general internists,
or as specialists in surgery or medicine pursuant to
completion of a “board certication” process.14,15
Over time, the number of specialties described by
their training has expanded and in the most recent
decades that expansion has accelerated.16 As
specialties change, so do the classications, but no
clear incentive exists for physicians, once classied,
to change their designation or board certication.
The trend to greater specialization has not been
uniformly viewed as benecial, with some claiming
that it generates inefciencies.17 In the words
of one study, the rise of more specialties has
“confounded workforce projections,” as it is more
and more difcult to understand what physicians
either are doing or can do.18
State Responsibilities in Determining
Physician Supply
In the United States, individual state medical boards
have the responsibility for licensing physicians and
state appropriations are often used to support
medical education. Thus, states have an important
stake in determining the optimal number of practi-
tioners to meet population needs. Additionally,
states pay for direct patient care services for
underserved and at risk populations, and are,
therefore, motivated to use resources in the most
efcient way possible to care for patients, prevent
taxonomies that better describe new and emerging
specialties. This may spread nationwide as interests
shift toward identifying practice areas in lieu of
training specialty. If so, it will be important to
clarify how physician specialty classications have
changed to prevent confusion in policy discussions
over the best ways to meet the nation’s physician
workforce needs in primary care and other specialties
in medicine.
Determining the number and capacity of the
physician workforce is a key component in the
development of appropriate policies to ensure
access to health care.8,9 Public policies to affect
the number and distribution of physicians have
been part of the political landscape since the
development of state-supported medical schools.
Concern over the balance of the supply of physicians
to the need for their services has been expressed
by inuential national commissions since the
early 20th century and by the national government
since the 1960s with the passing of Medicare
and Medicaid legislation.10 The federal role in
supporting incentives to redistribute the supply of
physicians started with the National Health Service
Corps in 1968, then shifted to direct support for
training physicians in selected specialties under
Title VII programs along with support of graduate
medical education via the Medicare program in
the 1970s. These efforts were intended to solve
geographic and specialty imbalances. Over time,
debates have shifted back and forth over whether
the nation faced a “surplus”11 or “shortage”
of physicians.3,12 Recent discussions over the
best policies to ensure the supply of physicians
and the needs of the population have intensied
the national focus on physician supply. Policy-
makers have asked: do we have enough physicians
of the right kinds in the right places doing the
right things?
JournalMedReg_Vol102_2 r2.indd 14 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 15
or the various specialty boards approved by the
ABMS or AOA. Nevertheless, the 212 physician
code classes (Fall 2014) cover almost all possible
specialty groups. The NPPES system may be useful
in assessing the distribution of specialties when
the NPIs are merged with or included in other data
sets. The applicability of NPI les to the analysis of
supply issues is only now being tested.
Assigning Physicians to Specialties
The most common way of determining supply and
the distribution of physicians by specialty is the use
of inventories of licensed practitioners found in
three different administrative data sets: self-
reported specialty designation collected during
state licensing and renewal, specialty data reported
in the American Medical Association (AMA) Masterle,
and board certications reported by the American
Board of Medical Specialties (ABMS). There are now
more than 300 different physician specialty and
subspecialty titles in these data sets. No clearing-
house, central agency, or organization plans or
initiates the process for the development of newly
emerging specialties and subspecialties, but the
ABMS and its counterparts in osteopathic medicine
review and approve the majority of specialty programs
through their constituent boards. In 2011 24 ABMS
boards oversaw general and subspecialty certication.
In 2013 ABMS and AOA listed 260 individual clas-
sications of specialties and subspecialties. The
ABMS alone recognized 122 subspecialty certicates
in that year. In 2011, the AMA listed 259 specialties
as “self-designated” specialties in its Masterle,
including new certications and designations that
did not emerge from the traditional 24 ABMS
boards. These new, organizational specialties
describe what physicians are doing in an organ i-
zational context as opposed to a description of
their clinical scope of practice, (e.g., “hospitalist,
“student health,” “urgent care”) or forms of practice
that reect a combination of disciplines (e.g.,
“integrative medicine,” “sleep medicine,” “sports
medicine”). As these descriptors and their formal
denitions develop and gain acceptance, they are
displacing clinical specialty categorizations.
Primary Care as a “Collective Specialty”
Perhaps the rst new class of physician activity
based on a combination of organizational as well as
clinical roles was primary care. Primary care may be
viewed variously as a cluster of specialties that are
the rst-contact physicians for a broad population23
or as a way to practice medicine separate from a
disease and support public health obligations.
Many states make use of Medicaid matching funds
to support graduate medical education and, in at
least one instance, in Utah, have used a Medicaid
waiver to develop a prioritization of graduate medical
education needs. That process required current and
detailed knowledge of physician supply by specialty.19
States have become more active in the development
of accurate inventories of physicians to support
policy decision-making. The National Center for
Health Workforce Analysis has supported states in
their efforts to improve data collection.20
Federal Responsibilities
The federal government supports multiple programs
that are intended to enhance and optimize the supply
and distribution of practitioners, especially those in
primary care.21 Accomplishing this goal requires
current and accurate data on the distribution of
physicians by geography, activity and specialty. The
federal government has created its own inventories
for practicing clinicians, including physicians most
notably the National Provider Identier (NPI) issued by
the National Plan and Provider Enumeration System
(NPPES). That system was required by the Health
Insurance Portability and Accountability Act (HIPAA)
legislation and registration is required of all providers
who use electronic systems as part of their billing
process. The NPPES is maintained in the U.S.
Centers for Medicare and Medicaid Services (CMS)
and has, to date, captured almost all medical (MD
and DO) practitioners in the United States. No formal
evaluation of the accuracy of the system has been
conducted, but with its mandate in regulation
and link to the systems that support key federal
programs, suggestions to use it as a national
supply inventory and as the basis for assessing
under-service have been made within HRSA.22
The NPPES has created a physician specialty
“taxonomy” that roughly includes all physician
specialties under one or more headings or codes.
The NPPES codes do not necessarily coincide with
the “self-designated specialties” used by the AMA
JournalMedReg_Vol102_2 r2.indd 15 7/13/16 10:04 AM
16 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
emerged as a typology describing generalist care
for the inpatient.31 Various forms of the terms
“urgent care” or “critical care” have been used to
describe the area of practice of primary as well as
specialty care. These classications reect the
organizational role of the physician. Thus, two
axes of specialization describe the real world of
medical practice: rst, the clinical and second, the
organizational and they can occur simultaneously
to meet the demands of the patient and/or the
institution or organization.
