Speak Up For Women is a non-partisan feminist group concerned about the emerging conflict between transgender rights and the sex-based rights of women and girls.
We write to express our concern about the way in which the Petitioner has misrepresented the above Petition, and conflated “gay conversion therapy” with therapy designed to address gender dysphoria (a recognised mental health disorder, involving feelings of incongruity between a person’s body and their gender identity.i
Conventionally understood, conversion therapy – also known as reparative therapy – is the practice of “treating” homosexual or bisexual people, sometimes coercively, with a view to “converting” them to a heterosexual orientation. It is widely regarded as unethical, as well as ineffective. Mr Tweedie’s Petition (15448 signatories) addresses this harmful practice, and a number of our supporters signed the Petition on this basis.ii
However, in the publicity attending the Committee’s recent hearing of 13 June 2019, Mr Tweedie has repeatedly referred, incorrectly, to the Petition as addressing both sexual orientation and gender identity.iii We believe many people would not have signed Mr Tweedie’s Petition if they knew he would misrepresent it in this way.
There are fundamental differences between sexual orientation and gender identity and we believe it is a serious mistake to equate them in this context. It is an ideological position, not a scientific one, and it obscures the growing concern about the extraordinary increase in children and adolescents presenting for gender identity treatment (particularly girls); iv the absence of any consensus as to treatment approach; and the paucity of good quality data.
Key differences between sexual orientation and gender identity
“Although gender identity and sexual orientation may often be analogous and discussed together with regard to social or political values and to civil rights, they are nonetheless distinct – with distinct origins, needs, and responses to medical and mental health care choices.”
— Dr James Cantor (clinical psychologist and sexual behaviour scientist)
(i) Evidence base
The medical consensus is that “conversion therapy” for sexual orientation is not supported by science.vi In contrast, there are no studies of conversion therapy for gender identity, let alone a scientific consensus.vii There is no consensus on treatment approaches for children and adolescents with gender dysphoria, as illustrated by the range of expert opinion in the latest edition of the peer-reviewed journal Clinical Child Psychology and Psychiatry (April 2019), which is dedicated to trans youth issues.viii
The cause of gender dysphoria is not known. While some people believe in “innate” gender identities, there is scant evidence of a biological basis: it is likely a mix of biological, social and psychological factors.ix The overwhelming evidence, from multiple studies, is that the majority (up to 80%) of children with gender dysphoria will desist by puberty, with most of these children growing up to be gay or lesbian adults fully content with their biological sex. x There is no reliable method of distinguishing the “persisters” from the “desisters.” Under a conversion therapy model, however, anything short of immediate, uncritical “affirmation” of a child’s expressed gender identity risks being regarded as “conversion.” This becomes a self-fulfilling prophecy: children who are “affirmed” as being “in the wrong body” (e.g. by parents and authority figures) are more likely to persist.xi
We are concerned that clinicians treating gender dysphoric children will be prevented (or in the very least inhibited) from adopting mainstream approaches such as “watchful waiting,” and/or treatments designed to “increase the chances of successful, contented homosexual adaptation in adulthood”xii , thereby avoiding a lifetime of medicalisation and surgery.
(iii) Autism and co-morbidity
Around one half of children and adolescents seeking gender identity treatment exhibit autism spectrum traits. xiii Children with other psychiatric conditions (most commonly anxiety and depression), and those with a history of abuse, are also significantly over-represented.xiv A recent article in Adolescent Health, Medicine and Therapeutics noted that it “seems unlikely” that this psychopathology is “secondary to gender identity issues.”xv Yet a “conversion therapy” model would prevent therapists exploring and treating these potentially causal factors prior to “affirmation” of gender identity.
“This experimental treatment is being done not only on children, but very vulnerable children, who have experienced mental health difficulties, abuse, family trauma, but sometimes those other factors just get whitewashed…If someone was suggesting plastic surgery or any other permanent change we’d be saying hang on a minute.”xvi Former NHS gender clinician (quoted in the Times 8 April 2019)
Other evidence suggests that homophobia (parental/peer/internalised) also plays a part.xvii A recent investigation by the Times (UK) reported that NHS gender clinicians have expressed concern that “many children decided they wanted to change gender after suffering homophobic bullying.”xviii The article quotes several former clinicians as follows:xix
“There was a dark joke among staff that ‘there would be no gay people left’”
“It feels like conversion therapy for gay children”
“For some families it was easier to say, this is a medical problem, ‘here’s my kid, please fix them!’ than dealing with a young gay kid.”
