Why the “youth transition as anti-gay conversion therapy” myth doesn’t add up

An increasing share of anti-trans discourse is now occupied by the contention that a gender-affirming approach to transgender-identified youth, including social transition and puberty blockers, constitutes a form of anti-gay conversion therapy that serves to prevent these youth from growing up into cisgender gay and lesbian adults. This possibility is hinted at in articles such as those by Debra Soh:

Of the boys and girls seen in clinics like Dr. Zucker’s, a high percentage — up to 80% in a study of 44 gender dysphoric boys — grow up to be not transgender, but bisexual, gay or lesbian adults. Thus, helping prepubescent children feel comfortable in their birth sex makes more sense than starting a lifetime of hormonal treatments and surgeries that will in all likelihood turn out to be unnecessary and unwanted.

And Alice Dreger:

I’m going to say something incredibly politically incorrect: Some pink boys may benefit simply from meeting a swishy gay man—or better yet, two or three such men who can show them you can grow from being a pink boy to a pink man and have (dare I say it?) a fabulous life. I’ve actually met one therapist who whispered to me at a meeting that when he met a “gender dysphoric” pink boy who seemed to need this kind of “intervention,” it’s just what he provided (with a consultation by a colleague). The point was to let the boy know that there were even grown-ups like him, men who love “girly” things like beautiful clothes and Martha Stewart (and, um, men), and who are perfectly at home in their bodies and their selves. Why can’t you have (and keep) a penis and love sparkles? Lots of men have.

I asked Sarah—who has engaged with many parents in situations similar to hers—about whether she thought some parents seek out the transgender route for their children because it will mean they might end up going from having a gay son to having a straight daughter. Was homophobia motivating these parents?

Other sources advance a stronger and more explicit form of this argument. The avowedly trans-hostile community 4thWaveNow makes this far-reaching claim:

What’s more, a side effect of this pediatric transition propaganda is the proactive conversion of same-sex attracted young people into surgically and hormonally manufactured heterosexuals. It has been well known for decades that the vast majority of “gender dysphoric” young people resolve those feelings and grow up to be gay and lesbian.

As does anti-trans activist Stephanie Davies-Arai of Transgender Trend:

It is well established that cross-sex identity in childhood is overwhelmingly predictive of gay or lesbian sexual orientation in adulthood and not transsexuality. Reinforcing an opposite sex ‘heterosexual’ identity in childhood is therefore effectively gay conversion therapy by another name.

These talking points have filtered down into the everyday toxic soup of uninformed Twitter commentary on trans issues, with anonymous individuals hurling accusations of eugenics and “transing” kids:

This argument makes a number of contestable claims, and relies on assumptions that can be concretely pinned down, evaluated, and proven or disproven. A review of the current evidence reveals that this is not a plausible scenario for several reasons.

There is no evidence that gender-affirming treatment with puberty blockers will make an adolescent more likely to adopt a trans identity. If some form of conversion therapy were taking place, then conversion would be taking place. It does not appear to be the case that such conversion of gender identity is possible or can result from gender-affirming treatment. The clinical team in the Netherlands which pioneered the use of puberty blockers for trans adolescents have stated that these youth are given a sufficient window of time to experience their own early puberty before blockers are administered, helping to clarify whether they will or will not continue to identify as trans (de Vries & Cohen-Kettenis, 2012):

If the eligibility criteria are met, gonadotropin releasing hormone analogues (GnRHa) to suppress puberty are prescribed when the youth has reached Tanner stage 2–3 of puberty; this means that puberty has just begun. The reason for this is that we assume that experiencing one’s own puberty is diagnostically useful because right at the onset of puberty it becomes clear whether the gender dysphoria will desist or persist.

This is not consistent with the allegation that treatment is deliberately administered to forestall desistance from a trans identity. Furthermore, professionals involved in the treatment of these youth generally do not believe that the use of puberty blockers interferes with or alters their gender identity (Vrouenraets et al., 2015):

However, although most informants agreed on the fact that treatment with puberty suppression indeed may change the way adolescents think about themselves, most of them did not think that puberty suppression inhibits the spontaneous formation of a gender identity that is congruent with the assigned gender after many years of having an incongruent gender identity. …

Various endocrinologists made the comparison with precocious puberty; a medical condition in which puberty blockers have been used for many years, and no cases of GD have been described (at least to their knowledge). Besides, most of them emphasize that they deliberately start treatment with puberty suppression only when the youngsters have reached Tanner stage two or three to give them at least a kind of “feeling” with puberty before starting with puberty suppression.

Even if puberty blockers were being deliberately and improperly given to cisgender youth, there is no evidence that the use of this treatment in cis youth serves to produce any change in their gender identity development.

