Maryland Del. Meagan C. Simonaire (R), who is bisexual, supported a bill that made conversion therapy illegal in Maryland. The bill was signed into law in May, making Maryland the 11th state to have such a measure. (Brian Witte/AP)
J. Seth Anderson is a PhD student in history at Boston University and the author of "LGBT Salt Lake."

Approximately 698,000 LGBTQ Americans have undergone some form of conversion therapy, a discredited medical practice that attempts to change a person’s sexual orientation or gender identity, according to a UCLA study. The same study also estimates that over the next few years, an estimated 20,000 additional LGBTQ youth will work with a licensed professional to undergo conversion therapy, and 57,000 more will seek conversion therapy treatment from religious leaders. In other words, this odious practice is alive and well, a widespread part of our modern landscape and at the forefront of political debates over gay rights.

The National Center for Lesbian Rights has worked with state legislatures to ban the practice for those under age 18, and in 2015, the Southern Poverty Law Center brought a first-of-its-kind consumer fraud lawsuit, Ferguson v. JONAH, that successfully shut down a conversion therapy organization in New Jersey. Such legal action to eradicate the practice, as well as medical denunciations of its dangerous effects, are essential steps toward exposing the insidious trauma conversion therapy causes.

Yet conversion therapy persists because in the mid-20th century, heterosexuality became deeply intertwined with the rights of American citizenship. And conversion therapy played a role in the two being bound together. Mid-20th-century conversion therapy advocates insisted that a person could in fact modify his or her sexual orientation — which offered a justification for the state to extend benefits to heterosexuals while denying them to so-called sexual deviants. Even today, as LGBTQ Americans have made significant strides toward equality, the idea that therapy can change a homosexual orientation or gender identity to mirror heterosexual ideals lingers on, with a toxic impact on the lives of thousands of LGBTQ people.

Conversion therapy’s origins date to the Progressive Era. Doctors at the turn of the 20th century understood homosexuality as a medical problem. Therefore, they addressed what they perceived as sexual perversion though surgery. During the 1890s, some doctors tried castration, then from approximately the early 1900s through the 1920s, some began experimenting with testicle implants to treat physical problems associated with aging and low libido, as well as homosexuality.

Besides castration or implants, doctors sometimes recommended “bladder washing” and “rectal massage” as other forms of treatment. Bladder washing involved the doctor inserting a catheter to flush out the bladder with nitrate or silver solution, while rectal massage involved a doctor inserting a small device into the rectum to massage the prostate. One doctor hypothesized that rectal massage could “kill the homosexual cells” in the prostate so that “heterosexual cells” could take their place. However, by 1913, some doctors began questioning the efficacy of these procedures.

The rising prominence of psychotherapy in the early decades of the 20th century offered a different solution to cure homosexuality. Some medical professionals hypothesized that expressions of same-sex desire were a developmental problem, not a medical one. Abraham A. Brill, a student of Sigmund Freud, argued before the American Medical Association in 1913 that homosexuality was the most widespread sexual aberration and not confined to urban populations or those seen as “defective.”

Brill rejected castration, bladder washing and rectal massage as curative methods. He argued instead that homosexuality was a “psychic manifestation,” therefore only through psychotherapy could homosexuality be treated. He assured the other doctors in the audience of his conclusion by citing three case studies of his own patients, who he said left his treatment “perfectly cured.”

In the decades after the Progressive Era, doctors continued to debate the causes and possible cures for homosexuality. They focused primarily on men but increasingly recognized the existence of lesbians as well. Many, including Freud, came to believe that a cure was not possible for most homosexuals.

But after Freud’s death, the medical perspective shifted as new theories emerged. The American Psychiatric Association officially defined homosexuality as a mental disorder in the first edition of the Diagnostic and Statistical Manual (DSM), published in 1952. By the late 1950s, conversion therapy entered what psychiatrist Jack Drescher called its “gilded age.” Psychiatrists and psychoanalysts such as Sandor Rado, Irving Bieber, Lionel Ovesey and Charles Socarides proffered new theories and possibilities for therapeutic cures, which in addition to talk therapy sometimes included electroshock therapy and transorbital lobotomies.

Why would men and women go through such dangerous and painful operations or endure therapy to be “cured”? Because they were rewarded for it.

The state puzzled over what to do as sexual and gender variations become more visible during the early part of the 20th century. By World War II, the state had begun to enact explicit regulatory measures that linked heterosexuality with claims to citizenship and the benefits that came with it: access to welfare, government loans, the ability to serve in the military and the right to assemble, all of which the state increasingly denied to LGBTQ people. At the same time, legislatures began passing what came to be known as sexual-psychopath laws that were often used to target LGBTQ people. If convicted, they were sent to prison or mental institutions.

Conversion therapy lent a degree of credibility to the requirement that to be a good, law-abiding citizen, one had to be, and in fact could be, heterosexual. Practitioners of conversion therapy asserted that a person could change sexual orientation with therapy — which meant that homosexuality was a choice. And if homosexuality was a choice, then the state was justified in denying benefits to LGBTQ people to create an incentive to reject deviance and assimilate.

Throughout the 20th century, a small but growing minority of LGBTQ people resisted cultural homophobia by asserting that there was nothing wrong with them. By the 1950s, some began mobilizing to challenge the anti-LGBTQ notions present within legal and medical discourse.

But other LGBTQ people internalized the negativity surrounding homosexuality and sought ways to change. To be sure, as the 20th century progressed, state laws forced many people who had been convicted of homosexual activity to undergo conversion therapy treatments they did not choose. However, many men and women also subjected themselves to conversion therapy by choice, sometimes out of desperation to fit into a culture that rewarded heterosexual citizens and often out of fear that an LGBTQ identity would cost them their family relationships, jobs and religious communities.

Today, national health associations such as the American Medical Association, the American Psychological Association, the American Psychiatric Association and others agree that conversion therapy is at best ineffective and at worst harmful to those who experience it. At the legal level, 14 states have passed laws to ban the practice, and some municipalities have passed similar laws aimed at protecting LGBTQ youth.

Yet, while society has made great strides toward equality and inclusion of LGBTQ Americans, vastly improving the lives of many, the persistence of conversion therapy points to the deep currents of homophobia that remain a part of our national culture. LGBTQ Americans cannot be fully equal members of society so long as a practice exists that aims to convert them — implying that there is something wrong with being LGBTQ. Until conversion therapy is illegal everywhere, there will still be work to do to ensure equality for all Americans.