Is gender-affirming healthcare "gay conversion therapy?"

There is a lot of discourse about "conversion therapy" floating around. To what extent does research actually support the claim that gender-affirming healthcare could be a form of conversion therapy?

A few months ago we published a commentary paper in Healthcare Papers titled: “Affirming everyone in the rainbow: Is gender-affirming healthcare “gay conversion therapy?" This article was part of a broader set of papers in a series called “Advancing 2S/LGBTQ+ health equity: A call for structural action.”

Co-authored by Kinnon, Pablo, and others, we took some key data to explore the idea that gender-affirming healthcare is “gay conversion therapy.”

This is a serious claim. Given the history of the way psychiatry and the medical system has mistreated 2SLGBTQ+ populations, we felt it was important to put this rhetoric under empirical scrutiny.

All good sociology of medicine applies a healthy dose of skepticism toward the medical/psychiatric system and how it intersects with society. This paper is in that vein.

So, when opponents of gender-affirming healthcare talk about “transing the gay away,” do available data support this?

Short answer: mostly not.

But keep reading and we will provide a more nuanced perspective on gender and sexuality at the intersection of trans medicine.

We will also share the full commentary text (and references) below, since it’s behind a paywall.

Someone at Gender Crossroads already wrote a critique of it, so hopefully we can address some of those questions and their points as well. Feel free to share more thoughts in the comments section!

To help digest what comes next, our principal arguments levelled against the argument that gender-affirming healthcare is a form of “gay conversion therapy” include:

• Questioning the premise that sexual orientation is always innate and immutable and that sexual orientation identity should take precedence over gender identity as a person’s “true” or “authentic” self;

• Presenting research that challenges the notion that childhood gender nonconformity is an absolute predictor of adult gay/homosexual identity, and showing that both gender identity and sexual orientation can be fluid over the life course;

• Highlighting research indicating that trans and nonbinary people express a range of sexual orientations, largely bisexual and queer, which is not the sexual orientation we would find according to “trans away the gay” (i.e., trans people would be largely straight/heterosexual by this logic);

• Re-affirming how gender-affirming healthcare ought to be practiced, emphasizing a curious, neutral approach that allows free expression and exploration of sexuality and gender identity (we admit that this care is not always practiced in ideal circumstances that follows this approach, though).

We also acknowledge that more research is needed to understand gender identity development over time to improve current models of care.

Before presenting the article, we’d like to respond to the author of Gender Crossroads, who offered some critique.

The author offers two main retorts to our commentary. The first is that we’ve overlooked the fact that medical transition carries significant medical/health risks, so a better outcome, ethically, would be for young people to integrate their gender incongruence into a (presumably) gay identity.

The second point they raise is in response to our argument about the number of trans people who report sexual minority identities (L, G, B, or Q) post-transition. They wonder whether transness could function as a way of escaping heteronormativity and rigid societal gender norms, or even as a kind of Mecca for those who feel socially alienated.

With regards to the first point: we agree that medical transition carries known and unknown health risks. It is important for anyone considering hormonal or surgical treatments to understand these risks and trade-offs. However, where we diverge is with assuming that all (or even most) people pursuing medical transition are struggling with accepting their sexual orientation, or accepting themselves as gay/lesbian.

(That said, we do know some people for whom this realization was indeed part of their detransition process, so we agree this is an experience to better understand, especially from a research perspective).

On the second point, we have come across similar thinking from trans scholars such as Miquel Missé. Let’s briefly take a look at his latest book, co-authored by anthropologist Noemi Parra (only available in Spanish at the moment).

Missé and Parra argue that, in the current zeitgeist that encourages resisting traditional gendered relations (e.g., binary models of masculinity/femininity) and sexuality norms (e.g., heteronormativity), and in the absence of other possibilities for resisting these social power relations, some young people feel disoriented. As a result, they may seek out identities that signal their allegiance with social critiques of gender/sexuality. In essence, Missé and Parra argue that trans identities have become a place for young people to address social distress caused by rigid norms around gender or sexuality and that trans culture offers a place of exploration.

We find this perspective valuable in offering a socio-cultural explanation of the increase in the number of young people embracing trans and nonbinary identities in the last 5-10 years.

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Now, here’s the the article. Let us know what you think below!

