British mental healthcare responses to adult homosexuality and gender non-conforming children at the turn of the twenty-first century

Abstract

The roots of the recent controversy about how mental health professionals should respond to gender non-conforming children are traced. To make historical sense, this paper distinguishes between epistemological (discursive) and ontological (non-discursive) aspects and describes their features, since 1970. This helps to clarify some of the confusions at the centre of the still heated debate about sexuality and gender identity today. In the concluding discussion, the philosophical resource of critical realism is used to interpret the historical narrative provided. It cautions against the anachronistic tendency to amalgamate the short-lived, and now defunct, experiment of aversion therapy for homosexuality with more recent defences of exploratory psychotherapy. The latter have challenged a different form of experimentation: the bio-medicalisation of gender non-conforming children.

Introduction

In 2022 a recommendation to close the Gender Identity Development Service (GIDS) of the Tavistock Clinic in London was made in the wake of criticisms of its functioning. These came in part from a report commissioned by NHS England (NHSE) to examine the care of gender non-conforming children. ¹ The report was organised and chaired by Hilary Cass, a consultant paediatrician and clinical advisor to Health Education England. Her report and the closure of GIDS created much journalistic interest and it re-animated disputes about the appropriate way to respond to gender non-conforming children, which had been apparent in health policy since 1990.

At the centre of this contention, two considerations predominated. First, should the experimental service philosophy developed in the Netherlands – enabling children to remain pre-pubescent – have been used as a legitimatising blueprint for the specialist service set up at the Tavistock Clinic, London, in 1989? This point was salient, given that the GIDS managers had failed to keep systematic records of clinical outcomes, and to follow up patients after discharge.

Second, was a more cautious form of care, entailing a ‘wait-and-see’ exploratory therapeutic approach, preferable (or not) to the affirmative care triggered in the UK, by what has come to be called colloquially the ‘Dutch model’? In the past decade, this has entailed the regular referral of child patients to endocrinology services for ‘puberty blockers’. The affirmative approach to care, favoured by transgender activists and their allies, often starts a process of bio-medicalisation that is elaborated after childhood, with the use of cross-sex hormones and a range of surgeries, in order to align male bodies with a female form (or vice versa).

Historically this was commonly known as a ‘sex change’ in relation to adult patients, called ‘transsexuals’, whereas today the term ‘gender reassignment’ is the terminological replacement. Transsexuals are now included in a much wider set of psycho-social ‘transgender’ phenomena. That variation includes transgender individuals who simply ask for social tolerance, with no medical involvement at all, right through to full and ongoing bio-medicalisation. The expressed needs of transgender individuals vary widely across that spectrum.

The two factions of thought about how to respond to gender non-conforming children have divided opinion among mental health workers, with some embracing affirmative care and others defending cautious exploration, with some variations in between (Hilário, 2019). The academic community has also been divided along lines of supporting one or other group of clinicians, and similarly with the parents of the children in focus (Pilgrim, 2022).

The history of the contention

Although periodisation is always arbitrary (because it reflects an epistemic judgement about where to punctuate history), it can have a heuristic value to clarify what happened when. Clarification is particularly relevant, when very strong ideological positions are adopted about controversial mental health practices. These include the ‘great and desperate cures’, which have focused on intervening bio-medically, when aspiring to create social conformity and/or reduce distress in patients (Valenstein, 1986). (The title of Valenstein’s book is adopted from John Bunyan’s cynicism about medical arrogance in 1668.) With these thoughts in mind, this paper now offers a guide, decade by decade, since the 1960s.

Aversion therapy c. 1970

By the end of the 1960s, legislative changes in the UK, including the passing of the Sexual Offences Act in 1967, had ensured that homosexual activity was no longer illegal for men over the age of 21; lesbianism had not been illegal at all. Despite this formal legal change, much cultural prejudice was evident and enacted in daily life. Cultural acceptance did not automatically follow de-criminalisation. (The age of consent for male homosexuality was not lowered in Great Britain until 2000, when it was made the same as that for heterosexuality.)

Prior to legalisation, there had been some biomedical interventions to suppress homosexual desire. The best-known case in Britain was the prescription of a synthetic oestrogen to the mathematician and computer scientist Alan Turing, rendering him impotent. The legal concern then was to suppress his homosexual conduct, after he was prosecuted for gross indecency in 1952. The bio-medicalisation was a choice forced upon him to avoid imprisonment. There was no particular concern to re-orientate his sexuality, only to block conduct that was legally prohibited and morally condemned by many, with or without governmental power. Two years later Turing committed suicide.