“We had so many families who would talk about not wanting their daughter to be lesbian.”
“A parent was allegedly heard saying they did not want their child to have gay friends because they didn’t want them mixed up in that hedonistic lifestyle.”
“Young lesbians considered at the bottom of the heap suddenly found they were really popular when they said they were trans.”
“A lot of the girls would come in and say ‘I’m not a lesbian. I fell in love with my best girlfriend but then I went online and realised I’m not a lesbian. I’m a boy. Phew!”
Even in the absence of a “conversion therapy” model, these clinicians were concerned that “complex histories and adolescent confusion over possible homosexuality are being ignored in the rush to accept and celebrate every young person’s new transgender identity.” They report “ethical stress” arising from pressure from lobby groups to fast-track transitions, at ever-younger ages, in the absence of supporting data.xx
(v) Social contagion
Data are beginning to emerge about a phenomenon, described as Rapid Onset Gender Dysphoria, wherein teenagers (usually girls) with no previous sign of unhappiness with their bodies, suddenly announce they are transgender. This typically occurs in the context of a peer group where one or more friends have become trans-identified, and it often follows a period of increased social media/internet use.xxi The data is not complete but it suggests that social contagion may play a role in some adolescent cases, and it underscores the need for caution in applying existing research to this new population.
The Times (UK) reported an NHS gender clinician referring to his young patients “enthusing” about trans YouTube stars and similar transition stories in the media:xxii
“These are very simplified stories about how easy it would be to transition…that transition is a solution to feeling shit. This is very appealing to lots of teenagers.”
There is growing awareness of detransitioners (people who “transition” to the opposite sex, but then change their minds and stop treatment and/or undergo additional treatment to revert to their natal sex). It has been reported that “reversal” surgery is increasing. xxiii Despite considerable stigma,xxiv detransitioners have an increasing media presence, xxv including in New Zealand.xxvi
The stakes are high. The potential consequences of an uncritical affirmation of a child’s expressed gender identity are very serious: social transition, puberty blockers, cross-sex hormones (with consequential infertility), and high-risk invasive surgery, with potential loss of sexual functioning.
For the purposes of a recently-aired (March 2019) BBC Panorama documentary,xxvii Professor Carl Heneghan of the Centre for Evidence Based Medicine at Oxford University carried out an independent analysis of the evidence underpinning the treatment of gender dysphoric youth. Professor Henaghan described the quality of the evidence as “terrible,” and as inconsistent with informed consent and safe practice.xxviii Elsewhere, Professor Heneghan is quoted as characterising the treatment as “largely an unregulated live experiment on children.”xxix A more recent Swedish documentary echoes similar concerns.xxx
Until recently, puberty blockers have been touted as safe, “fully reversible” and designed to “buy time” while a child explores their gender identity. It is now recognised that they place the child on a pathway of escalating medical intervention, as virtually all children who start puberty blockers go on to take cross-sex hormones.xxxi There are questions around adverse effects on bone density, height, sex organ development, cognitive development and executive functioning.xxxii In March 2019, Associate Professor Michael Biggs reported that unpublished data from the NHS Tavistock clinic revealed an increase in dysphoric symptoms in patients after 12 months on blockers.xxxiii
We urge you to look beyond the rhetoric and to recognise that “gay conversion therapy” and counselling of gender dysphoric individuals cannot be equated. Ironically the unquestioning affirmation of a child or adolescent’s gender identity may be regarded as itself a form of conversion therapy (“transing the gay away”). Clinicians practising in this complex, rapidly developing and fraught area need to be able to treat their patients as individuals, and to adopt evidence-based, not ideological approaches.
