“Gender Affirming” Care Is Conversion Therapy

The following is an op-ed submission from Jay T. Allen, a board certified medical doctor currently living in Maine. He retired last year.

On July 26, 2023, Michigan passed a ban on conversion therapy. In doing so, it became the 22^nd state to pass such a ban. Conversion therapy is broadly defined as interventions imposed with the intent of promoting a particular sexual orientation and/or gender identity as a preferred outcome. This term is generally limited to efforts to align sexual orientation and gender identity with heterosexual and “cisgender” norms but in the broader sense it can apply to any efforts to change another person’s sexual orientation or gender identity. Conversion practices are heterogeneous and wide-ranging. They often include unethical techniques such as electric shock, surgical or chemical castration, deprivation of food and liquid, and chemically induced nausea.

A Policy Position Paper from the American College of Physicians states that conversion therapy may pose a threat to the overall health and well-being of an individual, especially children and adolescents. Conversion therapy, when performed on minors, may constitute a form of child abuse; it has been described by experts as torture, cruel, inhumane, or degrading treatment, and contrary to human rights. An AMA Issue brief states that conversion therapy is often administered coercively, using uninformed consent (lacking full descriptions of risks and disclosure of lack of efficacy or evidence), and indiscriminate and improper treatment (change efforts are recommended regardless of evidence). Children and youth are especially vulnerable to involuntary or coercive treatment.

The current practice in gender clinics throughout the United States is “gender affirming care”. It is endorsed by the World Professional Association for Transgender Health and by all the major medical associations within the United States including the American Academy of Pediatrics, the Endocrine Society, and the AMA.

[RELATED: Transgender Youth, Like Any Other American, Deserve the Highest Quality of Care…]

If you take your child to a gender clinic, your child’s gender identity will be “affirmed” as the initial step in “gender affirming care”. If you ask about alternative therapies, you will likely to be told that there are no alternatives. Gender ideologues will argue that delaying “gender transition” is a form of conversion therapy. If you ask specifically about supportive psychotherapy or “watchful waiting” you will be told that it’s a form of conversion therapy (because it delays gender transition) and that it is both harmful and unethical. The AAP guidelines specifically singled out “watchful waiting” as “outdated” and a form of conversion therapy. An article in the Journal of Medical Ethics stated that any treatment that delays gender transition (which would include watchful waiting) is also conversion therapy.

What is most frustrating is that American medical associations, hospitals, and gender clinics are quick to condemn conversion therapy but (because of their embrace of gender ideology) fail to even recognize, let alone condemn, “gender affirming care” as conversion therapy. In the years to come, “gender affirming care” will stand as one of the most egregious examples of harm committed by those who have sworn an oath to “First, do no harm.”

Below I lay out the case for “gender affirming care” as a form of conversion therapy which, like other forms of conversion therapy, should be universally banned. At a minimum, it should be banned for children and adolescents.

Conversion Therapy Promotes a Particular Sexual Orientation or Gender Identity

For 61 to 98 percent of teens and pre-teens with gender dysphoria, their dysphoria will resolve without intervention as they progress through puberty. However, under “gender affirming care”, nearly 100 percent will continue to have gender dysphoria. In “gender affirming care”, the new gender identity is confirmed immediately without question. Social transition, the first step in “gender affirming care”, also includes asking the patient to pick out a new name and new pronouns, and adopting clothing consistent with the chosen gender identity. Gender advocates defend social transition as a benign, fully reversible intervention, however, one author states that, “Although social transition is often described as a neutral intervention with little, if any, long-term consequences, several studies support the hypothesis that it can concretize gender dysphoria.” Dr. Kenneth Zucker also writes that social transition dramatically increases the rate of gender dysphoria persistence and that this persistence “might be characterized as iatrogenic”.

In other words, “gender affirming care” changes the developmental trajectory of 61 to 98 percent of treated patients, causing an iatrogenic increase in rate of persistence of gender dysphoria, and subsequently progression along the transition pathway. This is consistent with conversion therapy.

Conversion therapy has been described as torture, cruel, inhuman, and contrary to human rights.

“Gender affirming care” is cruel. The message of “gender affirming care” to children and adolescents is that the only way to relieve their stress is for the patient to take puberty blockers and wrong sex hormones and to physically mutilate their body. This is cruel especially since the “use of pharmacological and surgical interventions in the treatment of gender dysphoric youth…is mistaken both clinically and ethically.”