Case: The rise of the “Hospitalist”
The organizational role of hospitalists physicians
who specialize in caring for patients in inpatient
settings is perhaps the example with the longest
history as a “organizationally dened” specialty.32
The American health care system has embraced
hospitalists vigorously. The number of hospitalists
has been estimated to be approximately 30,000 in
2014 most of whom were trained in general internal
medicine followed by pediatric subspecialists,
internal medicine subspecialists, general pediatri-
cians and family physicians.33 The establishment
of the hospitalist has changed the dynamics of
physician practice and demand for physicians in
communities with hospitals. Far fewer general
internists have hospital practices and demand for
these jobs by physicians who wish to restrict their
practice to an inpatient setting is strong.34-37
Data: The North Carolina Case
Historically, the NCMB requested a physician’s
primary certication during the process of initial
licensure or license renewal, and initially included
only ABMS or AOA certications in the choice
options. In 2010, the NCMB began using a new
approach to determine the area of practice for
physicians licensed in North Carolina. This change
was prompted by an apparent recognition that the
traditional designation of practice specialty did not
provide an accurate depiction of the actual scope of
a physician’s practice. An additional impetus for the
move to the designation “area of practice” was the
policy guideline from the Federation for State
Medical Boards, passed in April 2011, which
recommended that states collect a minimum data
set (MDS) on their licensees. The FSMB developed
this MDS with support from the National Center for
Health Workforce Analysis (NCHWA) at the Health
Resources and Services Administration (HRSA), a
federal agency that has promoted the development
of minimum data sets for all licensed and some
specialty distinction. The “rst contact” label is the
most common way to dene primary care and it
usually includes family and general practice, general
internal medicine and general pediatrics. This denition
of primary care was supported by analysis of
ambulatory-care-visit content by Rosenblatt and
others and by Weiner and Stareld, who matched
services that comprised “good primary care” with
the specialties of the physicians providing those
services.24,25 Obstetrics-gynecology is sometimes
seen as the primary-care specialty for women26 and
recognized as such in some settings as primary
care.* Specialty boundaries have been disputed
for decades. The organizational aspects of primary
care that attract current attention are usually
found in the context of new payment and care
delivery models intended to reform health care
delivery, including patient centered medical
homes and accountable care organizations.
These organizations affect the quality and quantity
of the care provided by professionals and we
should consider not only how many physicians there
are27,28 but also where they work when we assess
overall supply.29
Primary care physicians treat a wide range of
conditions and are responsible for the coordination
of care for patients. However, a primary care
physician may specialize in older people (geriatrician),
children (general pediatrician or adolescent
medicine), adults (general internal medicine) as well
as the full range of the population in a community
(family medicine). As a multivalent eld of practice
in medicine, primary care has undergone its own
process of “specialization.30 The emergence of the
subspecialties of geriatrics, palliative care, and
sports medicine that are recognized in family
medicine by “Certicates of Added Qualications”
provide examples. There have been recent trends
toward an even ner focus: hospitalists have
* North Carolina General Assembly, Senate Bill 27, S.L.
1993-321, Page 75.
See: procedures.
JournalMedReg_Vol102_2 r2.indd 16 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 17
‘integrative medicine,’ ‘student health’
and so forth. Please select all of your area(s)
of practice and then designate one of them
as your primary area of practice.”40
These instructions are followed by a listing of
specialties with check boxes and a box for an
“other category” along with a space to enter that
specialization. More than 99% of North Carolina
physicians registering indicate an area of practice.
The current areas of practice for North Carolina
physicians are based on classications used by
AMA in its classication of physician specialties
supplemented by additional areas of practice that
are considered important by the NCMB.
2010 was the rst year in which NCMB asked
physicians to select an area of practice. In prior
years they were offered a listing of specialties that
matched the listing of specialties and specialty
codes published by the AMA and used in its Physician
Masterle® to categorize physicians. In 2010 there
were 241 AMA specialties, and the North Carolina
data system included 213. The AMA listing included
“hospitalists,” but not administrative medicine,
“integrative medicine,” “student health,” “body
imaging,” “physiatrist,” or “bariatric medicine.
These were in the NC listing because a physician
either entered that category on a prior license
renewal or an individual physician(s) requested the
creation of a category.
Physicians were able to select multiple areas of
practice. If more than one was selected, they would
select a “primary area of practice.” Use of these
updated licensure and re-registration forms began
in 2011 but selection of a primary area of practice
was not a required eld in that year. The NCMB
licensing and renewal processes have since been
updated, and all physicians are now required to
select a primary area of practice. Of the 21,340
active physicians practicing in North Carolina in
2011 who were not employed by the federal govern-
credentialed health professions to support HRSA
programs and policies. In particular, the FSMB
was interested in having physicians answer this
question: “Which of the following best describes
the area(s) of practice in which you spend most of
your professional time?” The FSMB Workgroup on
the Minimum Data Set explained that “This question
provides input on the true areas of practice for a
physician (primary care, dermatology, surgery).”38
The FSMB suggested that specialty data be collected
from the ABMS and included in a centralized data-
base that the FSMB maintains. The state could
continue to request a primary self-designated
specialty and other elds or areas of practice.
Members of the NCMB were involved in these
discussions from the outset and promoted the idea
of developing a better understanding of the content
of licensee’s practices as well as the particular
specialty of their training.
The North Carolina registration process, which
occurs online, directs physicians to indicate their
specialty in two ways. Physicians are asked about
their board certication:
Physicians who are board certied must indicate
their certications below. The NCMB recognizes
only certications issued by boards approved
by the ABMS, AOA or RCPSC (Royal College of
Physicians and Surgeons of Canada). Do not
report if you are ‘board eligible.’”39
A listing of ABMS and AOA specialty names
follows the instructions. Further, physicians are
asked to enter their board certications and
dates of their “most recent certications or
re-certications” in a free form entry, and many
varieties of descriptors are entered. The language
reads as follows:
Please select your primary/subspecialty board
certications along with the year of your most
recent certication/recertication.40
Physicians are also asked about the area of
practice. The denition of area of practice on the
website reads as follows:
“An area of practice is what you primarily
do as a physician. Your area of practice may
correspond to an ABMS/AOA certication
or generally recognized area of work, e.g.
‘hospitalist,’ ‘administrative medicine,
JournalMedReg_Vol102_2 r2.indd 17 7/13/16 10:04 AM
18 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
newspaper’s conclusion was based on a misunder-
standing about the shift in designation and reporting.
To characterize North Carolina physician supply as
declining ran counter to the data. North Carolina
experienced a 2.8% growth in the number of physi-
cians between 2010 and 2011, which was above the
average annual 1.2% growth in population since
2001. Figure 1 tracks physician-to-population growth
rates from 2002–2013. Overall, physician supply
has grown twice as fast as population growth for the
past decade and primary care physicians comprise
a signicant component of that growth.
In 2012 the numbers of primary care physicians
appeared to continue to diminish, but only by small
increments compared to 2011. In 2012, there were
103 fewer family physicians and 101 fewer internists
in practice, but there was an overall increase in
physician supply in the state of 566, with a gain of
86 general pediatricians. In 2013, the apparent
decreases continued, with family practice seeming
to lose 400 physicians and internal medicine losing
137. Again, these data do not point to a true loss
of providers, but rather suggest that physicians are
categorizing themselves into more sub-specialized
areas of practice. Figure 2 highlights how North
Carolina physicians chose to use new descriptors
of primary care practice, including “hospitalists,
“urgent care,” “student health” and “integrative
medicine.” This trend has accelerated to the point
where there were 1,828 practicing physicians
electing to use those descriptors as their “primary
area of practice” in 2013. Among those, 67%
listed a primary board certication in one of the
ment nor in a residency, 10,500 (49.2%) indicated
a primary area of practice from the list, 10,467
(49.0%) indicated at least one other area of practice
but not a primary area of practice, and 373 did not
indicate any area of practice. In the North Carolina
Health Professions Data System, those physicians
who did not indicate a primary care of practice were
assigned a primary care designation based on their
2010 specialty in the earlier NCMB les or their
most recent ABMS or AOA specialty certication.
