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Reparative therapy and beliefs in the practice of clinical psychology: A systematic review

Reparative therapy, popularly called “gay cure”, is based on the justification that every lesbian, bisexual, homosexual or transsexual person suffers from a disorder. Such irregular practices motivated by beliefs that pathologize the LGBT population are still identified. For this reason, this study aimed to investigate the beliefs and attitudes of psychology professionals about the use of reparative therapy in clinical practice with the LGBT population. A systematic literature review was performed, using a string “LGBT” OR “LGB” AND “reparative therapy” OR “beliefs” in the SciELO database; and “LGBT” OR “LGB” AND “reparative therapy” OR “beliefs” in Scopus and PubMed databases. A total of 339 productions were found, with the final analysis bank consisting of four articles. The results showed predominantly ideological and/ or religious beliefs that favor reparative therapy. More studies are needed that seek to understand what leads to the unpreparedness of professionals in relation to the LGBT population and the consequences of reparative therapy, mainly, in the national scenario.


Introduction
The LGBT population was seen, in the past, as having a mental illness based on the assumption that homosexuality is a disorder, assuming that the patient/ client must change their sexual orientation to heterosexual (Souza, 2010;American Psychological Association, 2018). For these reasons, mental health organizations, such as the American Psychiatric Association (APA) and the World Health Organization (WHO), do not support practices to change sexual orientation. These institutions adopt policy measures in the profession of psychologists and alert the public about the proposal for sexual reorientation therapies, since these practices homosexuality no longer as a disorder, but as a natural expression of human sexuality, as stated in Art. 4: "Psychologists will not comment, nor will they participate in public pronouncements, in the mass media, to reinforce the existing social prejudices towards homosexuals as having any psychic disorder". Also, the Professional Psychologist's Code of Ethics (CFP, 2005) legitimizes the prohibition of the professional's practice in inducing the patient to sexual orientation convictions, as mentioned in Art. 2 of the Code: "b) To induce political, philosophical, moral, ideological, religious convictions, sexual orientation or any kind of prejudice, when exercising their professional functions". It is also necessary to emphasize that Psychology is a science, on which it bases its studies and treatments on a Scientific Method. Therefore, the professional in this area should only offer treatments with scientifically proven efficacy, which differs from reparative therapy (Lakatos & Marconi, 2007).
In dissonance with these guidelines, the term "reparative therapy" was coined by the American psychologist Joseph Nicolosi, in 1991, to name psychotherapies that aim to reorient the non-heterosexual patient towards heterosexuality. With Benjamin Kaufman and Charles Chocarides, Nicolosi founded the National Association for Research & Therapy of Homosexuality (NARTH). This organization offers the sexual reorientation therapy modality to individuals who would be dissatisfied with their sexual orientation (American Psychiatric Association,

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Reparative therapy: a systematic review Psychologists, in their professional practice, are prohibited from proposing, carrying out or collaborating, under a pathological perspective, with private, public, institutional, community or promotional events or services aimed at conversion, reversal, readjustment or reorientation therapies for transgender and transvestite people (CFP, 2018). On the national scene, gender and sexuality issues have gained importance in several instances. This highlight is crossed by the human rights bias, which is based on the recognition and respect for the differences and particularities of each subject (Soares & Monteiro, 2019). The violation of rights and discrimination against sexual and gender diversity is considered a public health problem, since it is associated with negative impacts on the mental and physical health of this population, contributing to psychological and physiological suffering (Boccolini et al., 2016). In this sense, prejudice towards the LGBT population can be defined as actions and beliefs reproduced from models considered ideal about sexuality.
Psychology has been more successful in explaining prejudice than alleviating it, considering that it results from many interacting factors .
Furthermore, discrimination and prejudice against sexual and gender diversity can be based on representations that include prejudiced beliefs about the nature of such diversity (Lacerda, Pereira, & Camino, 2002). Gaspodini and Falcke (2018a)  Although there are laws and resolutions in the area of Psychology about reparative therapy, these dictatorial psychological practices are still identified, as well as the beliefs that pathologize the LGBT population, in addition to the violation of rights against this population in institutions or entities (Fjelstrom, 2013;Dehlin, Galliher, Bradshaw, Hyde, & Crowell, 2015). Thus, there still are psychologists whose professional practice contributed to such discrimination, a clear example of this performance is a popularly coined practice of "gay cure", which goes against what is defended in the Universal Declaration of Human Rights (Furlan, 2017). The study by Costa, Nardi, & Koller (2017) contributes to the theme by pointing out that the relationship between sexual and gender diversity and Brazilian Psychology has been discriminatory, being, therefore, an ethical responsibility of Psychology professionals to identify and repair such discrimination.
Faced with these premises, the goal of this review was to investigate the beliefs and actions of psychology professionals regarding the use of reparative therapy in clinical practice with the LGBT population.