Abstract

Many young people today embrace gender-diverse identities, with adolescents and young adults comprising the largest and fastest growing demographic of gender-affirming healthcare seekers. Simultaneously, gender-affirming healthcare for this demographic has been hotly debated and restrictions have been introduced on this care in many jurisdictions. Within this politically-charged climate, some journalists, cultural commentators, gender clinicians and politicians have leveraged rhetorical claims that gender-affirming healthcare comprises a new form of “gay conversion therapy.” In this commentary, we explore the extent to which empirical evidence supports or contradicts this discourse as a real phenomenon. While we conclude that gender-affirming healthcare is not gay conversion therapy, we also draw attention to opportunities to enrich gender-affirming healthcare by embracing the complexity and diversity of sexuality and gender.

Introduction

In “Beyond the Rainbow: Advancing 2S/LGBTQ+ Health Equity at a Time of Political Volatility,” Kia et al. (2024) provide a comprehensive summary of relevant literature on the social well-being, health and healthcare access of two-spirit, lesbian, gay, bisexual, transgender, queer and other sexual and gender minorities (2SLGBTQ+). The authors specifically draw attention to the growing anti-2SLGBTQ+ rhetoric and gender-affirming medical care restrictions in several geopolitical jurisdictions – this context has emerged in Canada (MacKinnon and Expósito-Campos 2024), the US, England and Europe (Brierley et al. 2024). The spate of government-imposed restrictions has sparked criticism from 2SLGBTQ+ communities as well as significant politicized discourse on the subject. In response, we examine the assertion that gender-affirming healthcare could reflect a new form of ‘gay conversion therapy’ as this idea has been repeatedly bolstered by politicians, clinicians, journalists and cultural commentators who are skeptical about pediatric gender-affirming care (Barnes 2023; Sapir and Figliolia 2023; Zivo 2023).

These ideologically charged debates offer an opportunity to reflect on sexuality and gender diversity at the intersection of care for 2SLGBTQ+ populations while challenging cisheternormativity – the dominant worldview that privileges cisgender and heterosexual alignment between sex, gender and sexual orientation.

Gender-affirming care encompasses a range of social, psychological, behavioural and medical interventions designed to support and affirm an individual’s gender identity (Coleman et al. 2022), although some mistakenly understand the term to apply to only hormonal/surgical treatments used for medical transition. Recognizing Kia et al.’s (2024) acknowledgement of adapting gender-affirming care for young people versus older adults, we focus on adolescents and young adults because they comprise the largest and fastest-growing demographic of care seekers (McKechnie et al. 2023; Zhang et al. 2021).

We also reflect on the words of Sadjadi (2020), who wrote in response to political volatility surrounding gender-affirming medical care:

[W]e need to preserve the space necessary for research, analysis, and debate over these issues, while adamantly holding open spaces in which young trans and gender-variant life is valued and can unfold along multiple pathways … . Justice for transgender children does not equal unexamined acceptance of all pharmaceutical offerings, just as it does not equal banning all care (p. 513).

Initially developed with adult transgender and gender-diverse (TGD) people, gender-affirming healthcare is predicated upon cisheteronormativity and transnormativity (Riggs et al. 2019).

Transnormativity [translation: transmedicalism] refers to dominant ideas and care practices that normalize biomedical, binary notions of being TGD, such as being born in the wrong body (Riggs et al. 2019).

Historically, clinicians were likelier to approve hormones and surgeries for TGD people who they determined would be able to pass convincingly as cisgender and blend into society without disrupting cisheternormative western ideas about gender and sexuality (Shuster 2021).

This came at a high cost to TGD people of earlier generations. It was only in 2014 that the Netherlands struck down a state policy requiring surgery and sterilization to legally change sex (Knight 2020). Gender-affirming healthcare historically followed a paternalistic approach whereby clinicians conducted eligibility assessments to discriminate between candidates they thought would truly benefit from medical interventions from those for whom the risks of medical intervention could outweigh any benefits (Steensma and Cohen-Kettenis 2018, p. 228).

These assessments included consideration of sexual orientation (Shuster 2021), with same-sex-oriented people predicted to have lower risk of surgical regret (Blanchard et al. 1989). Thus, the field of gender medicine itself emerged out of cisheteronormative ideology.

[Meaning: the history of this field has long been shaped by homophobia, heteronormativity, and medicine’s role in normalizing “deviant” sexual/gender minority people - aiming to blend them into dominant society.]

“Trans away the gay”

On the 50th anniversary of delisting homosexuality from the American Psychiatric Association’s list of mental illnesses, Eappen (2023) wrote an article in the Wall Street Journal titled “Most ‘Transgender’ Kids Turn Out to Be Gay,” wherein he opined that “the medical establishment is pushing a new kind of conversion therapy under the guise of transgender identity … rendering teenagers sterile and sexually dysfunctional for life.”

Others have claimed that gender-affirming healthcare is a way to “trans away the gay” (Perry 2023).

