Culture Wars, Diversity Debate, Identity, Mental Health, Top Stories

Replacing One Kind of ‘Conversion Therapy’ With Another

This week, British MPs called for a legislated ban on “conversion therapy.” This is a phrase traditionally used to describe pseudo-therapeutic techniques aimed at convincing gay individuals that they are actually straight. Given that a person’s sexual orientation cannot be changed by therapeutic intervention, such a legislative initiative would appear to be justifiable (even if many such discredited therapies would already be illegal under existing laws).

However, the term “conversion therapy” has taken on a broader meaning in recent years, and now is often taken to include efforts to scrutinize a person’s belief that he or she was “born in the wrong body.” The result is that the term can be used to conflate harmful attempts to suppress homosexuality with responsible therapeutic treatment of gender dysphoric children. Such conflation is unwarranted, as abundant evidence now shows that “desistance”—the reversion of trans-identified individuals to a gender identity consistent with their biological sex—is a common outcome of childhood trans identification. Indeed, Dutch research suggests it to be (by far) the most likely outcome.

The example of Keira Bell, the 23-year-old woman who recently prevailed in her legal case against the British gender clinic that transitioned her to a boy when she was still a teenager, is instructive in this regard: To the extent the concept of “conversion therapy” may be applied to the issue of gender identity, the risk associated with improperly encouraging mistaken cases of dysphoria is as concerning as the possibility of genuinely dysphoric individuals being pressured to ignore their symptoms.

As a trainee psychotherapist and volunteer children’s counsellor, I’ve come to conclude that the campaign to demand no-questions-asked “affirmation” of a child’s presented trans identification is of grave concern. As Canadian critics of a similar legislative initiative in Canada have pointed out, calls for criminalisation could end up outlawing beneficial therapeutic processes, thereby damaging the profession and the clients we seek to serve.

These initiatives are particularly concerning because the presentation of gender dysphoria—unlike the act of coming out as gay or lesbian—can, in some cases, lead to treatments that are now known to be irreversible. These include puberty blockers, cross-sex hormones, and sex-reassignment surgery. Surgery, in particular, can leave both physical and mental scars that may never heal. And once children embark on this medical course, they are typically encouraged to continue on it.

Certainly, some gender dysphoric individuals truly do benefit from these steps. But for those who later desist, such as Ms. Bell, they are harmful. Indeed, Ms. Bell’s situation could have been even worse if she hadn’t realized that her clinic was sending her down the wrong path. Studies show that if a child is encouraged to live as a transgender individual, it can lead to cognitive changes that systematically make it less likely that they will become comfortable with their biological sex—a pattern of learned behaviour that mirrors the effect that homophobic conversion-therapy techniques are designed to imprint on gay men and women.

As therapists Susan and Marcus Evans recently wrote in Quillette, the best way to treat gender dysphoric children and young people, at least initially, is with open-ended discussions. These serve to position the child’s situation within his or her other life factors, since expressions of dysphoria sometimes (though not always) may be associated with feelings of anxiety and shame, as opposed to immutable elements of identity. But such discussions will become impossible if parents, therapists, and other professionals are prevented from responding to a child in any way that does not affirm their announced sense of self.

Bill C-6, which was approved in principle by Canada’s parliament last year, would serve to criminalize “any practice, treatment or service designed to change a person’s sexual orientation to heterosexual or gender identity to cisgender.” And while the government insists that the definition of conversion therapy “does not include a practice, treatment or service that relates to a person’s gender transition or exploration or development of a person’s identity,” the law’s entire text is otherwise written in a way that suggests an individual’s announced identity corresponds to a revealed truth that cannot be challenged. Given the five-year jail term that the legislation would authorize, therapists would understandably fear that mainstream treatments might be categorized by government investigators or prosecutors as going beyond “exploration” or “development.” Even an unsuccessful prosecution could end their careers.

