December 7, 2021

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 — something which is often, unhelpfully, called “three-parent babies”. In reality, mitochondrial donation simply means taking the healthy mitochondria from another woman’s 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 “eugenics”. But was it? The word “eugenics” can be used to refer to things like mitochondrial donation, insofar as it means something like “efforts to remove ‘harmful’ genes from the gene pool”. 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 “eugenics” to refer to both was, I think, a semi-deliberate tactic. Opponents of mitochondrial donation were trying to associate those evil things in people’s minds with the more complex cases. That doesn’t mean that mitochondrial donation is automatically right. But the fact that a loose definition of the word “eugenics” 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 Government’s proposed legislation to ban conversion therapy. 

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 I’ve written before, there’s not much evidence that you can change someone’s 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.

“Conversion therapy” 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 Government’s legislation, though, refers not just to efforts to change a person’s sexual orientation, but also to efforts to change their gender identity. And I’m concerned that, just as with the word “eugenics”, using the term “conversion therapy” 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 — 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, people’s 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.

That’s not true of gender identity. While there clearly are many people who don’t identify as their biological sex, exactly what is meant by a “gender identity” is unclear. The Human Rights Campaign defines it as “one’s innermost concept of self as male, female, a blend of both or neither”. How one feels is important, but it is subjective — and unlike sexual attraction it’s not tied to obvious behaviours, such as choice of sexual partner.

It’s also not clear that it’s 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, that’s not true of everyone. According to several medical textbooks, perhaps as many as 85% to 90% of prepubescent children who are diagnosed with gender dysphoria — that is, severe discomfort in their birth sex — no longer do by adolescence, although they do say that if those children are still dysphoric in early puberty, it is “almost certainly permanent”.

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 they’re 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 “really” trans or not.

That’s why we should be concerned about the use of “conversion therapy” 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 don’t think it’s very common.

The Government’s own research refers to two main kinds of conversion therapy: spiritual, “pray the gay away” versions, and “psychological methods” 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 community’s religious beliefs.

There is much less research into how common gender identify conversion therapy is. But the Government’s assessment does say that “a much higher percentage of transgender respondents (29%) than cisgender respondents (15%) said their therapy had been conducted by healthcare professionals”.

That would make sense, if some therapists are assessing that some patients are mistaken about their transgender status, and offering them alternative routes — for instance, watching and waiting, or treating some mental health condition that they have — 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 it’s important to listen to patients, that doesn’t mean always assuming that they’re right in their self-diagnosis. 

The Government’s proposed legislation does make room for therapists to “support a person who is questioning if they are LGBT”. But as one GP says, “lots of my patients are not questioning; they are very assertive that they are trans”. Sometimes simply affirming a patient’s, especially a child’s, 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 patients’ gender identity in every case. But some therapists are clearly concerned: the GP quoted above goes on to say that “The way this is worded at the moment, I could end up in prison.” Surely it will not come to that, but it would be deeply concerning if there was a chilling effect on medical professionals’ willingness to talk about gender to their patients.

Like the term “eugenics”, the term “conversion therapy” 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 “because we use the same term to describe them as we used to describe Nazi atrocities”. 

Of course, there may sometimes be excellent reasons to affirm children’s 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 “conversion therapy”. Something has gone wrong if doctors are worried about going to prison for discussing the best treatment for their patients.