“Gender affirming care” is inhumane. “Gender affirming care” takes someone who is physically healthy and turns them into lifelong patients who will require daily medication and periodic surgeries. They also develop chronic health problems including chronic pain, decreased bone density, recurrent infections, depression, anxiety, persistently high risk of post-transition suicide, and infertility (among others).

“Gender affirming surgery” for females is contrary to human rights. “Gender affirming surgery” is one of the most severe forms of female genital mutilation. The practice of female genital mutilation (FGM) is recognized internationally as a violation of the human rights of girls and women. This practice is outlawed in the United States and most other countries. And yet, female genital mutilation in the name of “transgender care”, is not only legal, but also highly encouraged by Federal Officials (including within the department of Health and Human Services) and by all major American medical associations.

Conversion therapy is often administered coercively The mantra of “gender affirming” professionals and clinics, is the phrase “Would you rather have a dead daughter or a living son?” or “Would you rather have a dead son or a living daughter?” These “affirm or suicide” statements are not supported by the evidence. This mantra is, by its very nature, coercive. Dr. Erica Li, a pediatrician in Washington state, has called this “emotional blackmail [of the parents].” The top expert on pediatric gender medicine in Finland has called this purposeful disinformation and has said that spreading it is irresponsible.

Another tactic used by gender activists within the medical field and by Child Protective Services is the threat of removing the child from the home, sometimes with tragic consequences. In some jurisdictions there is also the threat of parents being arrested for speaking out against gender ideology or fighting the gender transition of their child.

In summary, “gender affirming care” relies heavily on coercion, including emotional blackmail, threat of removal of children from the home, and threat of arrest. Based on the above, “gender affirming care” is consistent with conversion therapy.

Children and youth are especially vulnerable.

“Gender ideology” is being pushed at all levels of education from Drag Queen Story Hours for preschool children to the halls of our most prestigious colleges and universities. School employees, including teachers, social workers, and administrators have all been trained in “gender affirming care”. It’s not unusual for schools to encourage and enable social transition and keep this information from parents. Children as young as elementary school age are being encouraged to choose new names and fake pronouns. Educational materials such as the “genderbread person” and the “gender unicorn” are designed specifically for young children and distributed in schools. State laws and school district policies encourage such activities. States, including Maine, have defeated bills that would have reaffirmed a parent’s rights to direct the healthcare of their child.

Of note: social transition is a form of psychosocial treatment. It should be initiated and monitored by an appropriately licensed health care professional. Schools are not the appropriate place for this sort of medical intervention.

There is ample evidence that gender activists who support “gender affirming care” are reaching down into the schools to recruit and indoctrinate children into transgender ideology. Because “gender affirming care” targets children and youth, it is consistent with conversion therapy.

Conversion therapy often relies on uninformed consent.

Informed consent includes an accurate disclosure of risks and benefits. However, gender clinics and providers exaggerate the benefits and minimizes the risks of “gender affirming treatment”.

Informed consent includes discussion of alternative treatments but, in gender clinics, “gender affirming care” is presented as the only available treatment. Appropriate alternative treatments are dismissed as “conversion therapy”.

Informed consent occurs when a patient has had a chance to weigh the risks and benefits of all options and then decides the best course of action to pursue based on his or her personal opinion. As pointed out above, “consent” for “gender affirming care” is obtained through coercion.

Since hormones and surgeries are often being performed on minors (despite clinic and hospital assurances that they are not), they require the consent of the minor’s parents. Minors do not have the insight to consent to such life-altering “treatments” and California Courts have ruled that parents have no authority to choose a harmful treatment for their child.

Since “consent” for “gender affirming care” is obtained by giving an inaccurate assessment of risks and benefits, alternative treatments are not mentioned or are dismissed as inappropriate, consent is obtained through coercion, and neither the minor child nor his/her parents have authority to provide consent, consent for “gender affirming care” would be considered uninformed consent. Again, “gender affirming care” is consistent with conversion therapy.

