August 29, 2023   7 mins

Group belonging is important for human beings. We are tribal mammals and evolution has left some of us as terrified of social exclusion as we are of physical death. But as always, you can have too much of a good thing, and when social cohesion becomes restrictive, when the rules of belonging to a society become rigid, then many despair they can ever fit in.

War tends to increase social cohesion, leaving those statistically at the edge, exposed. And in the aftermath of World War Two , discrimination against gay people reached its zenith. “Homosexuals” were thought too different to be tolerated: they were criminalised and given a psychiatric diagnosis and “treatment”. Considered relatively benign, the so-called “conversion therapy” was deemed a way for troubled people to avoid worse fates and social rejection. Some gay men and women requested the “therapies”, presumably with the hope of passing through life more easily and being socially affirmed as “acceptable”.

Today, conversion therapy is at the heart of another war, as the Government attempts to ban it. Again it involves a marginalised cohort, who despair of fitting in. But this time, “conversion therapy”, which was always ill-defined, has taken on several different meanings.

The term is used to describe a range of medical and psychotherapeutic interventions, early versions of which were offered to gay men and women on the NHS during the Fifties — although these were focused on aversion more than conversion. Pavlovian attempts were made to disrupt any association between (same-sex) sexual stimuli and sexual responses, with electric shocks or medically induced vomiting. Later therapists attempted to actively re-orientate people’s sexuality towards heterosexual stimuli. Methods also included religious counselling, talking therapies, and finally, for some gay men, hormonal treatments.

These attempts to either avert homosexuality or convert lesbian, gay and bisexual (LGB) people to heterosexuality didn’t work — and even killed people. Alan Turing committed suicide two years after opting for “chemical castration”, rather than imprisonment.  Eventually, though, society started to shift. In 1967, homosexuality was decriminalised in England. In 1973, the term was removed from the 2nd version of the Diagnostic Statistical Manual (DSM-II), a handbook used by healthcare professionals to guide the diagnosis of mental disorders. Outside of LGBT communities, the concept of conversion therapy may have comfortably drifted out of consciousness for a while.

The collective amnesia did not last long. In 2011, The Guardian reported that some religious therapists were still trying to convert gay men. This forced therapy organisations in the UK to confront their history, and in 2015 the first Memorandum of Understanding (MOU) on Conversion Therapy was signed by 16 organisations. All agreed that it was unethical for a therapist to try to change someone’s sexual orientation via any means. Two years later, a second memorandum — the MOU2 — was announced. This one had expanded the concept of conversion therapy to include any “therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other”. The inclusion of “gender identity” is significant.

Gender identity is the term used to describe the profound internal sense that some people have of their maleness, or femaleness, or neither. Gender non-conformity didn’t escape diagnosis for long; when the updated DSM-III was introduced in 1980, the concept of “gender identity disorder”, previously absent, slipped into the gap left by homosexuality.

In July 2018, the day before the MOU2 was officially launched in parliament, the government presented the results of its National LGBT Survey. The online survey of more than 108,000 self-selected respondents stated that, overall, 5% of respondents had been offered conversion therapy, and 2% had taken it up. This rose to 9% and 4% of transgender respondents.

The idea that conversion therapy could still happen in modern Britain is abhorrent to most. And this is why there has been a move to ban it in parliament.. Yet feelings and facts matter. The LGBT survey did “not provide a definition of conversion therapy”. As such, the survey measures whether people perceived something to have been conversion therapy. Furthermore, for those who did feel they had been offered it, only 19% said that it was via a healthcare provider or medical professional. No one knows how many of these were in the NHS.

It is easy to think we understand what we are talking about when it comes to conversion therapy when maybe we don’t. And given the controversy over Government’s decision to include trans people in criminalisation of the practice, it’s vitally important that we do.

In 2018, no one claimed to be receiving electric shock treatments, or medically induced nausea. These interventions are of course already and rightfully illegal. So what is it exactly that people are experiencing? In the NHS, the only conversion therapy treatments that are still offered — albeit not with the aim of “converting” homosexuals — are talking therapies and hormonal interventions.

Let’s address talking therapy first. There is no doubt that some “therapists” will have actively tried to alter their patients’ gender and sex-related thoughts, feelings and/or identities. We have troubling anecdotal evidence that this has happened to some trans-identified people in modern Britain. Whether this is happening away from religious settings — in the NHS or mainstream clinical or psychological practice — is harder to ascertain, but it is possible. After all, potentially damaging interactions between mental health professionals and trans- or gender-questioning people aren’t a new phenomenon.