A small number of primary care physicians were
assigned a category based on publicly available data
(identication in inventories and listings on the Internet).
The most immediate and concerning effect of the
change from collecting information about specialty of
training to collecting information about area of practice
was a 16.6% drop in the number of physicians
classied as “primary care” and a 17.8% increase in
other, non-primary care specialties. The drop in
primary care was largely due to a shift in the self-
designated area of practice by physicians previously
identied in internal medicine to hospitalist (471
physicians), from family practice to hospitalist (42
physicians), and from family practice or internal
medicine to administrative medicine (140 physi-
cians). The number of self-designated hospitalists
grew from 81 physicians in 2010 to 581 in 2011,
administrative medicine grew from 15 to 188, and
urgent care from 5 to 105. The lack of inclusion of
these categories in the denition of “primary care”
made the supply of primary care physicians appear
to drop precipitously, changing a trend that had
shown steady growth over the previous two decades.
This apparent drop caused concern to outside
observers. In December 2014, an op-ed article in the
Raleigh News and Observer cited these statistics as
evidence of a precipitous decline in primary care
physicians in North Carolina, imperiling the state’s
ability to care for patients included in any expansion
of Medicaid. The editorial stated: “North Carolina’s
supply of primary care physicians is dwindling,
dropping from 9.4 per 10,000 people in 2010 to
7.9 doctors per 10,000 people in 2011.41 The
Figure 1
Trends in Growth of Physicians and Population,
North Carolina, 2002–2013
JournalMedReg_Vol102_2 r2.indd 18 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 19
At present, there is no perfect mechanism to
guide assignment of specialty and specialty
groups to physicians, or, for that matter, physician
assistants and advanced nurse practitioners, who
also increasingly specialize. If primary care is to
continue to be a designation relevant to policy
such as in the generation of Health Professional
Shortage Areas or eligibility for bonus payments
and loan repayment support, then we must
carefully examine the taxonomy by which we
classify physicians. n
About the Authors
Thomas C. Ricketts, PhD, MPH, is Professor (Emeritus) Health
Policy and Administration and Social Medicine, University of North
Carolina at Chapel Hill.
Erin P. Fraher, PhD, MPP, is Assistant Professor of Family Medicine,
University of North Carolina at Chapel Hill.
Julie C. Spero, MSPH, is Research Associate, Cecil G. Sheps
Center for Health Services Research, University of North Carolina
at Chapel Hill.
1. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating
the residency expansion required to avoid projected primary
care physician shortages by 2035. Ann Fam Med. Mar
2. DesRoches CM, Buerhaus P, Dittus R, Donelan K. Primary Care
Workforce Shortages and Career Recommendtions from
Practicng Cinicians. Academic Medicine. 2015;90(2):on line.
3. Dall T, West T, Chakrabarti R. The Complexities of Physician
Supply and Demand: Perojections from 2013 to 2025. Final
Report. Washington, DC: Association of American Medical
Colleges and IHS, Inc.,;2015.
4. Richards MR, Saloner B, Kenney GM, Rhodes K, Polsky D.
Access points for the underserved: primary care appointment
availability at federally qualied health centers in 10 States.
Med Care. Sep 2014;52(9):818-825.
5. Rhodes KV, Kenney GM, Friedman AB, et al. Primary care
access for new patients on the eve of health care reform.
JAMA internal medicine. Jun 2014;174(6):861-869.
6. Fraher E, Spero J, Lyons J, Newton H. Trends in Graduate
Medical Education in North Carolina: Challenges and Next
Steps. Chapel Hill, NC: Cecil G. Sheps Center for Health
Services Research, The University of North Carolina at Chapel
Hill; 2013.
7. NC HPDS. North Carolina Health Professions Data Book.
Chapel Hill, NC: NC Area Health Education Centers
Program; 2011.
8. Ricketts TC, Fraher EP. Reconguring health workforce policy
so that education, training, and actual delivery of care are
closely connected. Health Aff (Millwood). Nov
9. Ricketts TC. Building and Effective and Sustainable Health
Care Workforce (1960s-Present). In: Oliver T, ed. CQ/Sage
Guide to U.S. Health and Health Care Policy: CQ Press;
four traditional primary care specialties (family
medicine, internal medicine, pediatrics and
obstetrics-gynecology)§. If the expanded deni-
tions including new primary care descriptors such
as “hospitalist,” or “student health” were used to
describe the physician workforce in the state, then
the trend in growth of primary care supply in North
Carolina would have continued proportionate to
overall physician supply growth or slightly faster.
By 2014, 245 named areas of practice were available
for selection by North Carolina physicians (including
“other”) on the NCMB online form. The North Carolina
experience suggests that diffusion of area of practice
will continue as physicians identify new practice
niches. Changes in the way physicians choose to
categorize themselves by the work and services they
provide will require researchers, policymakers, and
other stakeholders to closely examine the content of
what constitutes primary care. The construction of an
algorithm to classify physicians into primary care and
specialties will require inputs from multiple data
sources, including certication data from the American
Board of Medical Specialties and the American
Osteopathic Association as well as practicing
physicians themselves. The use of the NPI to
estimate number of practitioners will also create
another source for comparison. For example, the
NPI system in December 2014 classies 13,203
North Carolina physicians into the four primary care
specialties, a number much higher than results
from the approach described above.
§ OBG, Obstetrics-Gynecology is dened as a primary care
specialty by the North Carolina General Assembly.
Figure 2
Trends in Primary Care Physicians Totals,
North Carolina, 2010–2013
Other specialities
Other Generalist Areas
Internal Medicine
General Practice
Family Practice
JournalMedReg_Vol102_2 r2.indd 19 7/13/16 10:04 AM
20 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
28. Ladden MD, Bodenheimer T, Fishman NW, et al. The emerg-
ing primary care workforce: preliminary observations from
the primary care team: learning from effective ambulatory
practices project. Acad Med. Dec 2013;88(12):1830-1834.
29. Porter ME, Pabo EA, Lee TH. Redesigning primary care: a
strategic vision to improve value by organizing around
patients’ needs. Health Aff (Millwood). Mar 2013;32(3):
30. Schroeder SA, Schapiro R. The hospitalist: new boon for
internal medicine or retreat from primary care? Ann Intern
Med. Feb 16 1999;130(4 Pt 2):382-387.
31. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the
care of older patients by hospitalists in the United States.
N Engl J Med. Mar 12 2009;360(11):1102-1112.
32. Wachter RM, Goldman L. The emerging role of “hospitalists”
in the American health care system. N Engl J Med. Aug 15
33. Harbuck SM, Follmer AD, Dill MJ, Erickson C. AAMC Analysis
in Brief. August 2012 2012;12(3).
34. Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of
hospitalist workload on the quality and efciency of care.
JAMA internal medicine. May 2014;174(5):786-793.
35. Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA.
Training a hospitalist workforce to address the intensivist
shortage in American hospitals: a position paper from
the Society of Hospital Medicine and the Society of
Critical Care Medicine. Journal of Hospital Medicine.
