The United Kingdom Council for Psychotherapy recently issued a position statement. In it they recognised that therapists with ‘gender critical’ views are likely to want to help clients resolve their gender related distress psychologically rather than through invasive medical treatment. The statement goes on to acknowledge that gender critical views are protected in law, that the exploratory therapy associated with them is in line with the recommendations of the interim Cass Review, and that such therapy should not be conflated with concepts of conversion therapy.
Hilary Cass’s Interim Report on gender services for children and young people noted that primary and secondary care staff had said that they feel under pressure to adopt an “unquestioning affirmative approach” and that from the point of entry to the Tavistock GIDS children and young people were exposed to a “predominantly affirmative, non-exploratory approach”. She expressed the view that, instead, clinicians should remain open and explore the patient’s experience and the range of support and treatment options that may best address their needs.
The interim service specification for children and young people with gender dysphoria published by NHS England, based on Cass’s interim report, recommended that puberty blockers no longer be routinely prescribed and stated:
The clinical management approach should be open to exploring all developmentally appropriate options for children and young people who are experiencing gender incongruence, being mindful that this may be a transient phase, particularly for pre- pubertal children, and that there will be a range of pathways to support these children and young people and a range of outcomes.
The primary intervention for children and young people who are assessed as suitable for The Service is psychosocial (including psycho-education) and psychological support and intervention; the main objective is to alleviate distress associated with gender dysphoria and promote the individual’s global functioning and wellbeing.
Interim service specification:
Specialist service for children and young people with gender dysphoria (phase 1 providers)
20 October 2022
So the future direction of therapeutic approaches to children and young people is away from the “affirmative” medical model and towards an exploratory psycho-therapeutic one.
This change of thinking has not yet impacted on adult gender services. Given that there has been a significant change in the demographic of referrals to adult NHS Gender Dysphoria Clinics towards a higher preponderance of women under the age of 25, and many of the issues of comorbidities and complexity raised in relation to the child and adolescent services also apply to young adults, it would seem wise to keep open the possibilities of a wider range of therapeutic approaches with adults too.
Unfortunately, these possibilities are being threatened by legislative attempts to ban so called “conversion therapy” for gender identity, which risks criminalising exploratory therapies for children and adults with gender related distress.
On 20th November, a private members bill seeking to ban gender identity conversion therapy topped a ballot in the house of Lords. The current version of the bill is very short, with little detail. It contains no exemption for exploratory therapy and simply repeats the inadequate, trans affirmative definition of conversion therapy contained in the Memorandum of Understanding.
In this Act, “conversion therapy” is any practice aimed at a person or group of people which demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to another, and which has the intended purpose of attempting to—
Conversion Therapy Prohibition (Sexual Orientation and Gender Identity) Bill
- (a) change a person’s sexual orientation or gender identity, or
- (b) suppress a person’s expression of sexual orientation or gender identity.
Therapists who favour an exploratory approach, have been accused of “conversion therapy” because they do not immediately “affirm” their client’s belief that their body is wrong, putting them on a pathway of medical and surgical intervention, but instead support their client to explore the meaning and possible causes of their gender distress. While the intention of such an approach is not to “change” or “suppress” a person’s identity, an outcome of an exploratory approach could be that the client comes to accept their body and no longer wishes to have medical or surgical intervention. This is what the proponents of the “affirmative” model have labelled conversion therapy.
Therapists taking an exploratory approach could risk prosecution if the bill succeeds, leaving the field open for gender affirmative therapy and its associated medical treatments as the only option, and in the case of children and young people, undermining the recommendations of the Cass report that social and psychological approaches should be the first line of treatment for gender related distress.
“Gender affirmative” treatments include puberty blockers, cross sex hormones and genital and breast surgery. There is no good evidence of benefit of these treatments, and significant evidence of harm both to physical and mental health. Yet “affirmation” with unevidenced and potentially harmful treatments is likely to be consolidated as the only option available if this conversion practices bill were to pass. A cynic might wonder about the link between the generous donations made to the Liberal Democrats by Ferring pharmaceuticals– suppliers of the NHS’s puberty blockers- and the fact that a liberal peer sponsored this bill.
Similar laws have been passed in other jurisdictions such as the state of Victoria in Australia, and this has had a chilling effect on therapists there, many of whom have stopped treating people with gender dysphoria for fear of being accused of conversion therapy. Therapists in the UK have had complaints made against their professional bodies for providing or teaching about alternatives to the affirmative model, such as exploratory therapy, and as a result many are avoiding this area of work. This limits the availability of a wide range of therapeutic options for people looking for support with their gender related distress.
David Pilgrim’s paper on the history of conversion therapy clarifies the differences between the cruel conversion practices of the past and contemporary exploratory therapy. Sex Matters have gone further. They claim that conversion therapy is being practised in plain sight as affirmative therapy. Left untreated, childhood gender dysphoria resolves in the majority of cases. Affirmation, on the other hand, fixes people in their trans identity potentially converting them into life-long transgender medical patients.
CAN-SG does not believe that a court of law is the right place to adjudicate on these complex clinical and ethical issues. But if this, or a future labour, government is intent on criminalising ‘conversion therapy’ we wonder which definition it will choose; that of the trans activists and their affirmative allies, or that of the gender exploratory therapists seeking to ‘first do no harm’.
CAN-SG’s upcoming webinar on 7th December will explore some of these issues.
