TOLEDO, Ohio — When the city of Toledo approved a ban on “conversion therapy” this month, the law explicitly prohibited treatment designed to help patients align their gender identity with their biological sex.
“[N]o mental health provider shall engage in sexual orientation or gender-identity change efforts with any person,” read the law, which states that it would be a misdemeanor of the fourth degree for a therapist to provide such treatment, with a fine of $250 imposed on the perpetrator.
Media reports on the ban presented “conversion therapy,” also known as reparative therapy, as a widely discredited practice, though the actual treatment was unspecified.
“I think the science is clear that conversion therapy is harmful to individuals,” said Councilwoman Theresa Gabriel in a statement before the ban was approved.
Bans on “conversion therapy” — a term that until recently primarily described attempts to reverse unwanted same-sex attraction — are not new. California, New Jersey, Oregon, Illinois, Vermont and New York have barred or penalized the practice through legislative or regulatory action, as has Washington, D.C., and a handful of U.S. cities.
Opponents of reparative therapy claim the practice has harmed patients, who suffer from higher levels of depression and suicidal feelings. Its defenders say practitioners adhere to professional protocols and many people have benefited.
Now, “transgender-rights” activists are adopting similar claims of the therapy’s harm as they seek to ban therapies designed to help patients realign their gender identity with their biological sex. Their arguments have received relatively little public scrutiny, though the medical debate on treating gender dysphoria, formerly known as “gender-identity disorder”— an intense experience of conflict between one’s biological sex and the gender with which one identifies — in the young is far from resolved.
“Currently there is a vigorous, albeit suppressed, debate among physicians, therapists and academics regarding what is fast becoming the new treatment standard for [gender dysphoria] in children,” read a statement on gender dysphoria issued by American College of Pediatricians in August 2016.
“This new paradigm is rooted in the assumption that GD is innate,” the statement continued, noting protocols for medical intervention that suppresses puberty and then introduces cross-sex hormones that match the preferred gender identity.
Specialists on one side of this debate also support what clinicians call the “affirmative” treatment model, which encourages boys identifying as girls and girls identifying as boys to adopt the pronouns, clothing and school bathrooms that correspond with their gender identity. This model is designed to support, rather than discourage, the patient’s identification with the opposite sex.
In contrast, other clinicians note that most young people will outgrow this condition, and so they recommend either a neutral response to the patient’s identification with the opposite sex or a more explicitly corrective approach designed to help the patient embrace the gender expression that aligns with their biological sex.
Dr. Paul Hruz, a pediatric endocrinologist at Washington University School of Medicine in St. Louis, challenges the claim that science supports a ban on corrective or neutral responses to this condition. Likewise, he questioned whether research endorses an “affirmative model,” which has led to guidelines that direct students to use the bathroom that corresponds with their gender identity.
“The vast majority of children with gender dysphoria will realign their gender identity to match their sex,” Hruz told the Register.
“The transgender identity will persist in a small percentage, 5%-20%, and usually the dividing line is adolescence,” he added.
He noted that those who identify as their opposite sex after their teenage years are less likely to change. He also emphasized that specialists still cannot predict “who will continue in that transgender identity and who will not.”
Given these established facts about the small percentage of young people diagnosed with gender dysphoria — about 0.05% of the population — Hruz worried that the “affirming model” could lead more young people to retain their identification with the opposite sex into adulthood and may play a role in the reported increase in adolescents receiving puberty blockers and cross-sex hormone therapy, often in preparation for “sex reassignment” surgery that alters their bodies to appear more like the sex with which they identify.
Hruz is equally concerned about the long-term impact of puberty suppressants, which are introduced around age 12, and cross-sex hormones, introduced after age 14.
The Endocrine Society supports these medical interventions for children diagnosed with gender dysphoria. But the guidelines published by the professional society acknowledge that they are based on low-quality scientific evidence, and in many areas solely on expert opinion and not scientific studies, Hruz said.
“Puberty suppression — the first stage during which endocrinologists are asked to intervene — is presented as ‘safe and reversible,’” he said. “But there is no scientific evidence to support the view that this is safe.”
“You are disrupting the normal process of physical and psychological development that takes place during this period, and that could have serious long-term consequences,” Hruz stated.
The American College of Pediatricians’ statement raised similar concerns. Treatment protocols that combine puberty suppressants and cross-sex hormones result “in the sterility of minors,” the professional group stated, while disputing the scientific basis for arguments that present gender-identity disorder as “innate,” and thus fixed.
At one time, more medical specialists expressed similar reservations about the value of an affirmative model linked to medical intervention because the condition was understood to be fluid for most patients, who ultimately aligned their gender with their sex. But over the past decade, influential clinicians, like Dr. Norman Spack, the now-retired head of the gender-management program at Boston Children’s Hospital, have established new guidelines for treatment.
In a 2015 interview posted on the website of Boston Children’s Hospital, Spack acknowledged that his methods remained controversial, given the fact that gender dysphoria is resolved over time in most patients.
“There are still those who feel that because 60% to 80% of kids who act in a cross-gender way aren’t in fact transgender, we shouldn’t be encouraging this. This is one of the big debates,” said Spack.
“And why do you believe we should be encouraging transgender people to seek treatment?” he was asked.
“Forty-five percent of transgender 16- to 25-year-olds who don’t have any support attempt suicide,” he said.
He added that suicidal thoughts can persist in some children who begin treatment, but that changes when medical interventions begin.
“The minute these kids even know they’re going to get the puberty suppressants, their suicidal thoughts melt away,” he said.
Further, Spack questioned guidelines that restrict procedures, like the surgical removal of female breasts, to late adolescence.
“All you have to do is see a girl in a binder with clips all the way from her armpits to her hips,” he said. “Why should I make her wait until she’s 18 when I can relieve her suffering at 14?”