36. Meltzer DO, Chung JW. U.S. trends in hospitalization and
generalist physician workforce and the emergence of
hospitalists. J Gen Intern Med. May 2010;25(5):453-459.
37. Wachter RM. Growth in care provided by hospitalists.
N Engl J Med. Jun 25 2009;360(26):2789-2790; author
reply 2790-2781.
38. Federation of State Medical Boards (FSMB). Workgroup to
Define a Minimal Data Set Report on Recommended
Framework for a Minimal Physician Data Set. Euless, TX:
Federation of State Medical Boards of the United
39. North Carolina Medical Board. Unpublished License
Renewal Data acessed June 11, 2015.
40. North Carolina Medical Board. License Renewals at: retrieved
June 29, 2015
41. Balfour B. Why Medicaid expansion won’t boost N.C.
jobs. Raleigh News & Observer. December 26, 2014,
10. Starr P. The Social Transformation of American Medicine.
New York: Basic Books; 1982.
11. Steinwachs D. GMENAC’s projection of a future physician
surplus. Implications for HMOs. Group Health Journal.
12. Kirch DG, Henderson MK, Dill MJ. Physician Workforce
Projections in an Era of Reform. Annual review of medicine.
Jan 26 2011.
13. Ricketts TC. How many physicians? How much does
it matter? JAMA : the journal of the American Medical
Association. Oct 21 2009;302(15):1701-1702.
14. Barondess JA. Specialization and the physician workforce:
drivers and determinants. JAMA. Sep 13
15. Stevens R. American Medicine and the Public Interest: a
history of specialization. Berkeley: University of California
Press; 1998.
16. Cassel CK, Reuben DB. Specialization, subspecialization,
and subsubspecialization in internal medicine. N Engl J Med.
Mar 24 2011;364(12):1169-1173.
17. Baicker K, Chandra A. The productivity of physician special-
ization: Evidence from the Medicare program. American
Economic Review. 2004;94(2):357-361.
18. Stitzenberg KB, Sheldon GF. Progressive specialization
within general surgery: adding to the complexity of workforce
planning. J Am Coll Surg. Dec 2005;201(6):925-932.
19. Spero JC, Fraher EP, Ricketts TC, Rockey PH. GME in the
United States: A review of state initiatives. Chapel Hill, NC:
University of North Carolina at Chapel Hill; 2013. http://
20. NCHWIA. HRSA State Health Workforce Data Guide.
Rockville, MD: National Center for Health Workforce
Information and Analysis, BHPr, HRSA, ;2009.
21. GAO. Health Care Workforce: Federally Funded Training
Programs in Fiscal Year 2012. Government Accountability
22. Brickard K, Budashewitz P. Shor tage Designation Update:
State Office of Rural Health Orientation Meeting. Rockville,
MD: HRSA; September 10, 2014.
23. Stareld B. Primar y Care. Oxford: Oxford University Press; 1992.
24. Rosenblatt RA, Hart LG, Gamliel S, Goldstein B, McClendon
BJ. Identifying primary care disciplines by analyzing the
diagnostic content of ambulatory care [see comments].
J Am Board Fam Pract. 1995;8(1):34-45.
25. Weiner JP, Stareld BH. Measurement of the primary care
roles of ofce-based physicians. Am J Public Health.
26. Aiken L, Lewis C, Mendenhall R, Blendon R, Rogers D. The
contribution of specialists to the delivery of primary care:
A new perspective. New England Journal of Medicine.
27. Green LV, Savin S, Lu Y. Primary care physician shortages
could be eliminated through use of teams, nonphysicians,
and electronic communication. Health Aff (Millwood).
Jan 2013;32(1):11-19.
JournalMedReg_Vol102_2 r2.indd 20 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 21
guidance to health care facilities, physicians and
other health care professionals in dealing with the
issue of disruptive behavior in health care settings.
The American Medical Association (AMA) denes
disruptive behavior as physical or verbal personal
conduct that has a negative effect or potentially has
a negative effect on patient care. According to
statistics, an estimated 3% to 5% of all physicians
fall into this category of behavior.
The Board’s position statement notes that disruptive
behavior can arise from a variety of factors,
such as “impairment issues, personal and
professional stressors and specic personality
traits,” and inappropriate behaviors among
physicians and health care professionals
“present potential threats to the health and
safety of patients, the health care team and
the environment of care.
In its position statement, the Board recommends
health care facilities and health organizations
should consider taking several steps to address
disruptive and inappropriate behavior:
Health care facilities should establish a code of
conduct that denes acceptable behavior, and
behavioral policies and procedures that can be
reviewed and signed by physicians during their
initial credentialing and during subsequent
re-credentialing cycles.
On the rst reported occurrence of disruptive
behavior, a health care facility’s chief of staff,
chief of service or chief medical ofcer can speak
with the physician engaging in such behavior.
On the next reported occurrence of disruptive
behavior, the physician can be asked to appear
before the health care facility’s wellness committee
or other appropriate committee.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Colorado Becomes Latest State to Enact
Interstate Medical Licensure Compact
Colorado became the 17th state to enact the Interstate
Medical Licensure Compact recently when legislation
was signed into law by Governor John Hickenlooper.
With the addition of Colorado, ve states enacted
legislation in May and June to expand access to
health care by expediting medical licensure.
In addition to Colorado, other states that have
enacted the Compact include Alabama, Arizona,
Idaho, Illinois, Iowa, Kansas, Minnesota, Mississippi,
Montana, Nevada, New Hampshire, South Dakota,
Utah, West Virginia, Wisconsin and Wyoming.
The Compact offers an expedited licensing process
for physicians interested in practicing medicine in
multiple states. The Compact is expected to expand
access to health care, especially to those in rural
and underserved areas of the country, and facilitate
the use of telemedicine technologies in the delivery
of health care.
“It is encouraging to see Colorado join the Compact,
along with a growing number of states, as this will
improve and increase health care access in the
Rocky Mountain region and beyond, while still
ensuring that we protect patient safety and quality,
said Joan Bothner, MD, Chief Medical Ofcer of
Children’s Hospital Colorado.
For more information about the Interstate
Medical Licensure Compact, please visit
Source: FSMB news release, June 9, 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Florida Board of Medicine
Publishes Position Statement
on Disruptive Behavior
The Florida Board of Medicine has published a
position statement that offers background and
JournalMedReg_Vol102_2 r2.indd 21 7/13/16 10:04 AM
22 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
recruiter for physician staff members of the Mayo
Health System’s Albert Lea, Minnesota, Medical
Center, for several years until retiring in 2013.
Source: Des Moines Register, June 30, 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Louisiana Reports Significant Increase
in PMP Usage
Use of the Louisiana Prescription Monitoring Program
(PMP) rose sharply between 2014 and 2015,
according to the Louisiana Board of Pharmacy. The
program, which monitors the prescribing of controlled
substances in the state, logged 1,447,593
prescriber and prescriber-delegate searches in
2015, an increase of 49% over 2014. Pharmacist
and pharmacist-delegate searches in the PMP grew
by 132% over the same period, from 460,522 in
2014 to 1,066,781 in 2015. According to the Board,
prescribers, pharmacists, and their delegates are
currently averaging more than 7,330 searches of
the PMP per day.
