Exploratory Therapy Is Not Conversion Therapy

Here's why that's so important

Last week, U.K. Prime Minister Boris Johnson announced that he’d aim to ban conversion therapy for lesbians, gays and bisexuals but not for kids identifying as transgender. The reason, he said, was that the issue of trans kids has “complexities and sensitivities.” Embracing one’s sexuality doesn’t sometimes lead to “irreversible treatments,” he noted, as embracing a trans identity may. He asserted that parents should be involved in decision-making around such treatments and that age of consent was a complex topic. The Times also published a letter signed by a bipartisan group of trans people, clinicians and others worried about “criminalising ethical exploratory therapy” and “leaving vulnerable youngsters on a one-way path to irreversible medical interventions.”

Many people interpreted this as hateful, and couldn’t conceive of why you would try to dissuade someone from this identity for any reason other than being anti-trans; Johnson’s own LGBT adviser objected and one staff member quit. (Many liberals, meanwhile, had an identity crisis when Boris Johnson seemed to express moderate, sane views.)

This is not just about age of consent. It is about understanding the causes of and treatments for gender dysphoria, and its trajectory.

Historically, conversion therapy has only applied to sexual orientation, which was deemed not only ineffective but harmful. This is because sexual orientation is not particularly malleable (despite plenty of examples of, for instance, situational homosexuality). After some awareness-raising and activism around the issue, particularly by gay men, conversion therapy is now banned in 20 states, with partial bans in many others.

We do not have any good research about conversion therapy when it comes to gender identity. One low-quality survey asked the question, “Did any professional (such as a psychologist, counselor, or religious advisor) try to make you identify only with your sex assigned at birth (in other words, try to stop you being trans)?” There was a correlation between those who answered yes and poorer mental health/higher suicidality, but there is absolutely no way to establish causation in this equation. For one thing, this survey was for people who still identified as transgender. Those who might have stopped identifying that way and were doing well wouldn’t have answered the questions. It was also retrospective and unverified. So it tells us very little, but has been used to justify adding “gender identity” to conversion therapy bans. (If there are other studies, please let me know—I know only of this one.)

But here’s where it might be accurate that trying to dissuade someone from their inclinations could be loosely tied to worse outcomes. As more and more people are beginning to understand, historically there were two main types of people seeking help for gender dysphoria at clinics. Those with childhood onset were often extremely feminine boys and extremely masculine girls, some of whom may have had a cross-sex identity and some of whom may have been brought there by parents upset that their children weren’t properly performing their gender roles. The bulk of those kids desisted and the majority were later gay. Exploratory therapy—often improperly conflated with conversion therapy—is important for kids and teens, because if the source of their stress is their sexual orientation, then medical interventions are not appropriate. You gotta know what’s wrong to know how to treat it, and in these cases, they needed time and space and acceptance, both internally and societally.

The other cohort didn’t emerge until at or after puberty, sometimes not until middle age. They were mostly (but not entirely) autogynephilic males, who were aroused by the idea of themselves as women, which ranged from simply wanting to wear women’s clothes to wanting to have as close to a woman’s body as they could have. Because autogynephilia is a version of a sexual orientation—males attracted to themselves as women—therapy wouldn’t change that, and shouldn’t try to. But trying to get someone to understand themselves is quite different from trying to get someone to be someone else.

Therapy can certainly help someone process autogynephilia and manage it. Multiple autogynephiles have expressed how much they wish they’d come to understand autogynephilia as the cause of their discomfort, rather than the amorphous and unscientific idea of gender identity, or the notion that they were born in the wrong body. Some young people lucky enough to have accessed this research are already coming out as autogynephilic; some don’t need hormones and surgeries to move forward once they know this part of themselves. Others greatly benefit from them.

(Having said all that, some trans women vociferously object to the very idea of autogynephilia, and feel it paints them as sexual perverts instead of as victims of biology. I’m sensitive about calling them something they don’t want to be called. However, the term was intended as a neutral descriptor of a group, with no moral judgement.)

Exploratory therapy doesn’t preclude medical intervention, but it helps someone suffering from gender dysphoria understand if it’s likely to help them or not. Today there’s an unprecedented epidemic of adolescent-onset gender dysphoric teens, studied only in Lisa Littman’s ROGD paper and chronicled in Abigail Shrier’s book Irreversible Damage. It’s unlikely that the research on the two types of gender dysphoria applies to them, just as previous studies about medical interventions for kids with childhood-onset gender dysphoria don’t apply. It’s not bigotry to ask how to best help suffering children, or to agitate for the least invasive options first. And exploratory therapy and conversion therapy are not the same thing.

According to The Guardian, trans people have been having massive mental health crises (as have kids, and many other groups). I think we could all use all the [good] therapy we can get.

Photo from James Esses/Twitter