The development of an agreed set of good practice clinical guidelines for avoiding the risks of perpetuating prejudice and stigma against lesbian and gay people has evolved during the last decade into a set of instructions as to how psychological therapists should, and should not, work with patients/clients who present with transgender issues.
The term ‘conversion therapy’ has historically been used to refer to attempts to ‘convert’ people with homosexual or bisexual orientation to heterosexual orientation. Classical psychoanalytic theory defined homosexuality as psychopathology. Around the middle of the twentieth century some mental health practitioners and religious groups practised behaviour modification using aversive techniques to try to ‘undo’ homosexual desires, for example pairing homoerotic arousal with an unpleasant or painful stimulus, in order to try to reduce the homoerotic response by a process of negative reinforcement. The term ‘reparative’ therapy is sometimes used to refer to the same, discredited, practice.
The employment of these or other techniques to try to ‘cure’ homosexuality is now universally deplored as pseudoscience by mental health professionals in the UK. Today they would not be accepted as ethical practice by any of the professional organisations that regulate health practitioners in this country.
Opposition to attempts to modify sexual preference was originally based on the acceptance, at least in most countries of the western industrialised world, that homosexuality should not be defined as a form of mental illness. This position was endorsed by the removal of homosexuality from the USA’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973, and subsequently confirmed by the International Classification of Diseases (ICD) of the World Health Organisation (WHO) in 1992.
The second decade of the twenty-first century has brought a renewed focus upon the issue of conversion therapy, and the concept has recently been widened to include gender identity issues. In May 2021 the UK government stated a commitment to new legislation explicitly banning conversion therapy following a public consultation (Government Equalities Office, 2021b), which was launched on 29th October 2021 (Government Equalities Office, 2021a).
The Government Equalities Office commissioned research from Coventry University to support its case for new legislation against conversion therapy that would include gender identity (Jowett et al., 2021). However, the methodology, findings and conclusions of this commissioned research have been criticised by others (Sex Matters, 2021).
The issue has now assumed a high public profile in the UK, with debates in parliament (Hansard, 2021) and concerns from some psychological therapy practitioners that any legal ban could seriously inhibit ordinary professional practice and the quality of therapy they would be permitted to deliver (Dixon, 2021). The legislative proposals are welcomed by some activists (Broster, 2021), however other therapists have detailed their concerns, together with recommendations, in response to the government consultation (Jenkins and Esses, 2021).
The debate was not always quite so polarised. Following discussions between psychologists and psychotherapists, a ‘Memorandum of Understanding’ (MoU) was published in 2015, setting out an agreed position on ‘conversion therapy’ (NHS England et al., 2015). This was signed by leaders of fourteen professional organisations in the mental health field, including the British Psychological Society (BPS), the Royal College of Psychiatrists (RCPsych), the United Kingdom Council for Psychotherapy (UKCP), the Royal College of General Practitioners (RCGP), and several other relevant professional organisations, and also by the chief medical officers of NHS England and Scotland.
The MoU in its original 2015 statement set out its purpose unambiguously as seeking to protect the public from harms caused by any “efforts to try to change or alter sexual orientation through psychological therapies”. In its preamble the MoU 2015 recognised a “long history of medical and psychological professions seeing homosexuality as a form of arrested sexual development”. It referenced 2009 research showing that 17% of psychological therapists surveyed had admitted to trying to change their clients’ sexual orientation (Bartlett, Smith and King, 2009), although their responses were based upon retrospective recall over a considerable period of years. The signatories set out a framework for seeking to ensure that the public should be well-informed about the risks of conversion therapy and that professionals should be appropriately trained to ethically meet the needs of clients seeking help for distress about sexual orientation.
In 2017 the MoU was revised and updated (BPS et al., 2017). The definition of conversion therapy was expanded to state: “For the purposes of this document ’conversion therapy’ is an umbrella term for a therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other, and which attempts to bring about a change of sexual orientation or gender identity, or seeks to suppress an individual’s expression of sexual orientation or gender identity on that basis”. Thus, the concept of ‘gender identity’ was introduced into a consensus statement that had originally been devised to protect homosexuals from abusive practices, and the definition of conversion therapy was extended to include any attempt to suppress an individual’s “expression” of their sexual orientation “or gender identity.”