There is also no evidence that disaffirming or rejecting therapies will make a child or adolescent less likely to adopt a trans identity. Devita Singh worked closely with Dr. Ken Zucker at CAMH’s now-shuttered child gender identity clinic, which offered non-affirming treatment for gender-nonconforming and transgender preadolescent children with the intention of helping them become “more comfortable” with their assigned sex. While treatment was tailored to a child’s individual case, their broad clinical goal was to prevent the persistence of cross-gender identification and gender dysphoria into adolescence if possible, in the hopes of avoiding the need for transition.

However, Singh’s 2012 dissertation explicitly acknowledges that there is currently no evidence that their disaffirming approach reduces the likelihood of gender dysphoria persisting into adolescence, or that an affirming approach makes these children more likely to become transgender adolescents (Singh, 2012):

To date, there is no consensus on the best treatment approach for children with GID. This state of affairs has been maintained by the paucity of empirical data on treatment and also, in part, by theoretical disagreements among clinicians about gender identity development and its malleability in childhood. As a point of agreement, proponents of both the therapeutic and accommodation model agree that, if it is apparent that an adolescent is committed to transitioning, the recommended treatment approach is to provide cross-sex hormonal therapy, to be followed by surgery, if desired, in adulthood. Unfortunately, the debate about therapeutics for children is far from over largely because of scant research attention in this area. There have been no rigorous treatment outcome studies on children with GID and, certainly, no randomized controlled treatment trials that have compared the effects of these therapeutic approaches on gender identity outcome (Bradley & Zucker, 2003; de Vries & Cohen-Kettenis, 2012; Zucker, 2001a). In addition, there have been no studies that compared any of the different treatment approaches for GID to a condition of no treatment. Beyond resolving debate, there is an even more important reason to evaluate treatment approaches. As noted previously, most children with GID seem to desist in their gender dysphoria by adolescence. It remains unknown whether the aforementioned treatment approaches are associated with different long term outcomes (e.g., persistence vs. desistence of GID, general psychiatric functioning, psychosocial adjustment).

Singh further recognizes that there is currently no evidence to support a hypothesis that affirming treatment makes youth with gender dysphoria more likely to persist in their dysphoria:

It is an important empirical question whether these variations in treatment approaches across the Toronto and Dutch clinics have contributed to the variation seen in the percentage of children from each clinic who persist in their gender dysphoria. It is possible that a therapeutic approach that focuses on resolving a child’s gender dysphoria may result in a greater likelihood of desistence compared to an approach does not directly address the gender dysphoria. To address this issue, systematic treatment studies with long-term follow-up would be required.

She also notes that “one can only speculate on the effects of treatment on gender identity outcomes, if there are effects”:

Along the same lines, one can hypothesize that allowing children to socially transition in childhood may have the effect of increasing the chances of persistence into adolescence and adulthood. Without empirical comparative data on treatment approaches, one can only speculate on the effects of treatment on gender identity outcomes, if there are effects. At the follow-up assessment, participants in the present study were asked if they previously received treatment; however, a qualitative assessment of the interview data would be required to draw any substantial conclusions, which was beyond the scope of the present study. At the same time, it can be commented that some of the persisters in the study received treatment efforts aimed at helping them to resolve their gender dysphoria while in other cases much in the way of intervention was not attempted. The same can be said for the desisters.

Even those most motivated to find a way to alter a child’s ultimate gender identity have not been able to find evidence that this is possible.

Additionally, homophobic attitudes are not associated with trans-affirming attitudes – they are associated with transphobia. The speculative motivation of parental homophobia – a preference for a heterosexual transgender child over a gay or lesbian cisgender child – is contradicted by studies showing a correlation of homophobic attitudes with transphobic attitudes. Norton & Herek (2013) found that among heterosexual adults in the United States, higher levels of prejudice toward gay, lesbian, and bisexual people were associated with increasingly negative views of transgender people:

Consistent with Hypothesis #1, thermometer scores for transgender people and the four sexual minority groups were highly correlated. For the transgender thermometer, r(2276)=.80 with the gay men thermometer, r(2277)=.67 with the lesbian thermometer, r(2280)=.84 with the bisexual men thermometer, and r(2280)=.66 with the bisexual women thermometer (all ps<.001). Ratings of transgender people were negatively correlated with scores on the ATG and ATL (higher ATG and ATL scores indicate greater sexual prejudice).

Contrary to the notion that parents have a more positive attitude toward trans people than toward gays and lesbians, the study sample exhibited an even more unfavorable view of trans people compared to LGB individuals:

U.S. heterosexual adults’ feeling thermometer ratings for transgender people were strongly correlated with their thermometer scores for gay, lesbian, and bisexual targets, although it is noteworthy that attitudes toward transgender people were significantly more negative than attitudes toward sexual minorities. The significant correlations between transgender thermometer ratings and scores on the ATG and ATL scales—which, in contrast to the thermometers, focus on condemnation and tolerance of gay men and lesbians (Herek 2009a)—provide further evidence of a strong psychological linkage between the two attitude domains.