One ironic outcome of such legislation would be that it would serve to inflict more conversion-based pseudoscience on gay boys and girls—as gender dysphoria sometimes is exhibited by children trying to reconcile their identities with straight expectations and stereotypes (e.g., a gay boy might prefer to imagine that he is actually a straight girl). Indeed, past research suggests that most boys who demonstrate gender non-conformity in childhood will eventually end up coming out as gay or bisexual.

When I work with clients who have identity issues, I try to explore themes of control and acceptance. Often, only when you accept yourself as who you are, does real change actually take place. I help children ask why and where their unhappiness with themselves comes from. Sometimes, it is not clear, though often we can pinpoint various contributory causes or factors—ranging from past traumas and harassment, to fears about sexuality, to attachment issues with parents. I also encourage children to feel free to express themselves in ways that are atypical, as compared to traditional sexist stereotypes. There’s nothing wrong with being an effeminate boy or a tomboyish girl.

I am certainly not attempting to “cure” their gender identity, even if that is how legislators might seek to criminalize my work. In many cases, I observe a shift from the start of our conversation, at which point medication and surgery had felt like the only option. After the fact, young people I have spoken with have told me that what they appreciated was that I did not simply affirm them robotically, but asked them to reflect on a decision that would change their lives forever. In cases where these children hated who they were, my goal was to get them to stop the hate, rather than to remake their bodies. This isn’t conversion therapy: It’s conversion therapy’s antithesis.

Yet I am fighting an uphill battle, as many websites aimed at children with gender dysphoria read as more of a road map to transitioning (how to change your pronouns, how to seek medical interventions, etc.), without any reference to psychotherapy or counselling. We live in a world in which a young person need only perform a Google search to be transported into a world of social media unconditionally affirming transitioning as the only way for them to live happy lives—a movement cheered on by some of the same groups urging the UK’s parliament to criminalize conversion therapy. These are the same groups claiming that the “real” self is fundamentally separate from the physical body, yet then also insist that physically transforming one’s body is the only way to live congruently.

The United Kingdom Council for Psychotherapy (UKCP) has stated that it does not classify transgenderism as a mental-health disorder. But while no one should seek to stigmatize trans-identified individuals, prevailing UK law explicitly associates transgender identification with dysphoria, a recognised mental-health condition. There are, in fact, many types of dysphoria, all of them characterised by a state of unease, distress, or anxiety in regard to one’s body. Such dysphoria can arise seemingly at random, as well as following childhood trauma or other negative experiences.

To my knowledge, gender dysphoria is the only such condition in which the officially sanctioned treatment is to encourage, in all cases, the distressing and anxiety-provoking thoughts inside one’s own head. In the case of body dysmorphia, by contrast, patients are not encouraged to remain negatively obsessed with their physical appearance. Nor are patients with anorexia encouraged to believe they are fat. Sex re-assignment surgery does not cure gender dysphoria any more than liposuction cures anorexia.

In this way, sufferers of gender dysphoria may be encouraged to change parts of themselves, in search of something that does not actually exist. And while adults should be free to pursue such therapies, the root psychological cause should also be investigated before life-changing treatments are advised—especially given that transitioning generally does not reduce the prevalence of suicide attempts among people who identify as transgender.

Another example is Body Integrity Identity Disorder, a debilitating illness in which a person identifies as disabled, even though they have a fully functioning body. Sufferers may even go so far as to believe that one of their limbs is “bad,” does not belong to them, and so may even request that medical professionals amputate it. The correct treatment for this condition is not to amputate healthy body parts, in the same way that the treatment for gender dysphoria should not automatically be removal of physically healthy genitalia. And yet this seems to be the path on which we are setting dysphoric children, even those as young as eight years old.

Not every trans-identified person will know why they experience life in the way they do. In many cases, therapists will disagree on the cause, as will the patient himself or herself. But what is certain is that exploring the subject—without any preconceived expectations of the ultimate result, or how the patient’s true identity will resolve itself—should not be the subject of legal prohibition.

 

James Esses is a UK-based psychotherapist in training.