Similar calls have been promulgated by skeptics of gender-affirming medical care for minors in both left-leaning (Adu 2023) and right-leaning media outlets, including in Canada’s National Post (Zivo 2023). This position has also been voiced by some adolescent gender care clinicians (Barnes 2023) and politicians alike (Perry 2023) – many of whom are gay or lesbian and who could be broadly described as ideologically “gender critical.”¹

This idea is also central to right-wing commentary surrounding an American lawsuit brought by a former gender-affirming healthcare patient who transitioned medically as a young adult, later detransitioned and now identifies as a gay man (see Sapir and Figliolia 2023).

Below, we examine what is known about sexual orientation and gender identity development across the life course to understand the extent to which empirical data support or contradict trans away the gay as a real phenomenon.

As a rhetorical device, trans away the gay rests on several primary and secondary assumptions about the nature of sexual and gender diversity that are empirically inaccurate. The first assumption is that sexual orientation is innate, immutable and monosexual (e.g., only heterosexual or homosexual), suggesting, in essence, that gays or lesbians are always born this way.

This idea minimizes plurisexual orientations such as bisexuality and those who experience shifts in sexual attraction over time or people who only realize a sexual minority identity after decades of heterosexuality – phenomena already well-documented (Diamond and Rosky 2016; Katz-Wise and Todd 2022). Relatedly, it gives primacy to sexual orientation over gender identity, suggesting that sexuality must be an individual’s ‘true’ or ‘authentic’ self that gender transition risks distorting.

The idea that gay/lesbian children are being transed also presumes that they are all typically gender nonconforming from childhood to the extent that they develop gender dysphoria or an otherwise significant incongruence with their birth-assigned sex/gender that leads to the desire to transition. This rhetoric neglects gay, lesbian and queer people who were never gender nonconforming while casting childhood gender variance as an absolute predictor of adult sexual orientation when some of these children grow up to be heterosexual (Marino et al. 2023).

Does childhood gender nonconformity predict queer [L,G,B] sexuality or transgender identity?

We present three components of the empirical evidence for the assertion that gender-affirming healthcare acts as a form of gay conversion therapy.

First, per longitudinal studies relying on both gender clinic and community samples, a large majority of children who are gender nonconforming in behaviour and/or who meet diagnostic criteria for gender dysphoria grow up to be gay, lesbian, bisexual or queer adults (Marino et al. 2023; Ristori and Steensma 2016).

Moreover, it has been observed that butch lesbians and transgender men recall similar childhood developmental histories (Lee 2001), with the implication being that it might be difficult for parents or care providers to know which gender-nonconforming birth-assigned female children will grow up to affirm a butch identity or a transmasculine male gender identity.

This is not to discount individuals who could hold, at the same time, transmasculine and lesbian/queer identities but to acknowledge multiple trajectories of gender variance.

Second, there is some indication that homophobic bullying can affect gender identity development in children. DeLay et al. (2018) found that – even after controlling for social factors and the quality of relationships within adolescent peer networks – homophobic name calling was associated with a subsequent change in gender identity.

And third, exploratory studies on detransitioning indicate that some people, over time, shift from affirming a TGD identity to a sexual minority identity following a gender transition (i.e., moving from a TGD identity to a cisgender gay, lesbian or queer identity after gender-affirming interventions) (MacKinnon et al. 2023; Vandenbussche 2021).

Conversely, there is also empirical research that counters the argument that gender-affirming healthcare is gay conversion therapy. For example, a majority of TGD adults do not report a heterosexual/straight identity following gender transition. This, of course, is the identity one would expect to see represented among individuals suffering from homophobia who seek medical interventions to fit into a heteronormative society.

Instead, a majority report sexual minority identities (Bauer et al. 2013).

One national probability study of sexual orientation among 274 TGD American adults found that 82% were sexual minorities and, of those, 19% reported a bisexual identity (Reisner et al. 2023). Moreover, some adult TGD people also report changes in sexual attraction or sexual identity following hormonal treatments – for instance, moving from a lesbian woman identity and being attracted to birth-assigned females to, after gender transition, affirming a gay transgender male identity and being oriented toward birth-assigned males (Rowniak and Chesla 2013).

That said, these data do not necessarily apply to children (see de Rooy Frédérique et al. 2023).

[This is one context where, if never provided an opportunity to explore one’s sexual orientation through puberty, and the possibility for homosexuality is discouraged by clinicians, then the argument may apply. Longitudinal follow-up studies of trans adults who began the process as children do find a greater proportional of heterosexual identities, when compared to trans people who transitioned at older ages. See below for further details.]