Method
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) method, the present work was a Systematic Literature Review, The material selected for the present study consisted of articles on reparative therapy from the perspective of psychologists to identify the characteristics of clinical practice for the LGBT population. As a source of analysis, articles available in full, in Portuguese and/or English, without temporal delimitation, were used in the ScieELO, PubMed, and Scopus databases. The databases were defined considering the scope of studies, including national and international publications, as well as theoretical and methodological approaches.
In order to obtain greater results for the research, several attempts were made with different descriptors. After that first moment, it was concluded that the string that obtained more articles, both nationally and internationally, related to the goal was "LGBT" OR "LGB" AND "terapia reparativa" OR "crenças" in the SciELO database, and "LGBT" OR "LGB" AND "reparative therapy" OR "beliefs" in the Scopus and PubMed databases. The option "Advanced Search" was used to restrict the search fields (titles, subjects, abstracts, and keywords). When available in the database, articles were selected in English and Portuguese, using the Reparative therapy: a systematic review "language" filter. The last manual search was carried out in September 2020 by two judges.

Results
Independently, the authors analyzed the relevant articles and issued opinions on their inclusion or exclusion in the review. After the articles' selection and definition processes - for those included in the review - the data were tabulated.
It should be noted that there were no differences between the authors during the analysis of the inclusion and exclusion criteria, since all the criteria were previously clarified.
All articles found (n=339), without restriction on the year of publication, were exported to a spreadsheet. Then, articles that appeared in more than one database were excluded, thus leaving 332 articles. These were evaluated and submitted to the following inclusion criteria: 1. theme: beliefs and/or practices about reparative therapy; 2. population: psychologists; 3. types of study: quantitative, qualitative and/or mixed; and 4. Portuguese or English languages.
And the following exclusion criteria: 1. theoretical studies and systematic reviews;  Regarding the type of outline, it was identified that three articles used the quantitative approach (McGeorge et al., 2015, Lingiardi et al., 2015, Vezzosi et al., 2020. The only study that adopted a mixed-method, with quantitative and qualitative characteristics, was the publication by McGeorge et al. (2017). The study journal by Vezzosi et al. (2020) has A2 qualifications; the other articles presented Reparative therapy: a systematic review the impact factor, which varied between 1.61 and 2.528 (Lingiardi et al., 2015;McGeorge et al., 2015, McGeorge et al., 2017.
The R-SOCCS was validated using confirmatory factor analysis. Finally, the Modern LGBT individuals. In addition, participants who reported never having worked with an LGBT patient were significantly more likely to practice reparative therapy, as they also believe that such practice is ethical. Logistic regression from the MHS revealed that negative beliefs about LGBT individuals were a significant predictor in relation to participants who did or did not practice reparative therapy. In addition, not having worked with LGBT patients was considered a significant predictor of the practice of reparative therapy.  based on students' personal information and/or religious beliefs about sexual orientation. The therapist's autonomy was another common factor in referring LGBT clients provided by faculty members in this study. Yet, the participants argued that therapists have the right to protect their own personal and religious beliefs.
Furthermore, the subtopic that addressed religious beliefs revealed qualitatively that the research participants expressed the belief that reparative therapy is ethical when requested by the patient, based on their religious beliefs that LGBT guidance is sinful or immoral. Lingiardi et al. (2015) sought to study the perception of Italian psychologists on the subject of reparative therapy through an online questionnaire. Each research participant was asked to indicate general information such as age and sexual orientation on the Kinsey Scale, ranging from (0 'exclusively heterosexual' to 6 'exclusively homosexual'). It was also asked to indicate the political orientation (from 0 'most conservative' to 4 'most progressive'); religious commitment (0 'non-believer', 1 'non-practicing believer' and 2 'practicing believer') and professional characteristics such as clinical experience with homosexual patients.
To explore the frequency of corrective action of psychology professionals, a questionnaire was used (that varied from 0 "no", 1 "yes, if requested by the patient", and 2 "yes, always"). Also, in order to control the bias of social desirability, the abbreviated form (13 items) of the Marlowe-Crowne Social Desirability Scale was used -higher scores in this measure indicate a greater tendency to respond according to what is socially desirable. The study pointed out that political conservatism and religious commitment are associated with prejudice towards the LGBT population. The results of the questionnaire indicated that 58% of psychologists would choose to intervene, through reparative therapy/corrective attitude, to change the sexual orientation of the patient/client. Of these, 56% responded that, if requested by the patient himself, they would use such an approach; only 2% of respondents would have chosen reparative therapy in any case. Furthermore, it was revealed that the strongest predictors of corrective action were: 1. the belief that homosexuality is a symptom; 2. the belief that homosexuality is a consequence of psychological imprisonment in development; 3. the patient's sexual orientation; 4. religious commitment; 5. belief that homosexuality is due to a lack of identification with the gender role itself; 6. previous experience of clinical contact with patients concerned about their homosexuality; and 7. the belief that homosexuality is the result of troubled family interactions. The survey also revealed that the participants' social desirability did not significantly influence the results obtained.
The study by Vezzosi et al. (2020) is an adaptation of the work of Lingiardi et al. (2015). Therefore, it also used the online questionnaire to analyze the actions of a psychologist working in Brazil concerning the conversion of sexual orientation through reparative therapy for LGBT patients. Therefore, the statements used were: "if the patient requests, the psychologist should help to change the sexual orientation from homosexual to heterosexual" and "the psychologist should help to change the sexual orientation of homosexual (gay or lesbian or bisexual) to heterosexual". These statements were assessed using a 5-point Likert scale from (1 "strongly disagree" to 5 "strongly agree"