Source: Louisiana State Board of Medical Examiners Newsletter,
April 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Maine Board Releases Licensure
and Complaint Statistics for 2015
The Maine Board of Licensure in Medicine has released
information about its licensure and complaint activities
in 2015. Records show that 136 complaints were led
with the Board in 2015, along with 83 complaints
carried forward from 2014. Of these, 14 complaints
resulted in discipline, 15 were dismissed with a letter
of guidance, and 58 were carried forward to 2016.
A total of 132 cases were dismissed.
The Board granted 967 new licenses in 2015,
including 523 permanent medical doctor (MD)
licenses, 177 temporary MD licenses, 38 emer-
gency licenses, and 84 physician assistant (PA)
If the disruptive behavior continues, the physician
can be asked to voluntarily submit to an evaluation
by PRN to exclude impairment.
As a nal step, the health care facility can mandate
the referral of the physician for evaluation by a
third-party program that specializes in treating
impaired physicians.
In its position statement, the Board acknowledges
that “there is no easy solution to this issue.
The position statement may be viewed at
Source: Florida Board of Medicine website announcement,
June 14, 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
First Non-Physician Leads Medical
Board in Iowa
The Iowa Board of Medicine has installed the rst
non-physician to chair the Board in its 130-year
history. Diane Clark was elected chair at the Board’s
organizational meeting in April. Iowa Governor Terry
Branstad appointed Clark to the Board in 2011 and
reappointed her in 2014. For the past three years,
she has served on the Board’s executive committee
and was chair of the licensure committee.
One of three public members on the 10-member
board, Clark was trained as a registered nurse and
held several key administrative positions in health
care settings. She has a master’s degree in
organizational management and was the primary
JournalMedReg_Vol102_2 r2.indd 22 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 23
addition, the physician, physician assistant, or
advanced practice registered nurse who requests
the consultation retains ultimate responsibility over
the care, diagnosis and treatment of the patient. To
learn more about Maine’s new licensure category,
Source: Maine Board of Licensure in Medicine Newsletter,
March 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
State Lifts Cap on Number of DOs
Serving on Medical Board
Following two years of statewide discussion, Minnesota
recently passed an update to the Minnesota
Medical Practice Act bill that grants osteopathic
physicians (DOs) equal opportunity, with their allo-
pathic physician (MD) counterparts to serve on the
state medical board. Eleven physicians serve on the
Minnesota Board of Medical Practice; previously,
only one could be a DO, but now there’s no cap on
how many DOs may serve.
In an article in The DO, a publication of the American
Osteopathic Association, Minnesota DO Joe Willett
said that in the past, the Minnesota Board
“sometimes had very qualied DOs who wanted
to serve, but weren’t able to because the one
DO slot was already taken.
“Now if a DO wants to serve on the Minnesota State
Medical Board, he or she has an equal chance,
added Willett, who serves on the Minnesota Board.
In the same article, Ruth Martinez, Executive Director
of the Minnesota Board, echoed support for the
licenses. The Board renewed 2,387 licenses
during the year. The Board issued 96 percent
of its licenses electronically.
Source: Maine Board of Licensure in Medicine Newsletter,
March 2016
Maine Physicians Now May Work with
Pharmacists on Collaborative Drug
Therapy Management
The Maine Board of Licensure in Medicine has
adopted a joint rule with Maine’s Board of Pharmacy
that sets out the requirements for collaborative
drug therapy for patients by medical practitioners
and pharmacists. Requirements include continuing
education for pharmacists, a collaborative practice
agreement, a treatment protocol, and standards for
notications and record-keeping.
The new rule will allow medical practitioners to work
collaboratively with pharmacists in out-patient settings
to manage chronic medical conditions such as
asthma, diabetes, hypertension, infectious disease,
cancer, thyroid disorders and coagulation disorders.
Source: Maine Board of Licensure in Medicine Newsletter,
March 2016
Consultative Telemedicine Registration
Paves the Way for Out of State
Physicians to Provide Advice
The Maine Board of Licensure in Medicine has
developed an application process for a new cat-
egory of licensure called Consultative Telemedicine
Registration. The registration allows physicians not
located or practicing within Maine and not providing
direct care to Maine patients to provide expert
consultation on a regular basis at the request of a
Maine physician, physician assistant, or advanced
practice registered nurse.
The registration does not permit the physician to
open an ofce in Maine, meet with patients in
Maine, or receive calls in Maine from patients. In
JournalMedReg_Vol102_2 r2.indd 23 7/13/16 10:04 AM
24 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
The prescriber falls within the top 1% of those
prescribing 100 milligrams of morphine equivalents
(MME) per patient per day.
The prescriber falls within the top 1% of those
prescribing 100 MMEs per patient per day in combi-
nation with any benzodiazepine and is within the top
1% of all controlled substance prescribers by volume.
The prescriber has prescribed to two or more
patients who died in the preceding twelve months
due to opioid poisoning.
Source: North Carolina Medical Board Forum, Spring 2016
North Carolina Year-In-Review Shows
Downward Trend in Complaints
Medical complaints registered with the North
Carolina Medical Board have dropped in each
of the past several years, according to a report
from the Board titled “Year in Review: A look back
at data from 2015.
Complaints to the Board decreased from 1,416 in
2012 to 1,343 in 2013, decreasing again to 1,256
in 2014 and 1,196 in 2015.
The top ve causes of public action against licensees
in 2015 were quality of care issues (55 cases),
alcohol or substance abuse (32 cases), prescribing
issues (24 cases), action by another licensing
authority (15 cases), and other unprofessional or
unethical conduct (14 cases).
The Board issued new licenses to 2,156 allopathic
physicians (MDs), 929 resident trainees, 609
physician assistants, 245 osteopathic physicians
(DOs), 24 licensed perfusionists, and 10 anesthesi-
ology assistants in 2015.
Total licensee population in the state was 45,107,
in the following categories: MD, 34,248; physician
assistant, 5,880; resident trainee, 2,702; DO,
1,931; clinical pharmacist practitioner, 170; licensed
perfusionist, 151; anesthesiology assistant, 25.
Source: North Carolina Medical Board Forum, Spring 2016
change. “Minnesota recognizes the equivalent
training and examination standards of osteopathic
and allopathic physicians and advocates for a
practice act that fairly and accurately reects
these equivalencies,” she said. “The Board believes
these changes provide the equal recognition in
statute of MDs and DOs as is found in the health
care delivery system across Minnesota and through-
out the nation.
Source: American Osteopathic Association, The DO, June 1, 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
North Carolina
NCMB Safe Opioid Prescribing Initiative
Now Includes ‘Safe Opiods’ Web Page
The North Carolina Medical Board’s comprehensive
Safe Opioid Prescribing Initiative, which includes
stepped-up investigation and enforcement,
policy development and education and outreach
efforts, now offers an enhanced web page with
a variety of resources for physicians and other
health professionals.
The web page includes news, information about
Medical Board programs, prescribing resources,
online CME opportunities and other tools.
In recent years, as patient deaths from opioid poisoning
have continued to rise, the Board has intensied its
effort to ensure appropriate prescribing of opioids.
According to the Board, the Safe Opioid Prescribing
Initiative is “an attempt to reduce patient harm from
misuse and abuse of prescription opioids by identifying
and, where necessary, intervening to prevent
excessive and/or inappropriate prescribing.
