What is meant by the term ‘conversion therapy’?

A discussion of the different meanings of ‘conversion therapy’ and their practical and ethical implications.

David Pilgrim PhD, Visiting Professor of Clinical Psychology, University of Southampton & Honorary Professor of Health and Social Policy, University of Liverpool

Given that the term ‘conversion therapy’ is being used frequently today, in a range of policy contexts, this paper takes stock of its origins and diverse connotations. I consider three versions of the meaning of the term and offer a view of why they are different conceptually but also why they take the form they do. Broadly I consider the current emphasis of transgender activists, their allies and those agreeing with them before contrasting that position with an older focus on homosexual conduct. Finally I introduce a third connotation of the term for those critical of gender ideology. All three reflect the views of groups of activists about public policy development, and they contain within them different assumptions about both reality and moral values.

The transgender activist position on the term

The activist group promoting the first view of ‘conversion therapy’ is broadly located in the LGBTQ+ social movement. That view is widespread outside that group, particularly in the equality, diversity and inclusivity policies and training programmes of public, private and third sector organisations. The term there refers to any form of intervention from healthcare professionals deemed to be aimed at altering either the sexuality of a person or their gender identity. The clear connotation here is that sexuality and gender identity are to be considered as logically and empirically equivalent. For this reason, the two are commonly elided in policy documents. Two examples here would include the Memorandum of Understanding on Conversion Therapy in its 2018 edition and the historical review of the topic offered by the University of Birmingham.

The University of Birmingham agrees wholeheartedly with the British Psychological Society and the Royal College of Psychiatry [sic] and numerous other organisations and professional bodies, which state that there is no moral or ethical support for activities aimed at changing sexual orientation or gender identity (often called ‘conversion therapy’). The Memorandum of Understanding on Conversion Therapy in the United Kingdom is endorsed by 26 prominent health and therapy organisations, including NHS England and NHS Scotland. Crucially, there is no robust scientific evidence to support the use of ‘conversion therapy’. This report places that term in inverted commas, precisely because these interventions have no form of therapeutic value. Efforts to suppress same-sex desire or enforce conformity to social expectations of gender do not ‘work’ as intended; in fact there is substantial evidence that shows how harmful it is.
https://www.birmingham.ac.uk/news/2022/university-of-birmingham-publishes-report-on-conversion-therapy

An implication of this elision is that aversion therapy, circa 1970 for adult homosexuals and exploratory psychotherapy for gender confused children today are the same thing and they are equally unethical. That claim is rejected emphatically by the next two groups.

The emphasis in the Gay Liberation tradition

The push back against the pathologisation and criminalisation of homosexual conduct emerged in the early 1970s. Under this pressure homosexuality was dropped from DSM in 1973, though even after the decriminalization of male homosexuality (in the UK after 1967) voluntary presentations to mental health services seeking an alteration in homosexual orientation were the subject of research from psychiatrists and psychologists. Since that time, a standard policy position has been that such conversion practices should be condemned. However, ambiguity remained about its scientific and moral worth. Some gay activists went on to support the above position of conflating aversion therapy circa 1970 with exploratory psychotherapy offered to gender confused children since the 1990s. By contrast, some other gay activists have rejected that conflation. This was clearly evident with the formation of the LGB Alliance, which split off from Stonewall in 2019. That group were more sympathetic to the next position and are now an overlapping lobby group. The sympathies of gay activists then are divided about how they frame the meaning of conversions therapy.

The emphasis in gender critical groups

Objections to the framing of conversion therapy in the first position came from a range of groups. These included second wave feminists, scientific realists, some gay activists just noted and some religious groups. The consensus of these sub-groups has been that a woman is an adult human female and a man an adult human male. That description is based upon the fundamental fact of sexual dimorphism.

For this group, we emerge from nature and the latter in the mammalian population means sexual dimorphism and the separation of two types of gamete to ensure reproduction of the species. XX and XY chromosomes exist from natural necessity and cannot be talked out of existence.

Gender critics assert on scientific grounds that a man cannot be turned into a woman any more than lead can be turned into gold. However, medical and other forms of cosmetic manipulation can be used to alter a male to have some aspects of the appearance of a female (or a female to have some aspects of the appearance of a male). This allows a transgender person to ‘pass’ as the opposite sex. For gender critics, this is the real conversion therapy: healthy sexed bodies are turned into something they are not, using medical interventions that entail iatrogenic risk.

The medico-legal implications are then extensive; when medical interventions are demanded and offered the targeted body is typically healthy, being anatomically and physiologically unremarkable for age. A confounding discussion is the scarce occurrence of intersex phenomena or ‘differences of sexual development’ (DSDs). However, people with DSDs are rarely patients in transgender healthcare. Moreover, although these states are rare they are still, like the case with the sexually dimorphic majority, genetically fixed. Genotypes are always immutable and so gender critics concede that gender may be socially negotiated or constructed, but that is not the case with sex. The latter is a biological fact, described at birth or on a pre-natal scan. This position is at odds with the first one above which insists that sex is not described but ‘assigned’, as if it is an opinion open to challenge after the event.

Discussion

The above three versions of describing conversion therapy contain different assumptions about reality and reflect different ethical premises. In the case of transgender activism, which has been highly influential in shaping the diversity and inclusion policies of many organisations today, gender and sex are both given the same status in reality. Hence a transwoman is a woman’ according to this position. Also they argue that from a young age some people simply know validly that they were ‘born in the wrong body’.

