An LGBT parade in Krakow (Beata Zawrzel/NurPhoto via Getty Images)

A few years ago, there was a huge row about eugenics, abortion and disability. In 2015, the UK became the first country to vote to legalise mitochondrial donation â something which is often, unhelpfully, called âthree-parent babiesâ. In reality, mitochondrial donation simply means taking the healthy mitochondria from another womanâs eggs, and using them to replace faulty ones which could otherwise have disastrous effects: it can cause everything from learning disabilities to early death.
There was backlash from religious groups, calling the move âeugenicsâ. But was it? The word âeugenicsâ can be used to refer to things like mitochondrial donation, insofar as it means something like âefforts to remove âharmfulâ genes from the gene poolâ. But the classic example of eugenics are things like the Nazi programme of forced sterilisation; a programme that did awful things to people against their will.
Using the term âeugenicsâ to refer to both was, I think, a semi-deliberate tactic. Opponents of mitochondrial donation were trying to associate those evil things in peopleâs minds with the more complex cases. That doesnât mean that mitochondrial donation is automatically right. But the fact that a loose definition of the word âeugenicsâ can be used to apply to both it and Nazi murders does not make it necessarily wrong.
A similar sort of tactic appears to being deployed in the ongoing debate over the Governmentâs proposed legislation to ban conversion therapy.Â
It was not that many years ago that homosexuality was viewed as a mental illness requiring curing: the Diagnostic and Statistical Manual of Mental Disorders (DSM) listed same-sex attraction as a psychiatric disorder until 1973. And as Iâve written before, thereâs not much evidence that you can change someoneâs sexual orientation, while the methods used to do it have often been brutal: zapping people with electric shocks while showing them homoerotic images; chemical castration; even lobotomy, as recently as 1969.
âConversion therapyâ is, therefore, rightly held up as something unacceptable: the classic example of conversion therapy is a gay man or lesbian woman being forced, against his or her will, to submit to something approaching torture, in an almost certainly unsuccessful attempt to change his or her sexual orientation.
The Governmentâs legislation, though, refers not just to efforts to change a personâs sexual orientation, but also to efforts to change their gender identity. And Iâm concerned that, just as with the word âeugenicsâ, using the term âconversion therapyâ like this stretches it to beyond the point of usefulness.
Of course if someone is trans, they should not be told that they are not â or told that they are inferior, or defective. But sexual orientation is a fairly stable and well-defined concept: we know what is meant by being sexually attracted to one sex or another or both, and, on the whole, peopleâs sexual orientation remains the same throughout their adult lives. Importantly, also, if someone does change their sexual orientation, all they need to do is start dating people of the appropriate sex.
Thatâs not true of gender identity. While there clearly are many people who donât identify as their biological sex, exactly what is meant by a âgender identityâ is unclear. The Human Rights Campaign defines it as âoneâs innermost concept of self as male, female, a blend of both or neitherâ. How one feels is important, but it is subjective â and unlike sexual attraction itâs not tied to obvious behaviours, such as choice of sexual partner.
Itâs also not clear that itâs stable. While some young people are clear from a very young age that they do not identify as the sex they were born in, and remain so until adulthood, thatâs not true of everyone. According to several medical textbooks, perhaps as many as 85% to 90%Â of prepubescent children who are diagnosed with gender dysphoria â that is, severe discomfort in their birth sex â no longer do by adolescence, although they do say that if those children are still dysphoric in early puberty, it is âalmost certainly permanentâ.
And, crucially, the decision about whether a young person is trans or not can be much more consequential and irreversible than the decision about whether theyâre gay or not. Full transitioning may involve hormones, drugs to delay puberty, and surgery.
All of which may be absolutely necessary and right; there are plenty of examples of young people who transitioned and became much happier and healthier. But the combination of an unstable concept and a major, consequential life decision means that we need to be careful about deciding whether someone, especially a young person, is âreallyâ trans or not.
Thatâs why we should be concerned about the use of âconversion therapyâ as an umbrella term. Of course, if there are therapists telling trans people that being trans is shameful or sinful, or that it is a defect that needs to be purged, then that is wrong, and those people should be punished. But I donât think itâs very common.
The Governmentâs own research refers to two main kinds of conversion therapy: spiritual, âpray the gay awayâ versions, and âpsychological methodsâ such as talking therapies. About 5% of lesbian, gay and bisexual people in the UK have been offered conversion therapy, mainly of the spiritual kind, usually because their sexual orientation conflicts with their communityâs religious beliefs.
There is much less research into how common gender identify conversion therapy is. But the Governmentâs assessment does say that âa much higher percentage of transgender respondents (29%) than cisgender respondents (15%) said their therapy had been conducted by healthcare professionalsâ.
That would make sense, if some therapists are assessing that some patients are mistaken about their transgender status, and offering them alternative routes â for instance, watching and waiting, or treating some mental health condition that they have â and patients are unhappy at the lack of affirmation of their condition. And often such assessments are reasonable: gender dysphoria is often found alongside other conditions, such as autism. There are also other conditions, such as borderline personality disorder or dissociative identity disorder, which can lead to patients having unstable senses of self. While itâs important to listen to patients, that doesnât mean always assuming that theyâre right in their self-diagnosis.Â
The Governmentâs proposed legislation does make room for therapists to âsupport a person who is questioning if they are LGBTâ. But as one GP says, âlots of my patients are not questioning; they are very assertive that they are transâ. Sometimes simply affirming a patientâs, especially a childâs, beliefs about his or her identity, is not the right thing to do.
Perhaps the safeguards in the proposed law will protect doctors and therapists who want to be more cautious about affirming patientsâ gender identity in every case. But some therapists are clearly concerned: the GP quoted above goes on to say that âThe way this is worded at the moment, I could end up in prison.â Surely it will not come to that, but it would be deeply concerning if there was a chilling effect on medical professionalsâ willingness to talk about gender to their patients.
Like the term âeugenicsâ, the term âconversion therapyâ is powerful: it summons up images of torture, of homophobia, of religious and institutional abuse. And just as with eugenics, that power needs to be directed carefully. The arguments should never be âbecause we use the same term to describe them as we used to describe Nazi atrocitiesâ.Â
Of course, there may sometimes be excellent reasons to affirm childrenâs gender identities, rather than challenge them. I suspect it may be best to let clinicians use their best judgment, in some cases. But we should be careful about using the term âconversion therapyâ. Something has gone wrong if doctors are worried about going to prison for discussing the best treatment for their patients.
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