This 2017 edition of the MoU explicitly detailed what it did not consider to be conversion therapy. For example, it stated “This position is not intended to deny, discourage or exclude those with uncertain feelings around sexuality or gender identity from seeking qualified and appropriate help”. It advises “This document supports therapists to provide appropriately informed and ethical practice when working with a client who wishes to explore, experiences conflict with or is in distress regarding, their sexual orientation or gender identity. Nor is it intended to stop psychological and medical professionals who work with trans and gender questioning clients from performing a clinical assessment of suitability prior to medical intervention”. It included the statement: “Ethical practice in these cases requires the practitioner to have adequate knowledge and understanding of gender and sexual diversity and to be free from any agenda that favours one gender identity or sexual orientation as preferable over other gender and sexual diversities. For this reason, it is essential for clinicians to acknowledge the broad spectrum of sexual orientations and gender identities and gender expressions”.
The signatories to the 2017 edition did not include the RCPsych. Stonewall was also added as a “supporter” organisation. The addition of an explicit endorsement by a lobby group for transgender rights was a significant departure from the original consensus statement from professional health organisations.
The MoU was amended again in July 2019, with the RCPsych rejoining a now-extended list of 20 signatories (British Psychological Society et al., 2021). Also included in the 2019 version is Gendered Intelligence, another transgender lobby group without healthcare credentials. This latest version, whilst closely following the 2017 edition, has inserted an extra sentence expanding upon the reference to “medical intervention” in the 2017 version. The 2019 amendment added “Nor is it intended to stop medical professionals from prescribing hormone treatments and other medications to trans patients and people experiencing gender dysphoria.” The inclusion of this caveat has been a subject of debate and dissent between clinical psychologists, some of whom have expressed concern that this could be a way of normalising the practice of prescribing by psychologists, thus not only departing from the core values of clinical and counselling psychology, but also implying that psychological therapists should be prescribing “off label” medications (Boyle et al., 2019).
Whilst there is evidence that some forms of conversion therapy are still practised against people with same-sex attraction, especially in certain non-clinical and religious settings, there is a lack of high quality evidence about conversion therapy being disproportionately targeted towards transgender people. An editorial published in 2019 remarked “The evidence on conversion treatments in people who are TGNC [transgender and gender non-conforming] is more difficult to disentangle than that for people who are lesbian, gay and bisexual (LGB). It is not always clear from published descriptions of conversion therapies whether they include people who are TGNC. Perhaps more importantly, whereas people who are TGNC may need a diagnosis to access treatments for transition, this is of no relevance to people who are LGB”. (King, 2019)
In tandem with the revisions to the MOU, efforts continued to define and establish the prevalence of conversion therapy in the UK, where the government’s LGBT on-line survey, published in 2018, was widely reported (Government Equalities Office, 2018). It stated that 5% of respondents had been offered conversion therapy, and that a further 2% had undergone it. The majority (51%) of this practice was reported as having taken place in religious rather than healthcare settings. However, the survey report includes the statement: “We did not provide a definition of conversion therapy in the survey, but it can range from pseudo-psychological treatments to, in extreme cases, surgical interventions and ‘corrective’ rape”.
Another attempt to identify prevalence concludes: “We found limited published evidence on use, nature, structure and/or health consequences of conversion therapies and access barriers to transition in TGD [transgender and gender diverse] people. However, reports of restriction to access may indicate a more widespread problem” (Wright, Candy and King, 2018).
The proposition that the experience of “barriers” to any medical interventions patients demand of their healthcare providers can be likened to or defined as “conversion therapy” merits some attention. The inclusion of phrases such as “barriers to transition” and “restriction to access” clearly differentiate the difficulties reported by transgender people from those experienced by people who report attempts to “convert” their homosexual orientation. For the former, but not the latter, there is a presumption that healthcare providers should actively promote medical interventions that result in changes to the physical body. This is quite a different response from same-sex attraction being left alone, for healthcare providers to steer well clear of any interventions seeking to alter sexual orientation, yet the two concepts are conflated.
Thus, the development of an agreed set of good practice clinical guidelines for avoiding the risks of perpetuating prejudice and stigma against lesbian and gay people has evolved during the last decade into a set of instructions as to how psychological therapists should, and should not, work with patients/clients who present with transgender issues.
