This essay was originally posted on the Kelsey Coalition website on March 9, 2020.
Coercive practices associated with sexual orientation and gender identity change efforts that use shame, punishment, or other abusive strategies should be banned. Luckily, these interventions have long-been frowned upon in the psychological community. However, government officials may be unaware of a different type of conversion that will take place if conversion therapy bans extend to cover any investigation of gender identity, especially in children.
As a Licensed Professional Counselor, I provide individualized psychotherapy with gender-questioning teens and consult with parents whose children began experiencing gender dysphoria around the age of puberty. My clinical cases indicate that banning the thoughtful exploration of gender identity can prevent clinicians from properly assessing patients and from developing holistic treatments. I offer this personal testimony to explain how current conversion therapy bans prevent vulnerable patients from receiving appropriate psychological care.
During adolescence, identity is in flux and children explore different ways of being and relating to the world. This developmental process should be respected as
a fluid and dynamic. I have met many young people who explore gender as they navigate their teen years. Rather than being a “discovery” with a fixed outcome, cross-gender identity can be one way for a young person to understand the existential conflicts that emerge around puberty and young adulthood, such as independence, romance, sexuality, responsibility, and social belonging.
For example, many of my female clients began noticing their romantic attractions towards other girls in the pre-teen years. Despite having open-minded attitudes towards homosexuality, they felt confused and ambivalent about their emergent sexuality. In these cases, searching online for explanations of their same-sex attraction lead them consider if they may have a “male gender identity.” Though this had never occurred to them before, this suggestion became a powerful explanation for why they were feeling romantically attracted to girls, why they didn’t conform to stereotypes of feminine behavior, or why they felt uncomfortable with their developing bodies. Many also experienced homophobic bullying at school or online, and came to resent their same-sex attractions and nonconformity. These clients began obsessively researching gender transition online, coming to believe it would resolve their distress. In the course of therapy, we held this gender exploration in a non-judgmental way, remaining curious about sexuality, normalizing same-sex attraction, thereby affirming their sexual orientation. When greater self-acceptance was achieved, these clients no longer felt a cross-sex identity was authentic, and these girls came to understand themselves as bisexual or lesbian. Distress and body-hatred that accompanied attempts to be seen as boys (what they called “gender dysphoria”), also resolved once they came to accept their sexual orientation.
If conversion therapy bans include gender identity, therapy will either affirm same-sex attraction or it will affirm gender identity. We can’t simultaneously affirm both, since biological sex is the basis of sexual orientation. A therapist would feel obliged to agree emphatically with a client’s gender self-concept. In the above examples, had therapy prioritized gender affirmation, these young women might now be in the process of making unnecessary and irreversible medical changes to their healthy bodies in an attempt to become boys.
In the last few decades the number of adolescent females, like the ones I described, presenting at gender clinics has increased a few thousand percent. Prior to the 2010s, most children with gender dysphoria were males (M:F ratio approx 6:1), but now girls in gender clinics far outnumber boys. According to research by Dr. Littman at Brown University, these girls presented no indication of gender dysphoria as children. Around puberty, these girls (and some boys) declare a transgender identity after a close friend or peer has also come out as trans – this type of adolescent-onset gender dysphoria has been descriptively termed, Rapid Onset Gender Dysphoria (ROGD).
I can corroborate these findings anecdotally. After consulting with approximately 400 families and working directly with several dozen teens in my practice, it seems that the concept of transition comes before the development of gender dysphoria. This crucial distinction represents another way that this booming population of trans-identifying youth is clinically different from previous populations (gender dysphoria historically developed before the patient discovers the concept of transition). We clearly need more research on what treatments would most benefit these distressed youth. We do know, however, that most ROGD teens were struggling with social isolation, eating disorders, depression, anxiety, autism, or other mental health issues before they discovered transition and subsequently became gender dysphoric. This begs an important chicken-egg question, which a clinician could never ask under a gender identity conversion therapy ban.
As clinicians, when we encounter such distress in our patients, it’s imperative that we take a thoughtful approach to requests for identity change, hormones, or surgery in teenagers. No greater evidence for this need to be cautious exists than in the stories of detransitioning people themselves. Detransitioners are individuals who identified as transgender, began medical transition, and then came to see themselves, once again, as their natal birth sex. Most decide to cease medical transition, though many of the physical changes are irreversible.
I’ve met many such individuals and they often feel deeply harmed by the “affirmative therapy” they received. Affirmative therapy for gender identity refuses to consider if past trauma, eating disorders, family conflicts, autism spectrum disorder, depression, or anxiety may be contributing to a young person’s gender struggles. It’s a true disservice to the integrity of psychological therapy if clinicians blindly support cross-sex hormones, breast removal, hysterectomy or SRS for severely distressed patients. Banning any effort to investigate gender identity is a one-size-fits-all mandate on therapists that will harm vulnerable patients and prevent them from receiving appropriate psychological care.
Sasha Ayad, M.Ed., Licensed Professional Counselor
Exponential rise in children presenting at gender clinics and identifying as transgender
Rapid Onset Gender Dysphoria
Sexual Orientation Identity Development
The Big Problem with Outlawing Conversion Therapies (interview with “Jess”)