In April 2016, the Board emailed its licensees,
providing information about its new efforts to
address the opioid crisis, informing them of the
measures it is taking, including clarication on
prescriber investigations.
As a part of its initiative, the Board will investigate
prescribers who meet one or more of the
several criteria:
JournalMedReg_Vol102_2 r2.indd 24 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 25
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
New Laws Passed in Wisconsin
Take Aim at Pain Management
and Safe Prescribing
Several new laws related to pain management,
opioid prescribing and reporting were recently
passed by Wisconsin’s state legislature and signed
into law by Governor Scott Walker.:
2015 Wisconsin Act 266 requires practitioners
to review a patient’s state Prescription Drug
Monitoring Program (PDMP) records before the
practitioner issues a prescription order for that
patient for a monitored drug.
2015 Wisconsin Act 267 creates reporting
requirements for the PDMP to determine the
program’s effectiveness.
2015 Wisconsin Act 268 requires law enforcement
to report instances of inappropriate use of
opioids to the PDMP.
2015 Wisconsin Act 269 allows the state’s
Medical Examining Board, Podiatry Afliated
Credentialing Board, Board of Nursing, Dentistry
Examining Board, and Optometry Examining
Board to issue guidelines regarding best
practices in prescribing controlled substances,
as dened in § 961.01, for persons credentialed
by that Board who are authorized to prescribe
controlled substances.
The Medical Examining Board is currently drafting
guidelines, in addition to a continuing medical educa-
tion (CME) rule that would require CME in safe-and-
responsible controlled substances prescribing.
Comprehensive information about Wisconsin’s
new legislation is available at “2015–16 Session
Acts,” found at
Source: Wisconsin Medical Examining Board Med Board
Newsletter, June 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Board Plans to Cut Initial
Licensure Fee
The State Medical Board of Ohio is looking to
create nancial incentives to encourage new
physicians to stay in Ohio. In June 2016 it informed
licensees that although Ohio’s initial physician
licensing fee is already among the least expensive
in the country, it has approved a further reduction
from $335 to $305. It is now awaiting legislative
approval to implement the change.
Source: State Medical Board of Ohio Med Bd E-News, June 3, 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Quality Assurance Commission
Staffer Receives AIM National Award
for Medical Care Investigators
Renee Bruess, an investigator for the Washington
State Medical Quality Assurance Commission, has
been selected by the Administrators in Medicine
(AIM) as the recipient of the Ronald K. Williamson
Memorial Award for Board Investigators.
AIM, a national organization for state medical and
osteopathic board executives, recognized Bruess
for her work in a case that spanned three years,
encompassing 23 complaints against the same
practitioner. Bruess completed 24 separate investi-
gations concerning 52 patients and reviewed more
than 6,800 pages of medical records and other
evidence regarding standard of care.
Bruess, a registered nurse with a master’s degree
in Health Law, conducts complex standard-of-care
investigations for the Commission.
Source: Washington State Medical Commission Newsletter,
Summer 2016
JournalMedReg_Vol102_2 r2.indd 25 7/13/16 10:04 AM
26 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
The new guidelines, which will take effect on
October 1, 2016 to give medical practitioners
time to comply, require:
A seven-day cooling off period for all adults before
major cosmetic procedures.
A three-month cooling off period before major
procedures for all patients under the age of
18 and a mandatory evaluation by a registered
psychologist, general practitioner or psychiatrist.
A seven-day cooling off period before minor
procedures for all patients under the age of 18,
and when clinically indicated, evaluation by
a registered psychologist, general practitioner
or psychiatrist.
The treating medical practitioner to take explicit
responsibility for post-operative patient care and
for making sure there are emergency facilities
when using sedation, anaesthesia or analgesia.
A mandatory consultation before a medical
practitioner prescribes schedule 4 (prescription
only) cosmetic injectables, either in person or
by video consultation.
Medical practitioners to provide patients with
detailed written information about costs.
The guidelines provide explicit guidance on patient
assessment and informed consent, and require
doctors to provide clear information to consumers
about risks and possible complications.
“The Board listened to stakeholder feedback, and
responded with a new set of guidelines that will
best keep patients safe,” Dr Flynn said.
“The changes prioritize patient safety and reduce
some of the regulatory requirements proposed
in the previous draft guidelines, when either there
was no evidence of improved safety or the costs
signicantly outweighed the benets of a proposal,
she said.
Source: Medical Board of Australia news release, May 9, 2016
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Board of Australia Issues
New Guidelines on Cosmetic Medical
and Surgical Procedures
The Medical Board of Australia (MBA) has issued
guidelines for medical practitioners who perform
cosmetic medical and surgical procedures in an
effort to add new protections for patients
particularly minors undergoing such procedures.
The new guidelines apply to all medical practitioners,
including specialist plastic surgeons, cosmetic
surgeons and cosmetic physicians, regardless of
their qualications.
The Board consulted widely with physicians,
patients and other stakeholders in seeking out
opinions about Australia’s regulations for cosmetic
procedures, and whether there was a need for
changes. In 2015, the Board circulated draft guide-
lines and asked for feedback on other ways to
protect patients including making no changes to
existing regulations, providing consumer education,
or providing new and different levels of guidance
for physicians.
“There was very clear support from stakeholders
for clear guidance in this area and a strong
message that other options would not effectively
protect consumers,” said MBA Board Chair
Joanna Flynn, AM.
Among the changes are the strengthening
of mandatory “cooling off” periods, which ensure
patients have carefully considered procedures
with their physicians before they go forward
with them.
JournalMedReg_Vol102_2 r2.indd 26 7/13/16 10:04 AM
Copyright 2016 Federation of State Medical Boards. All Rights Reserved. JOURNAL of MEDICAL REGULATION VOL 102, NO 2 | 27
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
United Kingdom
UK’s General Medical Council
Publishes Findings from Early
Study of Revalidation
The United Kingdom’s General Medical Council
(GMC) has published preliminary ndings from an
independent three-year evaluation of revalidation in
the UK a comprehensive initiative designed to
promote lifelong learning among physicians.
With the vast majority of licensed physicians in
the UK now required to engage in the revalidation
process, the evaluation sought to gauge responses
to the new system among physicians, patients
and other stakeholders, as well as its effectiveness
and impact overall.
A total of 26,171 physicians completed surveys as
a part of the evaluation, along with more than 400
members of the public and other stakeholders.
Findings from the surveys show mixed views about
the process of “appraisal” for physicians in the UK,
during which their skills are evaluated. Responding
physicians who had had an appraisal within the
twelve months prior to the survey were positive
overall about their individual appraisal experiences.
However, less than half of respondents (41.8%)
agreed that appraisal is an effective way to help
improve clinical practice.
The evaluation also showed variation in the degree
to which physicians were able to collect patient
feedback about their skills a key feature of the
revalidation process. Respondents in some specialties,
such as pathology and public health, had lower
rates of patient feedback submission than general
practitioners, for example. Respondents in anes-
thetics, psychiatry and emergency medicine were
also more likely to report some degree of difculty
in collecting patient feedback, according to the
evaluation. Some of the responding physicians had
concerns about the ability of certain patient groups
to give feedback, such as those in intensive care,
patients with poor English language skills or where
older patients may not be familiar with online feed-
back tools.