After the legal changes, and 10 years after Turing’s death, British mental health workers began to argue that it might be possible to change same-sex desire to opposite-sex desire, using conditioning techniques for cooperative voluntary patients. This was more ambitious, because whereas hormones can reduce libido in men, they have no impact on the cognitive and conative aspects of sexual interest or orientation. Aversion therapy offered that more expansive prospect. Moreover, it might now be offered paternalistically, rather than under legal duress, with behaviour therapy being depicted as a ‘progressive’ mode of intervention.

However, an early sign of cultural opposition to aversion therapy for homosexuality was the symposium organised by the London Medical Group on 2 November 1972, at St Thomas’s Hospital. It was attended by Peter Tatchell, who was to become a leading light in Gay Liberation in Britain. He challenged the speakers, Hans Eysenck and Isaac Marks, about the use of aversion therapy. For his disruptive efforts he was expelled from the meeting. The speakers emphasised the voluntary nature of the treatment and that it was for the patient’s own good.

In 1960, in his general overview of behaviour therapy, Eysenck had drawn attention to an early interest in aversion therapy for homosexuality from the Czech psychiatrist Kurt Freund, who had used chemical nausea as a means of aversion, without therapeutic success (Eysenck, 1960). The persistence of the use of nausea induction by nurses under medical instruction in some mental health services into the 1970s is reported by Dickinson (2015) in retrospective personal accounts.

This ‘classical aversion therapy’ was based on Pavlovian conditioning, whereas that offered by those using electric shocks offered personal control to research subjects. It was a form of anticipatory instrumental conditioning, relying on what the patients did, not just what was imposed upon them, as in the earlier classical version. The anticipatory avoidance version was the focus of a spate of publications of experiments on homosexual volunteers between 1968 and 1974. Most of the subjects were homosexual men but a small number of lesbians were also involved (Carr and Spandler, 2019).

Isaac Marks had already published a defence of aversion therapy for homosexuality (Bancroft and Marks, 1968), arguing, by way of introduction, that talking therapies had reported some success at sexual reorientation, but this was both slow and hit-and-miss. These new methodological behaviourists were more confident about the use of anticipatory aversion, using intermittent electric shocks, which quite quickly displaced homosexual desire with heterosexual desire. However, note Kurt Freund’s earlier failure to produce sexual reorientation in the mid-1950s, using classical aversion and chemical means; this did not auger well for a variation on a theme from behaviour therapists.

Apart from the work of the metropolitan doyens of behaviour therapy in the late 1960s, two others were researching the same approach: the clinical psychologist Maurice (‘Phil’) Feldman in Birmingham and the psychiatrist Malcolm MacCulloch in Manchester. The target overwhelmingly was that of adult male homosexuality (Feldman and MacCulloch, 1967, 1971; MacCulloch, Birtles and Feldman, 1971). However, a wider interest in ‘sexual deviation’ (by the American John Bancroft) invited in other research cases, including exhibitionists, fetishists, transvestites, transsexuals and lesbians (Bancroft, 1969).

Behaviour therapists simply accepted social norms as defining criteria for warranted treatment: social adjustments to those normative expectations were a prospective way of ameliorating the angst and guilt of the homosexual patient. This was the research interest of Feldman and MacCulloch, to be discussed again below. The term ‘sexual deviance’ (favoured by Bancroft) reflected the positivism of these methodological behaviourists, when operationalising clinical need by the transgression of current norms. Eysenck’s case for aversion therapy being good for the patient reflected a scenario of some personally anguished homosexual adults, despite decriminalisation, wanting to comply with heteronormativity for family or religious reasons.

Note here the lag between cultural and legal processes. Despite legalisation, some homosexual men were still stigmatised, causing them shame and anxiety; they might also internalise a sense of guilt about their proclivity. This distress under psycho-social pressure, amplified at times by the standard disapproval of same-sex contact from the Abrahamic religious traditions, meant that some homosexuals would volunteer for help from mental health services. Others simply spent their lives in or out of ‘the closet’, without any service contact. The impact of religious ideology on shaping how we understand ‘conversion therapy’ is important and is discussed again below.

By the mid-1970s, two factors became important in the short, and even then controversial, period of clinical interest in aversion therapy for homosexuality in the UK. First, the behaviour therapy research failed empirically to demonstrate sustained therapeutic success, despite some early optimism in the follow-up from Feldman and MacCulloch. As with the case of Turing, this manipulation of the physiological system produced unhappy or impotent research subjects, leaving their same-sex erotic interest unaltered.

Second, Gay Liberation was becoming a radical and effective force, with a pushback that led to homosexuality being dropped from the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association in 1973. By 1980, the behaviour therapists effectively conceded defeat, and aversion therapy disappeared from clinical practice in the UK.