Clinical debate has polarised into a highly politicised stand-off, where the central issue now revolves around a binary choice between so-called “conversion therapy”, which seeks to alter a person’s preferred “gender identity” versus “affirmative therapy”, which incuriously confirms a patient’s presenting self-appraisal and seeks unrestricted medical intervention to alter the body, rather than a more nuanced and evidence-based, collaborative therapeutic endeavour. Some authors advocate for the latter approach: “We call on the scientific community to resist the stigmatization of psychotherapy for GD [gender dysphoria] and to support rigorous outcome research investigating the effectiveness of various psychological treatments aimed at ameliorating or resolving GD. The outcomes of psychotherapeutic treatments must be compared to those of biomedical interventions, so that evidence-based standards of care that allow patients and clinicians to make fully informed decisions about how best to alleviate GD can be developed and put into practice”. (D’Angelo et al., 2021)
On 1st April 2022 the UK government announced that it would be introducing a legal ban on conversion therapy for gay people but not for people identifying as transgender, thus indicating that future legislation would aim to separate gay conversion therapy from trans conversion therapy.
Bartlett, A., Smith, G. and King, M. (2009) ‘The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation’, BMC Psychiatry, 9(1), p. 11. doi: 10.1186/1471-244X-9-11.
Boyle, M. et al. (2019) Prescribing Rights for UK Psychologists – Should We Be Cautious?, Mad in the UK. Available at: https://www.madintheuk.com/2019/11/prescribing-rights-psychologists-cautious/.
BPS et al. (2017) Memorandum of Understanding on Conversion Therapy in the UK version 2. Available at: https://www.cosrt.org.uk/wp-content/uploads/2018/08/UKCP-Memorandum-of-Understanding-on-Conversion-Therapy-in-the-UK-WEB.pdf.
British Psychological Society et al. (2021) ‘Memorandum of Understanding on Conversion Therapy in the UK Version 2, Revision A (03/07/2019)’.
Broster, A. (2021) ‘7 Organisations Fighting To Ban Conversion Therapy In The UK’, Bustle.com, July. Available at: https://www.bustle.com/life/organisations-fighting-to-ban-conversion-therapy-in-the-uk.
D’Angelo, R. et al. (2021) ‘One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria’, Archives of Sexual Behavior, 50(1), pp. 7–16. doi: 10.1007/s10508-020-01844-2.
Dixon, H. (2021) ‘Therapists “Could Be Criminalised” for Treating Gender Dysphoria Under New Laws’, The Telegraph, 5 May. Available at: https://www.telegraph.co.uk/news/2021/05/05/therapists-could-criminalised-treating-gender-dysphoria-new/.
Government Equalities Office (2018) ‘National LGBT Survey: Research report’. Available at: https://www.gov.uk/government/publications/national-lgbt-survey-summary-report.
Government Equalities Office (2021a) Consultation: Banning conversion therapy, Gov.uk. Available at: https://www.gov.uk/government/consultations/banning-conversion-therapy.
Government Equalities Office (2021b) Government sets out plan to ban conversion therapy, Gov.uk. Available at: https://www.gov.uk/government/news/government-sets-out-plan-to-ban-conversion-therapy
Hansard (2021) ‘LGBT Conversion Therapy’. UK Parliament. Available at: https://hansard.parliament.uk/commons/2021-03-08/debates/552D6176-C4D5-47F1-A8C1-C900B58AEB7C/LGBTConversionTherapy.
Jenkins, P. and Esses, J. (2021) ‘Scoping Survey for Government Equalities Office Consultation on Conversion Therapy’. Thoughtful Therapists. Available at: https://thoughtfultherapists.org/scoping-survey-pdf.
Jowett, A. et al. (2021) Conversion Therapy: An evidence assessment and qualitative study. Available at: https://www.gov.uk/government/publications/conversion-therapy-an-evidence-assessment-and-qualitative-study/conversion-therapy-an-evidence-assessment-and-qualitative-study.
King, M. (2019) ‘Stigma in psychiatry seen through the lens of sexuality and gender’, BJPsych International, 16(04), pp. 77–80. doi: 10.1192/bji.2019.12.
NHS England et al. (2015) ‘Memorandum of Understanding on Conversion Therapy in the UK’. Available at: https://web.archive.org/web/20210124032533/https://www.psychotherapy.org.uk/media/npbjy1cw/memorandum-of-understanding-on-conversion-therapy.pdf.
Sex Matters (2021) A rapid review of the Coventry University research on “gender identity conversion therapy”. Available at: https://sex-matters.org/wp-content/uploads/2021/11/Coventry-University-research-on-conversion-therapy.pdf.
Wright, T., Candy, B. and King, M. (2018) ‘Conversion therapies and access to transition-related healthcare in transgender people: a narrative systematic review’, BMJ Open, 8(12), p. e022425. doi: 10.1136/bmjopen-2018-022425.