When asked the question of whether engagement
in revalidation is promoting medical professionalism
by increasing physicians’ awareness and adoption
of best practices, the majority of responding
physicians (57.6%) stated that they had not made
any changes to their clinical practice, professional
behavior or learning activities as a result of their
most recent appraisal, compared to 42.4% who
reported having made such changes. According
to the evaluation, survey evidence suggests that
older physicians may be the least likely to make
changes as a result of revalidation, compared to
younger physicians.
According to the evaluation, some physicians also
expressed “skepticism about whether revalidation
has led to improved patient safety, and about
whether the process will identify doctors in difculty
at an earlier stage,” and had mixed views about
“whether revalidation will improve standards
of practice.
In gauging opinions of patients and public stake-
holders about revalidation, the evaluation found
that two thirds of patient and public-involvement
representatives felt that patients were unaware
of revalidation or did not understand its aims
and purpose.
In addition, patient and public involvement repre-
sentatives raised issues of time, anonymity, and
perceived negative repercussions as barriers to
patient feedback.
To learn more about the evaluation, and about
revalidation in the UK, please visit: http://
Source: General Medical Council, Shaping the Future of Medical
Revalidation — Interim Report, April 2016
JournalMedReg_Vol102_2 r2.indd 27 7/13/16 10:04 AM
28 | JOURNAL of MEDICAL REGULATION VOL 102, NO 2 Copyright 2016 Federation of State Medical Boards. All Rights Reserved.
The Journal accepts original manuscripts for
consideration of publication in the Journal of
Medical Regulation. The Journal is a peer-reviewed
journal, and all manuscripts are reviewed by
Editorial Committee members prior to publication.
(The review process can take up to eight weeks.)
Manuscripts should focus on issues of medical
licensure and discipline or related topics of educa-
tion, examination, postgraduate training, ethics,
peer review, quality assurance and public safety.
Queries and manuscripts should be sent
by email to or by mail to:
Journal of Medical Regulation
Federation of State Medical Boards
400 Fuller Wiser Rd., Suite 300,
Euless, TX 76039
Manuscripts should be prepared according
to the following guidelines:
1. An email or letter should introduce the manu-
script, name a corresponding author and include
full address, phone, fax and email information.
The email or letter should disclose any nancial
obligations or conicts of interest related to the
information to be published.
2. The title page should contain only the title of the
manuscript. A separate list of all authors should
include full names, degrees, titles and afliations.
3. The manuscript pages should be numbered, and
length should be between 2,750 and 5,000 words,
with references and tables attached. Please ensure
that references adhere to the AMA Manual of Style.
For more information, visit
4. The manuscript should include an abstract of
200 words or less that describes the purpose of the
article, the main nding(s) and conclusion. Footnotes
or references should not be included in the abstract.
5. Any table or gure from another source must
be referenced. Any photos should be marked by label
on the reverse side and “up” direction noted.
Tables and gures can be supplied in EPS, TIF,
Illustrator, Photoshop (300 dpi or better) or
Microsoft PowerPoint format.
6. The number of references should be appropriate
to the length of the text, and references should
appear as endnotes, rather than footnotes.
7. Commentary, letters to the editor and reviews
are accepted for publication. Such submissions and
references should be concise and conform to the
format of longer submissions.
8. If sent by mail, a PC- or Mac OS-compatible
CD-ROM should accompany a printed copy of the
manuscript. Microsoft Word format is the preferred
le format.
9. Manuscripts are reviewed in condence.
Only major editorial changes will be submitted to the
corresponding author for approval. The original
manuscript and CD-ROM will be returned if the
submission is not accepted for publication only
if a SASE is supplied with sufcient postage.
JournalMedReg_Vol102_2 r2.indd 28 7/13/16 10:04 AM
FSC promotes well-managed
forests through credible certication
that is environmentally responsible
and economically viable.
Paper used for this journal is
acid-free and is certied to be
environmentally friendly and
100% recyclable.
JournalMedReg_Vol102_2 r2.indd 29 7/13/16 10:01 AM
Federation of State Medical Boards
400 Fuller Wiser Road, Suite 300
Euless, TX 76039
JournalMedReg_Vol102_2 r2.indd 30 7/13/16 10:01 AM
... Drawing on perspectives from science & technology studies (STS), some recent scholarship has therefore reframed the debate as one not of 'medicalization' but 'biomedicalization', which incorporates rather more plural co-productive ideas about causation, the relationships between 'the clinic' and wider society, and how identities and technologies intersect. Clarke and colleagues (Clarke, 2010;Clarke et al., 2003) have argued that (American) society has been undergoing a second 'transformation' from the mid-1980s, during which the processes outlined in the medicalization debate not only intensified, but (with legitimacy of 'curing' homosexuality has largely been eroded, with a growing number of jurisdictions banning 'conversion therapies' (Drescher et al., 2016). Despite stating that sexual identity is not in itself a disorder, a category of 'Psychological and behavioural disorders associated with sexual development and orientation' (F66) still exists in the International Classification of Diseases (ICD-10). ...
Technical Report
Full-text available
This review was commissioned by the Reproduction, Sexualities & Health Research Group at The Open University. It is part of a range of activities aimed at developing more critical research and scholarship agendas around lesbian, gay, bisexual and Trans (LGBT) health.
... At this point in history, some of us are more free of powerful institutions claiming the right to decide about who we are, who we should be and what is to be done to us to make it so. So-called conversation therapy, the attempt to change sexual orientation or gender identity, is now illegal in a number of states (Drescher et al., 2016;Newhook et al., 2018). One consequence of postmodernity, however, is that evidence becomes always partial-there can no longer be absolute proof of one absolute truth, since the postmodern reality is one of fractured, competing, different stories, narratives of and about difference. ...
... Despite this, the belief that same-gender attraction is a "treatable" disease has continued-even within the scientific community-into the 2000s (Waidzunas, 2015). And although many US states have prohibited subjecting minors to so-called "gay conversion therapy," its practice continues both in the US (Drescher et al., 2016) and worldwide (Bishop, 2019). Many practices encourage gender-typed behavior-masculinity for boys, femininity for girls-as a means to treat LGB sexual orientation (Robinson & Spivey, 2007), which indicates that the gender-inversion disease model continues to be endorsed by many practitioners. ...
Full-text available
We present an integrated interdisciplinary review of people’s tendency to perceive sexual orientation as a fundamentally gendered phenomenon. We draw from psychology and other disciplines to illustrate that, across cultures and over time, people view and evaluate lesbians, gay men, and bisexuals through how they conform or fail to conform to traditional gender expectations. We divide the review into two sections. The first draws upon historical, anthropological, legal, and qualitative approaches. The second draws upon psychological and sociological quantitative studies. A common thread across these disciplines is that gender and sexual orientation are inseparable constructs in the mind of the everyday social perceiver.
... At this point in history, some of us are more free of powerful institutions claiming the right to decide about who we are, who we should be and what is to be done to us to make it so. So-called conversation therapy, the attempt to change sexual orientation or gender identity, is now illegal in a number of states (Drescher et al., 2016;Newhook et al., 2018). One consequence of postmodernity, however, is that evidence becomes always partial-there can no longer be absolute proof of one absolute truth, since the postmodern reality is one of fractured, competing, different stories, narratives of and about difference. ...