Treatments attempting to convert gay and lesbian people to heterosexuality were just as unethical and also failed. But they gave rise to an affirmative practice which has taken hold today and which includes medicalisation. “Gay Affirming Therapy” was developed in the early Eighties as a reparative response. This approach wasn’t intended to be a whole-scale model of care, but a therapeutic position wherein the clinician demonstrated warmth and acceptance of a client’s non-heterosexual identity to counterbalance negative messages from society.

It is this affirmative position which has been adopted, and adapted, by clinicians working with transgender adults and gender-incongruent children. But the term “affirmative care” has changed. It has morphed to include, the offer at least, of “medical affirmation” — or hormonal intervention. Medical gender affirmation aims to help reduce an individual’s suffering by trying to better align their physical body with their felt gender identity. The World Health Organization defines it thus: “Gender-affirmative health care can include any single or combination of a number of social, psychological, behavioural or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual’s gender identity.” Note here how the idea of hormonal interventions has been turned on its head, previously offered as a “conversion therapy” for gay men.

Despite the fact that there is no consensus or good quality evidence to demonstrate that — on balance, on average and over time — these novel gender-affirming medical interventions do reduce suffering, and despite the evidence that they will certainly harm some, many people report that for them, personally, they have felt “life-saving”. These evocative first-person narratives have led some to argue that access to gender-affirming medical interventions should be a human right. From this vantage, anything other than immediate affirmation can be considered equivalent to conversion therapy. As a result, psychotherapy, which might explore different ways of understanding ourselves and in doing so may delay medical intervention, is now understood by some as inherently harmful.

This leaves us in a position whereby offering a medical intervention to someone who identifies as LGB is very clearly understood to be conversion therapy, while not offering the (sometimes same) treatment to someone who identifies as transgender is also understood, by some, to be conversion therapy. Meanwhile, offering psychotherapy that aims to reduce distress by increasing self-acceptance without the need for change is seen as the right approach for LGB people but, sometimes, the wrong one for transgender people.

To complicate things even further, the population of people understood to be transgender has broadened. “Trans” has become an “umbrella term” under which a broad range of experiences are collated. As well as those who identify as the opposite sex, the category now includes gender-questioning people, gender non-conforming people and the gender fluid, among others — depending on who is defining it. The term non-binary, used to describe people who identify as neither male nor female, entered the clinical literature less than a decade ago, but is already being medically treated in the NHS.

We must also note that the demographics of those who identify as trans have also changed significantly over the recent years. No one yet knows why. These changes are particularly striking in younger people, with the number of adolescents and young adults questioning their gender and sexuality has increased exponentially in recent years in particular among young women.

On top of this, sometimes the same individuals move between identity categories — from LGB to T or T to LGB for example — increasing the risk that a treatment felt to be right, lifesaving even, the first time can be experienced as devastatingly wrong for the same person the second time. One person’s affirmation therapy might be another person’s conversion therapy — but no one can agree on which is which.

History doesn’t repeat but it often rhymes. And the NHS is once again trying to reduce the suffering experienced by some gender non-conforming people. Once again, it is offering a range of treatments that don’t — yet — have sufficient evidence to allow us to guarantee any outcome. Once again, people seeking to pass through their lives with more comfort are requesting treatments. And once again, the profound uncertainty about what will work for whom leads to inevitable medical risk-taking. If a patient can’t always predict how they will feel about something in the future, then a doctor or therapist certainly can’t.

No one can envy Dr Hilary Cass, the paediatrician charged with delivering an independent review of the NHS’s gender identity services and find a way forward, for children and adolescents at least. She finds herself on a battlefield where people are fighting over how to define key clinical terms, not least the concept of conversion therapy itself. Yet a quick search of her interim report makes it clear that Cass isn’t too worried. The word “conversion” doesn’t feature once. Instead, without taking medical treatments completely off the table, she calls for the NHS to increase access to psychotherapy. According to Cass, then, gently supporting people to explore identities in therapy is not akin to conversion therapy as most people understand that term.

As we turn our minds to the future, we must keep one eye on the past. Wars, cultural or otherwise, aren’t good for anyone, particularly minority groups. No ethical clinician wants to repeat history and inadvertently hurt the very people they are trying to help. We must focus now on developing therapies that will be acceptable to and appropriate for everyone who might seek them, minimising the risk of current or future harm. To do this we must accept that when it comes to issues of sex and gender, uncertainty and cultural change are the only things we can predict.

Dr Anna Hutchinson is a clinical psychologist who specialises in adolescent mental health, gender and physical health. She works in the NHS and private practice.