Proponents of the “conversion therapy” hypothesis of youth transition have responded by pointing to the example of Iran, where homosexuality is not accepted but gender transition is widely encouraged for gay people. However, this does not account for the 99% of the world which has not adopted this Iran-specific fatwa.

Untreated gender dysphoria and lack of gender affirmation can itself interfere with a trans person’s development of a sexual identity. For trans people who haven’t transitioned, sexual interactions can entail being desired for a body with which one does not identify or actively dislikes. It can mean being expected to use body parts which cause deeply uncomfortable dysphoria. Those with untreated dysphoria may experience their sex drive as an unwelcome and alien intruder that is distracting and unpleasant rather than a well-integrated part of one’s whole being. They may experience depersonalization, a state of dissociative detachment which can impair them from ever feeling truly involved with the world or with other people, leaving them lacking in a sense of personal agency and feeling as though they’re merely going through the motions of everything (Steinberg et al., 1993). Numerous trans people have reported that their bodily incongruence prior to transition directly interfered with their ability to have a genuine experience of their own sexuality and desires (Doorduin & van Berlo, 2014):

Reporting a cross-gender subjective sense of self for much of their lives, living closeted, coming out, and transitioning all greatly affected participants’ sexual life trajectories and development. Many participants reported skipping essential stages in sexual development, because growing up with transgender feelings made it difficult to discover sexuality the way many of their cisgender peers did. As Paul reported:

“I don’t think I went through a ‘normal’ process in terms of sexual development. In puberty [I avoided] it, discovering only at a relatively late age that I actually have something like sexual organs … I knew, but I never physically discovered or explored it. So I think I have had quite a faltering journey of discovery there.”

Whereas Paul speaks about avoiding sexuality altogether during puberty, all participants (including Paul) reported masturbating, and most had sexual relationships before coming out as transgender. However, they frequently expressed the sense that these sexual activities did not bring them closer to learning about their own sexual desires, nor did they feel they could satisfactorily practice their skills in communicating about their own and their partners’ sexual likes and dislikes.

A number of factors made it difficult to obtain these sexual skills. For some participants, sexuality before transitioning was not really a part of their own lives even though they technically participated in it, because of feeling so incongruent with their own gendered bodies. Rosa, for example, experienced sexuality as something instrumental: “That which took place was simply the managing of a physical reaction to create a child. Instrumentally, it is a mechanic you put into action. I knew enough about biology to know that my body reacts if you perform the right actions. […] Well, that is not sexuality.”

Additionally, a number of case reports have since emerged suggesting that rather than cisgender gay and lesbian youth being pressured to be transgender, transgender youth have at times faced pressure from clinicians to identify as cisgender and gay (Steensma & Cohen-Kettenis, 2015), with unsatisfactory results and unneeded delays in treatment.

Ultimately, this argument itself advances an unacceptable form of anti-trans conversion therapy for unjustifiable reasons and with no clear benefit. Withholding affirming care from youth in whom this is indicated will not cause their transness to go away – being denied necessary treatment has never made a trans person any less trans. In the name of the false concern that gender-affirming treatment is being given to children who do not need it, these popular medical conspiracy theories threaten to jeopardize access to this treatment for children who do need it, putting them at risk of untreated gender dysphoria, its many comorbid conditions, and even the very same disrupted sexual development that these conspiracists purport to fear. ■

References

• de Vries, A. L. C., & Cohen-Kettenis, P. T. (2012). Clinical management of gender dysphoria in children and adolescents: the Dutch approach. Journal of Homosexuality, 59(3), 301–320. [Abstract]
• Doorduin, T., & van Berlo, W. (2014). Trans people’s experience of sexuality in the Netherlands: a pilot study. Journal of Homosexuality, 61(5), 654–672. [Abstract]
• Norton, A. T., & Herek, G. M. (2013). Heterosexuals’ attitudes toward transgender people: findings from a national probability sample of U.S. adults. Sex Roles, 68(11–12), 738–753. [Abstract]
• Singh, D. (2012). A follow-up study of boys with gender identity disorder (Doctoral dissertation). [Full text]
• Steensma, T. D., & Cohen-Kettenis, P. T. (2015). More than two developmental pathways in children with gender dysphoria? Journal of the American Academy of Child & Adolescent Psychiatry, 54(2), 147–148. [Abstract] [Full text]
• Steinberg, M., Cicchetti, D., Buchanan, J., Hall, P., & Rounsaville, B. (1993). Clinical assessment of dissociative symptoms and disorders: the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Dissociation, 6(1), 3–15. [Full text]
• Vrouenraets, L. J. J. J., Fredriks, A. M., Hannema, S. E., Cohen-Kettenis, P. T., & de Vries, M. C. (2015). Early medical treatment of children and adolescents with gender dysphoria: an empirical ethical study. Journal of Adolescent Health, 57(4), 367–373. [Abstract]