By contrast the other two positions reject that assumption about reality and insist that a transwoman is a man, or a transman is a woman, who desires to become the other sex for psychological reasons, some understandable and some not. Reality then lies factually beyond our individual desires and expectations, according to positions two and three. In particular the first position underpinned by postmodern ideas and third wave feminism place an emphasis on social constructivism not on the facticity of biological sex. The incompatibility between strong social constructivist reasoning and the empirically proven fact of life of immutable sexual dimorphism is made here by the critical realist philosopher, Roy Bhaskar:

… God makes the spectrum, man makes the pigeon holes; so that genera, species, essences, classes and so on are human creations. I can find no possible warrant for such an assumption. Taken literally, it would imply that a chromosome count is irrelevant in determining the sex of an individual, that the class of the living is only conventionally divided from the class of the dead, that the chemical elements reveal a continuous gradation in their properties, that tulips merge into rhododendron bushes and solid objects fade gaseously away into empty spaces …
Bhaskar, 2008: 213

When we move from the matter of reality to motivating values in the three stances, then we also find differences. Position one from transgender activists focuses on demands for equal citizenship for adults (transsexuals) and the demands for an early process of transitioning for children who are gender dysphoric and may believe that they were ‘born in the wrong body’. They also expect others to recognize their true state and so others must not ‘misgender’ them.

This is where the link between assumptions about reality and ethical warranting articulate differently in the different groups. The truth about sex and gender for the second and third groups is based in biological reality (an external feature) but for the first it is all about subjective assertion (a feature of our interiority). Accordingly, for transgender activists recognition of who they really are is both a civil right and it warrants demands for bio-medicalisation in order to reduce or eliminate distress (‘gender dysphoria’).

The latter position is ethically offensive, and not warranted in logic or evidence, for those in the second position. For example, those creating the LGB Alliance consider that many transgender children often turn out to be gay as they mature, but they are not permitted to accept that existential state because of the pressure to conform to the hegemony of recent transgender ideology. The first position is also offensive to the third group because the rights to citizenship are at odds with the rights of both women and children. This is particularly the case when anti-social transwomen intrude into women’s spaces (changing rooms, refuges, prisons and hospital wards). The ethical contention of this sort extends as well to the role of transwomen in female sporting activity, for their unfair advantage because of going through male puberty and the alterations in large muscle strength created by testosterone.

Having given a broad brush stroke description of the three positions, it is important to note that there is some overlap between them and some ambiguities within each one. I noted that gay activists can be found in all three. Also, the position of some religious objectors can be found in relation to both homosexual behaviour and transgender claims. Some religious groups still offer ‘reparative therapy’ for homosexuals, whereas others are fully accepting of gay and lesbian priests and their flocks. Also some transgender people accept their sex is not assigned but described. The ‘depathologisation’ movement within the transgender community rejects the argument that being transgender intrinsically implies having a mental health problem, while also arguing that bio-medicalisation to ameliorate gender dysphoria is a healthcare consumer right.

This open-ended consumerism from transgender activists implies that healthcare professionals or biological scientists should simply accept any and every subjective perspective adopted by transgender individuals. For example, clinicians are expected not to explore the reasons for the transgender identity of a particular patient, only affirm it. And yet, patient-hood status is being demanded in biomedical terms (hormones and surgeries) by these patients and legitimized by professionals sharing an ideology of unconditional affirmation. This led to the paradox of a psychologically led service (such as GIDS) favouring a biomedical solution to existential distress. Another paradox is that transgender activists appeal to a caricatured binary of sexed bodies, thereby reinforcing a binary approach to gender appearance and performance. The hormonal and surgical procedures being demanded generate forms of phenotypical artifice, which bear only a weak relationship to the appearance of most natal men and women.

A final ambiguity in the third group (gender critics) relates to their differential concerns about MtF and FtM populations. The former include autogynephiles, whereas the latter do not contain this clinical dimension about sexual arousal and the ensuing raised probability of anti-social or criminal risk to others. The clinical implications of the FtM group are less about risk to others, though the maternity service costs for this group are higher than for females without prescribed hormonal interference. Given the recent shift in ratio between these groups, the further challenge of working clinically with ‘regretters and de-transitioners’ will be greater for natal females than males. The medico-legal implications overlap between the groups (to do with complaints of iatrogenic harm) but the particular follow up management of males and females raise different clinical and ethical challenges.

This a complex topic that requires more, not less, discussion, contra the attempt on the part of transgender activists to defend a ‘no debate’ position and to push for the no platforming in academic settings of those disagreeing with them. A constraint on that needed discussion is coming from a number of directions. These include the authoritarian mobilization of transgender activism to shut down discussion, as well as the unreflective alacrity of those managing organisations to simply accept without question the first position noted at the outset. Consumerism in higher education and mental healthcare have encouraged this trend, as has the crude norms of new social media to replace proper debate with top dog virtue signaling.

The most troubling aspect of this shut down on reflection is the willingness of many academics to self-censor and to accept a new routine restriction of free expression in debate, teaching and research. Positions two and three advocate freedom of expression as a pre-requisite of resolving the current contention about sex and gender, whereas transgender activists self-righteously wish to close down free and respectful debate in policy discussions. For now many outside of their ranks leading organisations are complying with that expectation.