However, while Spack defended surgical intervention as a valuable treatment option for patients who contemplate suicide, some studies report a higher than average rate of suicide attempts in this demographic even after surgery has taken place.
“The scientific evidence summarized suggests we take a skeptical view toward the claim that sex-reassignment procedures provide the hoped-for benefits or resolve the underlying issues that contribute to elevated mental-health risks among the transgender population,” stated “Sexuality and Gender,” a summary of the findings of almost 200 peer-reviewed studies on gender identity and related topics.
Released in August 2016, the report was written by Dr. Lawrence Mayer, scholar in residence in the Department of Psychiatry at Johns Hopkins University and professor of statistics and biostatistics at Arizona State University, and Dr. Paul McHugh, professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine who served for 25 years as psychiatrist in chief at Johns Hopkins Hospital.
The authors expressed grave concern about the high rate of suicide associated with individuals who identified as “transgender,” but they also said the science did not support recourse to medical intervention and surgery, and more research was needed.
In the years before bans on reparative therapy emerged as a mainstream political issue, gender-management programs like the one established at Boston Children’s Hospital drew little scrutiny outside of the medical profession and the small number of parents struggling to help children who were profoundly uncomfortable with their bodies.
Now, such clinicians may find themselves under attack if they seek to cure, rather than affirm, patients dealing with gender dysphoria.
The story of Kenneth Zucker, a leading Canadian researcher and clinician who adopted a nuanced two-step approach for treating children with gender dysphoria, is instructive.
For decades, Zucker operated without much public controversy as he encouraged his patients to realign their gender with their biological sex and only approved medical interventions when the initial therapy proved unsuccessful.
“Just because kids are saying something doesn’t necessarily mean you accept it, or that it’s true, or that it could be in the best interests of the child,” said Zucker, explaining his approach in a BBC documentary, Transgender Kids: Who Knows Best?
Then, a few years ago, Zucker began to face mounting criticism from “LGBT” activists. And in late 2015, he was fired from his post.
“For more than 30 years Dr. Kenneth Zucker ran Canada’s biggest child gender clinic and was considered a recognized authority on childhood gender dysphoria, until he lost his job,” read a statement released by the BBC, defending the film. “He believes he was fired for challenging the gender affirmative approach.”
Hershel Russell, a critic of Zucker’s methods, argues in the documentary that people who identify as “transgender” don’t need psychiatric evaluations. “It’s not about mental health, so why does it belong in a mental-health institution?” he asked.
Activists launched a petition campaign to prevent the airing of the BBC documentary. That effort failed, but it marked their strong desire to control the debate over treatment options and force skeptics in the medical community to fall in line.
The perplexing refusal to tolerate therapies designed to foster an alignment between gender identity and sex has already made it tough for psychologists, doctors and families who want to help patients resolve problems that are associated with serious mental-health problems.
“If a family is dealing with this issue, they should seek guidance from a trustworthy source,” said John Di Camillo, a staff ethicist at the Philadelphia-based National Catholic Bioethics Center.
Di Camillo said that it was important to establish whether a child actually suffered from gender dysphoria, as opposed to a bodily condition arising from a disorder of sexual development where the anatomical sex is ambiguous.”
Common symptoms of gender dysphoria include a marked incongruity between gender expression and biological sex that lasts six months or longer, and such conditions are accompanied by “some kind of experience of detrimental or harmful social impacts,” he said.
The child or adolescent “can’t function well because of the anxiety that comes from the perception of being in the wrong body.”
In such cases, professional help is recommended. Therapy in accord with Catholic anthropology will help these persons “learn to understand and accept their actual bodily sex and see their body as good,” Di Camillo noted, and it will likely foster a process of gender clarification that allows the patients to accept their bodies and be at peace.
But Di Camillo warned that most specialists will adopt a treatment model that affirms the patient's gender identity and is not designed to realign their gender with their biological sex.
“We have lost sight of the deeper underlying sense of who the human person is, and that is causing us to focus on short-term happiness or satisfaction, as opposed to an authentic fulfillment and a genuine florishing of that human person,” he said, and suggested that concerned parents obtain a referral for a trustworthy therapist from their Catholic school or church.
As he turned from issues in clinical practice to the public-policy debate, Di Camillo predicted that the campaign to extend antidiscrimination protections to gender identity will increasingly shape the response of the medical community and insurance carriers.
Already, Catholic hospitals have faced mounting pressure to accommodate the new protocols designed to help teenagers transition to their preferred sexual identity.
Meanwhile, the furious reaction of activists to the nuanced methods of experts like Kenneth Zucker highlights the political stakes for the “LGBT” movement, which increasingly opposes any suggestion that gender may not be a fixed condition. That resistance deserves more scrutiny from policymakers than it has received, say critics who argue that gender ideology, not science, is behind this trend.
“For decades, gay activists have claimed that people who have same-sex attraction are born that way,” said Katherine Kersten, a policy fellow at the Minneapolis-based Center of the American Experiment, who published an article on gender ideology in the February issue of First Things.
“The claim of an inborn trait is their link [to similar claims of discrimination based on] race and sex. It allows activists to bring their claims under the civil-rights rubric.”
“They are hostile to anything that suggests that might not be the case,” said Kersten, noting the angry pushback against patients who resolved their condition with therapy.
Indeed, as the debate over the therapeutic response to gender dysphoria becomes more toxic, specialists like Hruz fear that much-needed research to evaluate the outcomes of various treatment models, including alternative approaches that help the patients accept their bodies, will never be approved.
“The controlled studies that are needed, but likely will never be done,” said Hruz, “can include efforts to support and affirm the inherent dignity of people with gender dysphoria while acknowledging biological reality.”