Once more, with peer review: Transitioning is not anti-gay conversion therapy

For years now, anti-trans activists have made the contention that the availability of gender-affirming care for trans youth, including social transition and medical transition with puberty blockers and cross-sex hormones, functions as a form of anti-gay conversion therapy in which youth who would supposedly grow up to be cisgender and gay are instead somehow induced to be transgender via this treatment, resulting in a heterosexual orientation. The anti-trans group 4thWaveNow offers a representative example of this argument:

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.

I’ve previously addressed this argument in 2017, and it is implausible on essentially every level: The use of puberty blockers does not appear to cause cisgender youth to become transgender; refusal to accept trans youth’s gender identity does not appear to be effective at making them become cisgender; and transphobic attitudes are strongly associated with homophobic attitudes, making it unlikely that these youth’s parents would be accepting of a trans child while rejecting a gay or lesbian child.

Florence Ashley, a bioethicist at McGill University, has now refuted these “conversion therapy” arguments at length in the Journal of LGBT Youth (Ashley, 2019). Ashley highlights the findings of a Human Rights Campaign survey that parental hostility toward a transgender identity is more frequent than parental hostility toward cis youth’s LGB identities:

The Human Rights Campaign’s survey on LGBTQ youth found that the families of 64% of transgender youth, including non-binary, made them feel bad about their identities compared to 34% of cisgender LGBQ youth (Human Rights Campaign, 2018, p. 8).

Moreover, a distinct preference among parents for a cisgender gay child over a transgender child has been noted by clinicians working with trans and gender-diverse youth – and this value judgment is even shared by some clinicians:

Clinicians at the now-defunct Toronto youth clinic observed that while many parents do not have particular qualms with their child growing up to be LGBQ, they would prefer that their child not grow up trans (Zucker, Wood, Singh, & Bradley, 2012, pp. 391–392). Indeed, many clinicians appear to share these beliefs, with one prominent clinician who led a major gender identity clinic claiming (Green, 2017b, p. 82): “I am convinced that it is a helluva lot easier negotiating life as a gay man or lesbian woman than as a transwoman or transman.”

Perhaps most strikingly, Ashley cites numerous surveys and studies which strongly undermine the assumption that transitioning is a way to ensure that youth grow up to be straight. Transition would not be an effective means of anti-gay conversion therapy – because the vast majority of trans youth are not heterosexual:

A Human Rights Campaign survey of over 5,600 trans youth ages 13 to 17 found that 5% of them were straight (Human Rights Campaign, 2018, p. 38). Identification as straight in reported other studies that included youth under 16 years old also form a minority: 11.6% for non-binary youth (n = 344), 44.8% for trans girls (n = 202), and 19% for trans boys (n = 175) ages 11 to 19 (Toomey et al., 2018); 47.2% for trans boys and girls (n = 180) and 2.9% for non-binary youth (n = 70) ages 14 to 25 (Aparicio-García, Díaz-Ramiro, Rubio-Valdehita, López-Núñez, & García-Nieto, 2018); 7.3% for trans young people (n = 652) ages 14 to 25 (Strauss et al., 2017, p. 21); 14% among trans youth (n = 923) ages 14 to 25 (Veale et al., 2015). Combining the studies gives us a percentage of 8.7% for straight trans youth, include the survey from the Human Rights Campaign, and 16.8% without. In either case, the percentage of trans youth who are straight is a clear minority. These percentages accord with those observed among trans adults (James et al., 2016; Katz-Wise, Reisner, Hughto, & Keo-Meier, 2016).

Moreover, Ashley points out, gender-affirming care for trans youth does not actually function to alter the targets of their sexual attraction – while a trans woman (or man) exclusively attracted to men (or women) may be labeled as gay before transitioning and as straight after transitioning, their underlying sexual orientation has not changed at all:

Yet even this conceptualization does not mean that gender affirmation is a change in sexual orientation since gender affirmation merely affirms and nourishes a gender identity that is already there. The trans man who goes from being viewed as a Butch lesbian to affirming himself as a straight man is not changing the structure of his sexual attraction by transitioning, merely aligning its external expression with his internal schema. Just before he transitions, he’s already a straight man—others just don’t know it.

Crucially, unlike anti-gay conversion therapy, gender-affirming care is not an approach that views certain sexual orientations or gender identities as being undesirable or something to be discouraged: “Since gender affirmation has neither fixed end goals regarding sexual orientation nor views being LGBQ as negative or pathological, it cannot reasonably be accused of being a form of conversion therapy.” And conversion therapy efforts have themselves aimed to change gender-nonconforming expression among youth, under the belief that changing this behavior would serve to prevent both homosexuality as well as transness: “When it comes to youth, conversion therapy has historically targeted gender non-conformity, not gender identity or sexual orientation per se.” Anti-gay conversion therapy has been an anti-trans effort – not a pro-trans or even trans-neutral one. And whereas conversion therapy is known to cause harm to those subjected to it, gender-affirming care is not associated with such harms to any extent:

There is no comparable evidence of psychological harm with the gender-affirmative approach. While medical transition bears risks, it is relatively safe and adverse events do not appear to negatively impact overall psychological wellbeing (Bauer et al., 2015; Center for the Study of Inequality, 2018; Chew, Anderson, Williams, May, & Pang, 2018). Although some youth whose gender is affirmed later retransition to the gender they were assigned at birth, many are grateful at the opportunity to better explore their gender and regrets appear mediated precisely by the shame dynamics highlighted by Wallace and Russell (Ashley, 2019a, 2019c; Blasdel et al., 2018; Turban, Carswell, et al., 2018; Turban & Keuroghlian, 2018).

At every step of the “transition as conversion therapy” hypothesis, evidence contradicts this possibility. Parents and others do not desire to have a straight trans child more than they desire to have a gay cis child – the supposed motivation is absent. Transition does not change the substance of a person’s sexual orientation, and a majority of trans youth are not straight – the alleged desired outcome is absent as well. Nothing of what is known about trans youth and gender-affirming care reflects this speculative notion, and using such a groundless argument to cast doubt on this important and beneficial care for vulnerable youth is simply irresponsible. ■