Before leaving this period, other points are relevant to note for emphasis. Although transvestites were a minority clinical group (for Marks and Bancroft), along with the main group of interest, i.e. male homosexuals, they were taking part in research, entailing very small numbers. For example, the research samples were 10 in Bancroft’s study and 43, and in a subsequent study 30, in studies by Feldman and MacCulloch. While there is a small literature of retrospective interview data from professionals and patients, it is simply not clear, from that qualitative research, what the prevalence of aversion therapy for adult homosexuality was in daily NHS mental healthcare in the early 1970s.

As for adult transsexuals (some of Marks and Bancroft’s transvestite group), they were dealt with typically in the clinical services of the 1970s by monitoring psycho-social adjustments, not offering them aversion therapy. Psychiatrists would check on transsexual patients living as members of the opposite sex and then give their blessing (or not) to be referred on to medical colleagues, for cross-sex hormones and surgery. Psychiatrists then were gatekeepers, not therapists, for this clinical group of transsexuals. This was illustrated by the BBC2 documentary A Change of Sex (1979), showing a rather persecutory psychiatric assessor of a ‘drag artist’, who was seeking what is now called ‘gender reassignment’.

This routine of assessment was largely predicated on the work of the endocrinologist and sexologist Harry Benjamin (1966). The clinical rationale was to check that the patient genuinely wanted hormones and surgery, and then to enable that outcome sympathetically. This rationale was systematised in the 1970s in the standards of care suggested by the Harry Benjamin International Gender Dysphoria Association, which became the World Professional Association of Transgender Health in 2007.

We can see that in the 1970s the clinical rationale evolving about transgender patients was different from the aversion therapy rationale applied to homosexuality. Benjamin conceptually separated homosexuality from both transsexualism and eroticised transvestism. The latter was to be later conceptualised as one aspect of variegated transgender phenomena, ‘autogynephilia’ (Blanchard, 1991).

Behaviour therapy, as its name suggested, focused on behaviour, and therapeutic success would be judged by behavioural criteria. This historical marker is important discursively: this was aversion therapy, not ‘conversion therapy’, which is the term now the focus of transgender activism, especially in relation to children. To summarise, this phase from 1970 to 1980 reflected a dominant focus on homosexuality, not gender identity. Its target was research subjects and so it did not reflect routine clinical practice. Moreover, the patients (research or otherwise) were adults, not children.

After 1980

If aversion therapy petered out by the early 1980s for reasons just given, this did not mean that contention about sexualities and gender non-conformity disappeared. Moreover, although transgender people had been on the margins of Gay Liberation in the 1970s, their political profile was to become much more visible in what is now called the LGBTQ+ movement. The 1980s in the sub-culture of the young began to witness a celebration of what at that time was called ‘gender bending’, which had been anticipated earlier by the cultural commentator Susan Sontag (1966: 280): ‘Camp is the triumph of the epicene style (the convertibility of “man” and “woman”, “person” and “thing”). But all style, that is artifice, is ultimately epicene. Life is not stylish. Neither is nature.’

Sontag was vindicating the second-wave feminist position about the materiality of embodied sex (having XX chromosomes and being raised under the socio-economic and cultural expectations of patriarchy). At the same time, second-wave feminism conceded that gender was a psychosocially negotiated subjective state, as well as a form of social performativity. Thus, gender was accepted as being socially constructed but sex was not (Oakley, 1972). One ideological emphasis reflected immutable genotypes, but the other signalled the possibility of manipulating phenotypes by human desire and intervention and of altering performativity. This meant biological men, dressing as women and acting in a feminine manner (or in the case of biological women, vice versa). Those like Germaine Greer were to note that men could dress as women and call themselves ‘she’ (a discursive matter of naming and performativity) but they could not be a woman (a non-discursive matter of biological ontology) (Greer, 1999).

The third-wave feminism of the 1980s privileged the cultural emphasis upon appearance and performativity, i.e. Sontag’s ‘epicene style’ (Butler, 1999). Second-wave feminists (socialist and radical) had promoted a future where gender was to become irrelevant, whereas later feminists were more concerned to prioritise personally experienced gender identity. At times, paradoxically, this actually reinforced traditional gender stereotypes. The latter were reflected in the caricaturing art form, still seen today, of ‘drag artists’ (who poorly resemble typical natal women, seen daily in society), as well as in the phenotypical preferences expressed by patients seeking reassignment surgery.