Conversion therapy uses indiscriminate and improper treatment

There are numerous conditions that can cause gender dysphoria including depression, anxiety, PTSD, sexual trauma, social contagion and trying to please a parent. Each of these conditions warrant treatment specifically targeted toward that condition. An extensive evaluation is required to appropriately identify the correct diagnosis or diagnoses so that the appropriate treatment can be provided. Under “gender affirming care”, these conditions are all presumed to be a symptom of gender dysphoria. Rather than gender clinics performing an extensive evaluation, these patients are all automatically diagnosed with gender dysphoria and started on the pathway to transition. In other words, gender dysphoria is diagnosed in all cases and “gender affirming care” is recommended even though it is inappropriate treatment for any of these underlying conditions, including gender dysphoria, itself.

Since “gender affirming care” is used indiscriminately for numerous psychiatric and other conditions, and it is improperly recommended for conditions it does not treat, “gender affirming care” is consistent with conversion therapy.

Conversion therapy lacks scientific credibility and is not evidence-based.

The guidelines published by WPATH, the AAP, and the Endocrine Society are considered the most authoritative guidelines here in the United States. These guidelines are used by other medical societies as a basis for their own recommendations.

All three guidelines are based on weak evidence. Systematic reviews performed in the United Kingdom, Norway, Finland, Sweden, and Florida have all concluded that the evidence used to support “gender affirming care” is either of low or very low quality. Each of these reviews have all concluded that the harms outweigh the benefits.

WPATH’s scientific credibility has been undermined by allowing non-medical and non-scientific trans activists to dictate “scientific policies” and undermine scientific discussions.

The chapters related to adolescent care in the WPATH Standards of Care specifically state that they were unable to perform a systematic review, the highest standard of evidence.

The AAP guidelines, published 5 years ago, are seriously out of date. After four years of resisting calls from member pediatricians to review the data underlying this policy, they have finally announced that they will commission such a study but it will take several years to perform this type of review. Instead of acknowledging the recent systematic reviews, which all concluded that the harms of “gender affirming care” outweigh the benefits and recommending a hiatus of “gender affirming care” until their own systematic review is completed, the AAP reaffirmed “gender affirming care” in the form of the 2018 AAP policy.

The Endocrine Society guidelines are now six years old. By their own assessment, these guidelines are based on low or very low quality evidence. On 05 July 2023, Stephen R. Hammes, M.D., President of the Endocrine Society, published an open letter in which he claimed that evidence supports “gender affirming care”. He reaffirmed support for current policies and practices. Dr Hammes’ claims were refuted in an open letter published by 21 gender specialists in 9 countries. They encouraged the Endocrine Society (and other American medical societies) to stop politicizing transgender care and to align their recommendations with the best available evidence.

“Gender affirming care” lacks scientific credibility and is not based on high quality evidence. As such, it meets the criteria for conversion therapy

Conversion therapy may cause emotional harm.

Transgender activists claim that “gender affirming care” is beneficial for mental health issues and that it is critical for decreasing suicide risk. On the other hand, as noted by Levine and Abbruzzese, “none of the many studies convincingly demonstrated enduring psychological benefits. The longest-term studies, with the strongest methodologies, reported markedly increased morbidity and mortality and a persistently high risk of post-transition suicide among transitioned adults.”

Because “gender affirming care” increases suicidality and overall morbidity and mortality, it is consistent with conversion therapy.

Conversion therapy may cause physical harm

As noted in systematic reviews of the evidence for “gender affirming care”, the harms far outweigh the benefits. The physical harms include urethral compromise, surgical complications, recurrent infections, osteoporosis, cardiovascular disease, infertility, vaginal atrophy, painful intercourse, anovaginal fistulas, necrosis, stenosis, and incontinence.  All-cause mortality is nearly three times higher in transgender patients who have transitioned than in non-transgender patients.

Because “gender affirming care” causes significant harm and very little benefit, it is consistent with conversion therapy.

“Gender Affirming Care” Is Conversion Therapy

Because “gender affirming care” matches many of the features of conversion therapy, it is rightly classified as conversion therapy. Even for those who disagree with this conclusion, there are significant harms, as listed above, which result from “gender affirming care.” These harms are sufficient to warrant limiting “gender affirming care,” especially in the treatment of children and adolescents. It is time for American medical associations and societies to acknowledge these harms, as many of the countries of Europe have already done. It is also time for the American medical community to align itself with current best evidence and stop promoting “gender affirming care” as an appropriate treatment for gender dysphoria, especially in children and adolescents.