Taken together, ‘trans away the gay’ as a broad, universal cultural phenomenon is unconvincing.

It is important to stress that ‘trans away the gay’ may be part of an ongoing discursive project to construct an inaccurate picture of how gender-affirming medical care is typically practised with young people.

In our view, to be considered for gay conversion therapy, contemporary gender-affirming clinicians would need to practise gender-affirmation in such a way that clinically discourages a gay or lesbian identity/behavioural outcome specifically among individuals who have adopted a TGD identity as a psychological response to homophobia/heteronormativity.

Indeed, some detransitioned lesbian and gay individuals – in hindsight – feel that they pursued gender-affirming medical interventions in response to a broader culture of cisheternormativity (MacKinnon et al. 2023), in turn undergoing a form of identity conversion (Paul 2024).

[However, it may be that this type of reflection will always be done in hindsight. Which makes the argument around conversion therapy dubious. In cases where someone transitioned with a trans identity, and later rejects it for a gay/lesbian identity - what is the border between trans and gay? Internalized homophobia versus internalized transphobia? Self-identity? We do not have the answers to these questions.]

This is why gender-affirming practitioners working with young people are encouraged to adopt a neutral, curious clinical position and facilitate gender identity exploration without a preference for a TGD or cisgender outcome, per the World Professional Association of Transgender Health Standards of Care Version 8 (WPATH-SOC-8)(Coleman et al. 2022). This entails a thoughtful exploration of young people’s age-specific understandings of identity development and acknowledgement of the possibility of a future identity shift occurring.

Motivated opponents of gender-affirming healthcare, though, could raise some questions:

(1) What about children who have not yet reached puberty or had the opportunity to discover their sexual orientation due to their age and developmental stage?

(2) To what extent could heteronormative/homophobic social environments discourage youth from ever exploring same-sex/gender sexual or romantic attraction at a developmentally typical age, before initiating a gender transition (particularly a transnormative one)?

In such cases, ethical considerations arise given sexual and reproductive health issues that come with blocking puberty with gonadotropin-releasing hormone agonists (Sadjadi 2020). These are questions that are best answered by taking a developmental understanding of both gender and sexual identity, recognizing that for some people, identities can evolve over time.

Resisting cisheteronormative and transnormative social environments that suppress or discourage gender nonconformity and sexual orientation/gender identity (SOGI) exploration is fundamental to promoting 2SLGBTQ+ affirmation and equitable care.

How can gender-affirming healthcare providers recognize and affirm identity fluidity?

More young people today are embracing TGD identities, which could be explained by socio-cultural changes such as broader acceptance of sexual orientation/gender identity diversity, an embodied strategy for resisting cisheteronormativity and/or expected identity exploration in adolescence (Missé and Parra 2023).

Similar to sexual orientation identity, for some young people, gender identity and expression could shift over time. According to recent Canadian census data, 7.3% of nonbinary people defined their gender as “fluid” (Statistics Canada 2022). Gender identity fluidity is also reported by many TGD adolescents who were surveyed longitudinally, with 20–40% reporting shifts between binary transgender and nonbinary identities or to cisgender (Real et al. 2023; Katz-Wise et al. 2023).

However, identity fluctuations after gender-affirming hormonal care are estimated to occur less frequently – about 5.3–9.8% of adolescents and young adults detransition (Boyd et al. 2021; Butler et al. 2022).

Reasons for detransitioning are complex, not always due to sexuality or gender identity fluidity and often comprise a combination of social, psychological and medical factors (Expósito-Campos et al. 2023).

On their own, support for sexuality and gender identity exploration is positive and conversion efforts, as Kia et al. (2024) point out, are associated with isolation, anxiety, depression and suicidality (Goodyear et al. 2021; Salway et al. 2020). However, if shifts in identity occur following irreversible gender-affirming medical interventions, there is a chance that people will experience the physical outcomes of treatment as no longer affirming or even distressing, and many of these individuals are 2SLGBTQ+ (MacKinnon et al. 2023).

Providers should acknowledge that identity fluidity can and does occur and integrate this knowledge into an affirming model of care.

Gender-affirming care, when practised according to the standards outlined by the WPATH-SOC-8, is not gay conversion therapy. Rather, this healthcare is demonstrated to benefit a majority of TGD people (Mahfouda et al. 2019).

This care could be enriched by acknowledging the full breadth of SOGI diversity, recognizing that gender-variant young people’s trajectories may unfold in complex ways, and by resisting cisheteronormative and socio-political efforts to restrict 2SLGBTQ+ lives.

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