Discussion
This Among the studies that comprised the sample, the majority (n=3) revealed ideological and/or religious beliefs, accompanied by a speech that pathologizes Since 1990, homosexuality has not been included in the diagnostic manuals.
However, both Psychology and Psychoanalysis still carry the legacy of outdated conceptions that categorized and pathologized LGBT individuals. It is known that Psychology has endeavored not to legitimize practices that violate and discriminate the LGBT population. Thus, psychologists who support and/or practice this type of therapy do not base their practices on evidence, but merely on their personal beliefs (American Psychological Association, 2008;2009). In this sense, the belief that homosexuality is a pathology was presented in Vezzosi et al.'s (2020) study, which reinforces this relevant current data. Still, the belief that homosexuality is a symptom was a significant predictor in the study by Lingiardi et al. (2015). In this study, the authors relate this belief to the concept of Psychoanalysis, considering that the aspect still carries such inheritances, agreeing with other research that revealed a perversion belief about LGBT patients, also relating it to the Psychoanalysis approach (Gaspodini & Falcke, 2018b). There is no denying that psychoanalytic theory has already produced pathological discourses. However, the research data by Vezzosi et al. (2020) demonstrate that Psychoanalysis professionals had a lower percentage of corrective action among the analyzed approaches. Still, it is known that psychoanalytic theory discusses a choice of sexual object, which is indeterminate and which is not related to a perverse psychic structure. Psychoanalysis professionals have dedicated themselves to the assumption that treating homosexuality as a disease is not accepting the subject in their expressions - agreeing with scientific consensus and ethical guidelines (Maya, 2007;Vieira, 2009;Couto & Lage, 2018).
Considering the significantly high data of Psychology professionals who believe that the practice of reparative therapy is ethical, with the patient asking or not, as well as the transmission of such practice, it is necessary to position professionals and teachers regarding these irregular practices during psychologist training. It is essential to have an ethical responsibility for not reflecting discriminatory actions which are based on negative personal beliefs about the LGBT population. In this perspective, the recent study by Mizael, Gomes, and Marola (2019) highlights that, especially with regard to transsexual identities, as well as to the themes of gender and sexuality, academic transmissions (disciplines, seminars, discussions, events) are not enough, portraying the scarcity of investments on the subjects in the field of Psychology. A possible solution that the authors highlight is the responsibility of the Psychology courses, but not limited to it, in highlighting Reparative therapy: a systematic review homophobia and deaths of the LGBT population. Still, McGeorge et al. (2015) pointed out that having never worked with LGBT patients was a significant predictor for the practice of reparative therapy. The literature revealed that individuals who had previous contact with friends, patients, or non-heterosexual acquaintances tend to positively affirm sexual and gender diversity. In contrast, those professionals without previous contact with LGBT subjects have higher rates of prejudice and negative beliefs in relation to this population (Biddel, 2014;Costa, Bandeira, & Nardi, 2015).
There is a need for greater positioning of Psychology professionals on sexual and gender diversity, considering that abstaining from a position in favor of the LGBT population supports collusion with such discriminatory practices. Still, accepting such a condition is to remain in a position in favor of the violation before the human rights guidelines and class council (Oltramari, 2010). For Lobato et al. During the review, emphasis was placed on the practice of reparative therapy, from the perspective of Psychology professionals, in relation to the LGBT population, as well as on the prejudices manifested by psychologists based on their personal beliefs. In summary, the characteristics of clinical practice with the LGBT population are still significantly permeated by beliefs that favor reparative therapy/action, such as the understanding that homosexuality and bisexuality is a pathology or a symptom or that the religious belief of the psychologist should be prioritized, this being the main belief expressed in the reviewed studies. Furthermore, the present review also presented the limitation of the low number of publications on the subject.
It is suggested that undergraduate courses offer the possibility of approaching the theme of sexual and gender diversity, as well as using the findings of this study in an academic context. We highlight the need for a clearer regulation on the