After 1980, clinically, homosexuality was now virtually absent as a target for intervention in mainstream mental health services. If there was any meaningful connotation of ‘conversion therapy’ (note not aversion therapy) at the time, it resided in socially conservative religious organisations. By contrast, the psychiatric gatekeeping of transsexual adults, of the sort noted above, continued. This raised an ambiguous semantic question, which is still pertinent: What is actually meant by ‘conversion therapy’?

The social and cultural contexts of the 1980s in Western Europe and North America, which enveloped and shaped the priorities of clinical services, had many relevant features that inform an answer to that question, some just noted. Notable changes during the 1980s included the following: a rupture between second- and third-wave feminism; the social constructivist claims about fluidity of identity from postmodern Queer Theorists; the raised campaigning salience of T, not LGB, within expansive identity politics; the decline of the term ‘sex’ and the rise of ‘gender’ in academic discourse; and the shift from ‘women’s studies’ to ‘gender studies’ (Haig, 2004; Henderson, 2019; Hull, 2008; Jeffreys, 1997; New, 2005; Sigush, 1998; Watkins, 2018).

This list of generative mechanisms reflected a re-shaping of the context of the salience of what today is called ‘conversion therapy’. In the 1970s the emphasis was on behavioural consideration of homosexual acts, at a time of legal changes and the successful pushback from Gay Liberation to de-medicalise same-sex attraction, i.e. it should be neither pathologised nor treated. By contrast, in the 1980s, psychological framings of normality and abnormality were now under the sway of postmodernism, triggering other forms of demand in relation to medicine.

With the postmodern turn, all operationalised positivist certainties (from psychiatric nosologies to psychological criteria of ‘unwanted’ or ‘undesirable’ behaviours) were being rejected. As a result, concerns about ‘conversion therapy’ no longer focused either on aversion therapy or predominantly on homosexuality. The discursive shift was now about respecting diverse perspectives and rejecting psychological causal reasoning about psychopathology (whether these were from behaviourist or psychodynamic models of explanation), in favour of assertions of unique personhood. In the case of transgender patients, this focus on choosing subjects was summarised well here by the transgender activist Janet Mock (2014: 15):

Self-definition and self-determination is about the many varied decisions that we make to compose and journey toward ourselves, about the audacity and strength to proclaim, create, and evolve into who we know ourselves to be. It’s okay if your personal definition is in a constant state of flux as you navigate the world.

This summary by Mock of identity emergence and flux pointed gender non-conforming citizens, if they wanted it, to medical services to improve their existential state by biomedical means. This put into reverse the political stance of Gay Liberation, which had pointedly eschewed medicalisation.

In the 1990s, the emerging implications for transgender healthcare of this more recent summary of patient-centredness, rather than older professional paternalism epitomised by the aversion therapists c.1970, were to become clear. Gay Liberation in the 1970s meant de-pathologisation, whereas transgender activism now was more ambivalent, with a demand some of the time for much more medicalisation and, controversially, that was proposed for pre-pubescent children.

The ambivalence is evidenced by the counter-current in the transgender community of some who refuse to be seen in a mental health context at all and who argue for depathologisation (see Cabral, 2017) and the International Network for Trans Depathologisation and its ‘Stop Trans Pathologization’ campaign. ² This has resonances with Gay Liberation in the 1970s and is at odds with transgender activists today who seek hormones and surgeries on demand. These campaigns are ambiguous as they demand that transgender is not seen as a mental disorder, while also at times considering that biomedical interventions are completely legitimate and highly desirable, leaving the role of medical authority intact for one reason but not for another.

The importance of the 1990s and afterwards

For the purposes of this paper, the 1990s were of particular significance with the above epistemological changes after 1980. If gender identity was now a de rigueur consideration, because of the rise of third-wave feminism and Queer Theory, this was to have implications for traditional understandings within developmental psychology.

Children with a homosexual interest were still considered to be problematic, and in 1988 the controversial Section 28 bill was passed by the Conservative government. This banned teachers from ‘promoting’ homosexuality in schools, leading to their anxious silence. Thus, a gay orientation was still deemed to be problematic culturally for children, even though when they reached the age of consent they would have been able to express their sexuality quite legally.

Alongside this problematisation of sexual orientation in childhood, came the wider shift to a focus in identity politics from sexuality to gender identity. This seemingly represented a progressive response to events such as the passing of the Section 28 bill, but it was being shaped by other forces, some of them quite conservative: neoliberalism as an economic regime and the atomised consumerism generated in its wake. That is, policies were driven by a focus on the reported experiences and expressed needs of individual customers. These were soon reflected in the New Public Management approach to state-run organisations, including the NHS in the UK. Patients became customers, and they were to be allotted consumer rights. Their views of services were to become a new defining criterion for quality assurance. Now user involvement was required to mould individual case work and shape service philosophies across healthcare.