ii We acknowledge that the related Petition, presented by Maria Lubek, does include gender identity treatment, but this Petition attracted only 5143 signatures
iii See for example https://www.rnz.co.nz/national/programmes/thehouse/audio/2018699487/parliament-hears-call-to-ban-conversion-therapy
iv In England, the NHS Tavistock clinic’s referrals rose from 97 in 2009, to 2519 in 2017. Previously a minority, girls now make up 70% of referrals. There is a small study relating to Wellington’s endocrine services (Delahunt et al, 2018) which reflects similar trends. Late last year, the UK government announced an enquiry into the reasons for this startling increase, and the Tavistock clinic has undergone an internal review after clinicians publicly raised concerns.
v James Cantor, “American Academy of Paediatrics policy and trans-kids: Fact checking” 17 October 2018, Sexology Today
vi For example: Halderman “The practice and ethics of sexual orientation conversion therapy” Journal of Consult. Clinical Psychology; 62(2) 221-227
vii James Cantor, “American Academy of Paediatrics policy and trans-kids: Fact checking” 17 October 2018, Sexology Today
x https://en.wikipedia.org/wiki/Gender_dysphoria_in_children ; https://www.docdroid.net/hY664Sc/steensma2013.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841333/ (“Evidence from the 10 available prospective studies from childhood to adolescence…indicates that for ¬80% of children who meet the criteria for GDC[gender dysphoria in childhood], the GD recedes with puberty”). Cantor, “American Academy of Paediatrics policy and trans-kids: Fact checking” 17 October 2018 Sexology Today at http://www.sexologytoday.org/2018/10/american-academy-of-pediatrics-policy.html . For a mainstream media discussion of these issues see https://www.theatlantic.com/magazine/archive/2018/07/when-a-child-says-shes-trans/561749/ . (Critics point out that the higher percentages in some of the older studies are likely inflated by overinclusive definitions of dysphoria).
xi Zucker The myth of persistence: response to ‘A Critical Commentary on Follow Up Studies and ‘Desistance’ Theories about Transgender and Gender Non-Conforming Children’ by Temple Newhook et al (2018) International Journal of Transgenderism
xii Professor Ray Blanchard (The Star, 5 April 2015) https://www.thestar.com/opinion/letters_to_the_editors/2015/04/05/conversion-therapy-billopposed.html
xiii https://www.jaacap.org/article/S0890-8567(17)31682-9/fulltext ; https://www.ncbi.nlm.nih.gov/pubmed/26753812; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4345542/ Data from UK’s Gender Identity Development Service (GIDS) between 2011-2017 reveal that approximately half of children and adolescents referred to GIDS present with features of ASD: https://drive.google.com/file/d/16D2m4dRWCTZWfQ029tFb962JKZhaQGDn/view (those with moderate or severe ASD are approximately 35%)
xxi http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330 (Lisa Littman, Rapid Onset Gender Dysphoria in adolescents and young adults: a study of parental reports (16 August 2016).
“Emerging discussions raise concern for post-pubertally abruptly emerging cross-gender identification (“rapid onset”) particularly among biological girls, suggesting a role for intensive media influences and generous group validation as shaping the understanding of, and giving new meanings to, the body discomfort common among female adolescents at large. The persistence of increasing adolescent onset transgender identification is not known.”
— Gender dysphoria in adolescence: current perspectives
See also discussion of Dr Littman’s study in the Economist.
xxiii https://www.telegraph.co.uk/health-fitness/body/gender-reversal-surgery-rise-arent-talking/ ; https://www.westernjournal.com/doctor-reveals-transgenders-regret/ ;
xxiv https://www.somersetlive.co.uk/news/somerset-news/bath-spa-universityhttps://www.independent.co.uk/life-style/gender-reversal-surgery-demand-rise-assignment-menwomen-trans-a7980416.html-caspian-2557060 xxv See e.g. https://www.piqueresproject.com/
xxvii https://www.bbc.com/news/health-47456938 ; https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-andadolescents-evidence-review/
xxviii The principal problems with the evidence include: small sample sizes, retrospective methods, loss of considerable numbers of patients to follow-up; absence of controls; lack of blinding.
xxxii https://journals.sagepub.com/doi/full/10.1177/1359104518822694 ; https://blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-andadolescents-evidence-review/