Full-text available
The book was inadvertently published without the acknowledgement texts of funding from the Library of the University of California, Berkeley, for this book in the front matter. This has been updated in the book.
... At that time, charges were made that Kenneth Zucker, who chaired the DSM-5 Sexual and Gender Identity workgroup, was practicing "conversion therapy" of transgender minors (Drescher, 2010). As I have written about the harms of conversion therapies for more than two decades (Drescher, 1998;Drescher et al., 2016b), I was surprised by this allegation because "conversion therapy," at that time, usually referred to attempts to change a homosexual orientation to a heterosexual one and did not refer to changing gender identities. 2 My curiosity piqued, I tried to learn more about the treatment of children and adolescents with GD/GI. Toward that end, my colleague William Byne, MD, 3 and I invited clinicians of different viewpoints to engage in a non-polemical discussion surrounding these clinical issues. ...
This responds to “Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults” by Levine et al., part of a small but growing, critical response to contemporary treatments of gender dysphoric/incongruent (GD/GI) children and adolescents. This author, while disagreeing with Levine et al. and other critics, hopes that with dialogue, research and engagement with the wider world, needs of all children, adolescents and young adults—those who have GD/GI and those who may not—will be best served. Critics of gender affirming treatments cite growing numbers of cases, “low level of evidence” supporting treatment, irreversible side effects and expressing regrets as reasons to oppose gender affirmative treatments. Although sharing similar concerns, the author does not conclude treatments should not be offered when appropriate. The critics’ alternative reads as “just talk to the young people and find out what is really bothering them.” Lacking empirical evidence for that approach does not appear to trouble them. Levine et al.’s caricature of informed consent, which this author parodies, would dissuade anyone from treatment. Their approach does not appear to be written for purposes of engaging frontline clinicians with the aim of improving treatment. Instead, they read as appeals to third parties unfamiliar with the clinical presentations of these children—parents, caretakers courts, legislatures, state health departments and national health care systems—to discourage treatments from proceeding. This impression is further buttressed by a declaration of financial support from The Society for Empirical-Based Gender Medicine, a small group of outliers from mainstream clinicians treating minors with GD/GI who present as “truth-speaking” experts regarding “facts” being ignored, elided over or perhaps even covered up by the mainstream. The author concludes by noting that clinicians who advocate for delaying treatment to GD/GI minors who need and may benefit from it to “protect” those who “aren’t really” transgender is an ethically troubling issue. In other words, “first, do no harm” is a sword that cuts two ways.
Full-text available
Is there a legitimate basis for religious exemptions from laws that prohibit gender identity discrimination on the basis of people’s beliefs? The author argues that much depends upon how gender dysphoria is understood. If it is seen as a problem requiring medical diagnosis and treatment, then arguably there is no religious basis for discrimination, except in a few situations where being a biological male or female is theologically essential to a particular role. Transgender identification, understood as a medical issue, fits within a belief system that God created two sexes of human beings, male and female. Within that belief system one can make room for an understanding that there are those who experience disorders of sex development and those who have such a profound sense of being born in the wrong body that they undertake steps toward medical transition to align their bodies, as far as possible, with the opposite sex. However, recent reinterpretations of what it means to be transgender involve an assertion that it should not be seen as a medical issue, that affirmation of a person’s self-declared gender identity, with or without having hormonal treatment or surgery, is a matter of human rights and that the law should recognize that people may have a gender that, however described, is nonbinary. These views rely on certain beliefs and positions that have a very weak basis in science. They challenge religious beliefs, which accord with mainstream scientific understanding, that human beings are intrinsically a sexually dimorphic species. People of faith need the freedom to reject beliefs that are incompatible with their worldviews. That does not mean that ill-treatment of someone on the basis of their gender identity can ever be justified; but it does support a religious exemption from a legal obligation to accept someone else’s self-declared gender identity. It is one thing to ask me to respect your beliefs about yourself. It is another to ask me to act toward you as if I share your beliefs.
Members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community experience stigma from both within (e.g., self-stigma) and without (e.g., discrimination by others), and LGBTQ youth may be particularly vulnerable to its effects. LGBTQ youth of color may be at additional risk for mental distress compared to white LGBTQ adults due to their need to adapt to the stressors of stigma while simultaneously developing their identity. These interlocking stressors can have a devastating impact on the development and mental health of these youth. This chapter reviews the literature related to stigma against and within the community of LGBTQ youth of color. We will use an intersectional, ecological-developmental model to examine the interactions between the individual and social structures and review research that delineates processes that maintain stigma in intersectional spaces. A community-resilience framework will be used to review research investigating coping strategies of LGBTQ youth of color. In doing so, we review effective practices that professionals can use to mitigate and prevent stigma formation in this vulnerable community.
Full-text available
Sexual orientation change efforts (SOCEs) signify activities designed to change or reduce homosexual orientation. Recent studies have claimed that such therapies increase suicide risk by showing positive associations between SOCE and lifetime suicidality, without excluding behavior that pre-dated SOCE. In this way, Blosnich et al.’s (2020) recent analysis of a national probability sample of 1518 sexual minority persons concluded that SOCE “may compound or create…suicidal ideation and suicide attempts” but after correcting for pre-existing suicidality, SOCE was not positively associated with any form of suicidality. For suicidal ideation, Blosnich et al. reported an adjusted odds ratio (AOR) of 1.92 (95% CI 1.01–3.64); the corrected AOR was .44 (.20–.94). For suicide planning, Blosnich et al.’s AOR was 1.75 (1.01–3.06); corrected was .60 (.32–1.14). For suicide attempts, Blosnich et al.’s AOR was 1.75 (.99–3.08); corrected was .74 (.36–1.43). Undergoing SOCE after expressing suicidal behavior reduced subsequent suicide attempts from 72 to 80%, compared to those not undergoing SOCE, when SOCE followed a prior expression of suicidal ideation (AOR .17, .05–.55), planning (AOR .13, .04–.45) or intention (AOR .10, .03–.30); however, SOCE following an initial suicide attempt did not significantly reduce further attempts. By violating the principle that a cause cannot occur after an effect, Blosnich et al. misstated the correct conclusion. Experiencing SOCE does not result in higher suicidality, as they claim, and may sharply reduce subsequent suicide attempts. Restrictions on SOCE will not reduce suicidal risk among sexual minorities and may deprive them of an important resource for reducing suicide attempts.
Full-text available
This chapter explores therapeutic modalities that fit with a complicit theory of human being: feminist therapy, Interpersonal Neurobiology, Polyvagal Theory, Internal Family Systems and intersubjectivity. It examines how to be both systems-oriented and work from a depth approach which is an element of complicit thinking. In exploring how to work therapeutically within this frame, the chapter reiterates the importance of a nonbinary understanding of human being, which has been one of the main points argued throughout the book. This, ultimately, is why the psychological humanities is important: It allows for both the art and the science of psychotherapy to co-exist in a nonbinary way. The chapter also addresses another of the ongoing themes of the book, a complicit approach to identity politics, which is connected to a social-justice-oriented psychotherapy practice.