Failing to address its history has left trans healthcare in a global crisis
Transgender healthcare and social policy is undergoing a period right now of conflict between on the one hand, an alliance of fringe practitioners and shock journalism and on the other hand, the global expert consensus, which is strikingly similar to the MMR scandal. A great deal of this can be attributed to long running failures to take a cold, hard look at the harms done by historic practices and the way current practices rest on that scientific history. Until this is addressed, profit driven froth will be stirred up in the press against the existing scientific evidence and expert consensus.
I use the phrase "MMR Scandal" not to endorse it, but to jog people’s memories about a time when anxious parents were encouraged by unscrupulous people including a handful of quack practitioners trying to make a quick buck to think there was a scandal when there wasn’t and in a number of cases attempt radical (sometimes lethal) curative action causing harm to children afflicted with dangerously guilt ridden parents.
In the case of transgender healthcare, part of the problem is that extremely pseudoscientific elements of the psychiatric profession who used to be associated with sexuality and gender identity conversion therapy in the 20th century never had a proper reckoning, disestablishment of their ideology nor a serious autopsy of some of the issues with their worst ideas. This would have been difficult to undertake, given the field has been a very small one. It is perhaps understandable that with a small number of practitioners dominating over decades of its history, understandably competition for rigorous mutual scrutiny was low. The size and experimental nature of the field also implies serious challenges in terms of researchers’ willingness to properly go over (and explicitly falsify) their own historic beliefs.
That’s not to say that the field did not evolve and change. Initially many trans people were treated as psychotic, or otherwise insane, and attempts were made to deter trans people from being trans. A pattern emerged of deterrence first, and then supporting transition as the last possible resort. Over time often practitioners softened their deterrent approaches, as these were shown to be ineffective. Lobotomies were dismissed, then electroconvulsive therapy and electroaversive therapies were rejected. Behavioural conditioning was rejected. Occasionally a trans person would be successfully “cured” of their gender identity woes, but this was rate enough that a single successful patient was enough for researchers to report the result (only for their method to fail to be replicated).
Researchers as early as the 1950s (possibly earlier) were explicitly reporting that psychotherapy was not effective, but every new generation of psychotherapists gave it a try anyway.
In the 1980s to 1990s Lothstein developed a group therapy technique and Nicolosi was developing “reparative therapy" techniques which saw being gay or trans as a result of psychic injury which could be identified and repaired. However by that time homosexuality was officially depathologised and most (but by no means all) therapists understood it was wrong to attempt conversion therapy for lesbian and gay ppl.
The largely behavioural therapy driven sexual orientation and gender identity conversion effort (SOGICE) techniques developed previously continued to be deployed however against trans people who were not yet depathologised. It should be noted that there is a continuum also with the behavioural techniques deployed by therapists against autistic people to “break down" the person and rebuild them. So called ABA therapy to make autistic ppl mask their autism is still practiced in British special schools (including a chain of schools run by a prominent evangelical lawyer associated with ex-Trans cases in the UK).
Very rarely was it recognised that these techniques, being rooted in the ideology of changing the individual’s personality to meet desired norms, are fundamentally abusive even when they take the form of long term talking therapies. However, in the early 2010s a consensus started to appear for trans healthcare that psychotherapy to "cure" trans ppl was harmful and implicated in patient suicidality. In fact growing bodies of research on survivors of all kind of conversion therapy show the high rates of suicidality which have long been thought to just be an expected comorbidity in the trans community.
Psychiatry and psychotherapy has been able to maintain a longer hold on trans people than on lesbian gay and bi because we are dependent on clinical alliances with psy professions to access endocrinological and surgical referrals as well as medical insurance where applicable. As such trans people have been wary of premature depathologisation potentially risking losing medical support altogether. In combination with the lack of a serious reckoning with the historic evolution of psych medicine wrt LGBT people generally and a root cause analysis of how these devastating errors of clinical judgement were made for decades, this has meant the stain still lingers in the field and a minority of practitioners are still clinging on to the reins of control rather than focusing on facilitating healthcare.
One of my Trans Safety Network colleagues wrote this piece. It touches on the published clinical practice of a man who is editor still of Archives of Sexual Behaviour, who invented and practiced a framework of using behavioural therapy to bully gender non conforming youth into confirming to stereotypes based on their sex. Through the 90s and 00s he was a big supporter of giving an academic platform to members of conversion therapy orgs like NARTH. His work and theories are still championed by so called "gender critical" campaign groups, and he is still widely cited by others in the field, despite having been fired (around the time that anti conversion therapy laws came in in the jurisdiction where his practice was). Trans activists have long been blamed for “smearing" him, while the field itself fails to take necessary steps to take a clear united public stance against the specific instances of real world SOGICE in recent years as exemplified in his work. I invite anyone concerned I am engaged in hyperbole to read the source material linked in the Trans Safety Network piece above before passing judgement.
I attended a conference last Saturday, run by psychotherapists skeptical of transition as a valid solution for trans children and young adults. Kenneth Zucker, the man who pioneered the modern protocol for behavioural therapy against gender non conforming young people was in attendance, and one of the conference speakers, celebrity psychotherapist Stella O’Malley, dismissed conversion therapy as a relic that only happened in the “1950s and 1960s” when questioned by a therapist in the audience. The British media gave her a slot to run an hour long documentary on trans issues not long ago. Our institutions are failing to address the historic failings of a duty of care towards trans people.
