conversion therapy review

Should UK medical schools sign GLADD Charter on So-Called LGBTQ+ ‘Conversion Therapy’?

GLADD is the UK’s association of LGBTQ+ doctors, dentists, medical and dental students. All medical schools throughout the UK have been sent a copy of GLADD’s charter relating to the so called ‘conversion therapy ban’. It was co-authored with Lancaster University, and the document has been endorsed by Dr Michael Brady, national LGBT Advisor at NHS England. To date, 32 medical schools have signed the document along with medical organisations such as the BMA.

As more schools sign the charter, it becomes harder for those with reservations to withhold signing. It seems likely, if not inevitable, that all medical schools will ultimately sign. 

On the face of it, any campaign to outlaw a regressive and repressive practice, as the traditional understanding of ‘conversion therapy’ is, should be supported. However, following the Government consultation on the proposed outlawing of conversion therapy, a number of concerns were raised. The Government has now committed to a ban for conversion therapy in cases of sexual orientation but introduced a pause on any proposed legislation for its use in gender identity. 

To understand the details of this complex and controversial issue, it is necessary to have a clearly understood definition of ‘conversion therapy’. Broadly, it refers to a group of interventions developed over the twentieth century that attempted to change an individual’s homosexual orientation to a heterosexual one. This was particularly relevant at a time when male homosexuality was illegal.  Whilst usually it involved the use of talking treatments arising from the early schools of psychotherapy, it later included a range of physical, hormonal and other aversive interventions. As social attitudes changed, homosexuality was legalised and these treatments fell out of favour, increasingly regarded as cruel and ineffective. It seems unlikely that any such treatment is offered in an NHS clinical setting now.

In the GLADD charter, conversion therapy for sexual orientation is conflated with that for gender identity. The decision to treat the two as comparable is deeply problematic. Whilst it is ethically right that the Government should support efforts to end coercive and abusive attempts to change any identity, sexual orientation should be seen as distinct from gender identity.

Sexual orientation is conceptually distinct from gender identity, in that the former refers to the material reality of the sex of a desired partner and is undeniable, whereas gender identity is a contested construct, difficult to demonstrate or refute, and might come with the request for invasive bodily modifications. It is not clear what is actually meant by conversion therapy in gender identity, and the Government’s own research failed to find evidence that any such interventions were being delivered.

The urge for caution over the correct approach when dealing with gender confusion, particularly in children and young people, is important because of the complexity and seriousness of the various interventions offered. These include, puberty blockers, cross sex hormones and surgery. Gender distress might lead a person (including children, as they have not been excluded from the charter) down an irreversible medical pathway which could lead to infertility, loss of sexual function and even removal of primary and secondary sexual characteristics. 

The charter makes the bold assertion that gender identity cannot be changed, yet there is a body of evidence that, certainly amongst children who display strong cross-sex identification, it does indeed change, possibly in as many as 90% of cases. (See Zucker for an analysis of desistance literature). There is less evidence available on the outcomes of the newer, mainly female cohort, primarily comprising adolescents and very young adults. However, there is no doubt that there are a growing number of ‘detransitioners’ and they often have remarkably similar stories of difficult puberty, growing awareness of same-sex attraction, and underlying mental health issues that had not been diagnosed. Worryingly, autism seems overrepresented in the gender clinic population. For a comprehensive look at the reasons for embarking on a transition pathway and the factors involved in decisions to detransition, see ‘detrans’.  

The charter states that its call for a legislative ban on conversion therapy in gender identity, should not impact the ability for gender non-conforming individuals to access gender identity health services, or impact on them engaging with medical transition. Yet, it fails to acknowledge an alternative outcome: one in which a patient’s gender dysphoria resolves, they come to accept their sexed body, and decide against medical transition. This outcome, we assume, would fall under the definition of ‘conversion’. 

When working with patients seeking medical interventions, exploration of the roots of gender dysphoria should be undertaken, along with assessment of any co-existing diagnosable mental illness. Common causal factors need to be understood and addressed.  Patients suffering from depression should be treated for this before embarking on life altering treatment.  Under GLADD’s charter, attempts to explore, formulate and treat co-existing mental illness, might be considered ‘conversion therapy’. As there is evidence that many psychiatric disorders persist despite positive affirmation and medical transition, it is questionable why transition would be seen as the key goal rather than any number of alternative outcomes such as improved quality of life. Taking a supportive, exploratory approach with gender-dysphoric patients should not be considered conversion therapy, even if the patient changes how they view their gender identity.

There is a lack of evidence demonstrating that the medical interventions offered to patients who are referred to gender clinics are safe and effective. The National Institute for Health and Care Excellence concluded that the evidence for puberty blockers and cross-sex hormones in paediatric gender medicine is of ‘very low certainty’ (Evidence for puberty blockers use very low, says NICE – BBC News). Long term outcomes following medical and surgical transition in adults are equally uncertain, see  here and here.

The Government’s commissioned review of gender identity services for children and young people has similarly highlighted the lack of consensus about the nature of gender dysphoria and the appropriate clinical response. 

At best, this is a confused and confusing charter, with a lack of definitions and poor evidence to back it up. At worse, this might have the very opposite of the intended consequence of a legislative ban, ‘converting’ gay, lesbian and gender non-conforming youth into simulacra of the opposite sex, with all the negative health outcomes associated with gender medicine. Therapists risk being criminalised for offering exploratory psychotherapy, as offering any approach other than affirmation and medical and surgical intervention is being labelled as ‘conversion therapy’.  Medical schools and other health organisations should think very carefully before signing this partisan charter.