Service users were soon to become ‘experts by experience’, an emphasis to be supported in New Social Movements more generally. Their emphasis on human rights and citizenship (‘diversity and inclusion’) was to define social justice afresh. In the past, the latter reflected an aspiration for the reversal of structural inequalities, with social class at its political centre (Benn Michaels, 2006).

Now diversity displaced that focus and spawned a range of social groups claiming an oppressed status. With that normative shift, in a healthcare context patient need was being defined less and less by objective criteria and evidence from epidemiology (showing recurrently that the poor were sick more often and died younger). Instead, it was about what patients said about themselves as individuals. This provided them with an ‘epistemological privilege’, not just to report, quite legitimately, their unique biographical perspective, but also, at its most aspirational, to determine whole service philosophies.

Consumerism was also aligned with the desire to be more patient- or person-centred in healthcare. Whereas the latter had a long history from phenomenology and American humanist psychology, it had now found its time and a healthcare management context of consumerism. The merits of the latter for improved service quality could not be gainsaid. However, this brought about new ethical challenges for clinical professionals. Should they now simply agree with the demands of consumers at all points of contact? What if there was a gap between the expressed need of the patient (what they wanted) and the defined need, assessed in good faith, by the professional?

In the case of children, with their limited cognitive capacity, should listening to them credulously and without challenge outweigh any cautions derived from warranted paternalism (from parents themselves or professionals)? For example, those working with anorexic teenagers would not agree with a child that she or he was overweight, when in fact they were visibly skeletal, but might a different stance be warranted with other clinical groups, such as gender non-conforming children, and, if so, why? This ethical problematic was at the centre of the newly emerging GIDS and its service philosophy (Pilgrim and Entwistle, 2020; Steensma, Wensing-Kruger and Klink, 2017).

GIDS was set up in 1989 at the zenith of postmodern populism in cultural production and academia, especially in social science and the arts and humanities. This shaped the confidence of affirmative therapists at the Tavistock that sex was ‘assigned’, not factually described, at birth. To even question that assumption might be deemed to be inherently ‘transphobic’ in the GIDS staff culture. This presupposition about the term ‘assigned’ rejected the legitimacy of a basic ontological assumption of sexual dimorphism, taken for granted in both biological science and second-wave feminism. The child’s subjective experience of ‘being born in the wrong body’ was now to be ‘affirmed’, which in practice meant ontologically confirmed (Brunskell-Evans and Moore, 2018).

The notion of ‘cis’ from Queer Theory emerged in the mid-1990s, offering a discursive framework, even if it also prompted objections. These gender critics opposed the theory and practice of transgender activists. The epistemic matter of dividing people into transgender or ‘cis’ became reified as a new form of social ontology at odds with biological ontology and rejected by gender critics. It separated those who considered themselves to be male or female, by the traditional visible evidence from their pelvic anatomy, from those who rejected what they saw, in favour of a subjective sense of self. A child could now be born self-evidently, according to their personal account, in the ‘wrong body’, rather than a body he or she did not like or which repelled them. Later they might even become a ‘woman with a penis’ or a ‘trans-lesbian’ or even a ‘man’ that can give birth, prompting tabloid intrigue. These scenarios invoked ideological opposition and objection from gender critics.

The diverse permutations of ‘Queer’ self-presentations were not always easy to comprehend for those who had been socialised, before the hegemony of the postmodern turn. The term ‘cis’ had to be explained to newcomers, who then may or may not have accepted its ontological legitimacy. All these preferred assumptions about identity diversity, from postmodern social science and the new regime of identity politics, alongside the neoliberal encouragement of consumerism, shaped the service philosophy of GIDS.

Across the English Channel, that constellation of features could be technicalised and operationalised. In Amsterdam, the Center of Expertise on Gender Dysphoria began to experiment with the impact of puberty suppression, while affirming the child’s subjective identity. From the outset, no one knew whether this would be effective or what its iatrogenic impact might be. The optimistic assumption was that puberty suppression would be readily reversible and would simply press a ‘pause button’, so that the gender-confused child could consider options about their identity in the future (Biggs, 2022; de Vries and Cohen-Kettenis, 2012). This idea that identity can change fluidly over time is an important legacy of the postmodern turn, but it had some support from older forms of humanism, i.e. becoming who you really are or want to be, and being accepted as such by others.

If the ‘Dutch model’ now guided the Tavistock GIDS philosophy, it was not without its critics. Some emerged from within the service itself. Many therapists left, unhappy with the tramlines set by an affirmative model; 35 psychologists resigned between 2016 and 2019. Their views were reported by a clinician in the Tavistock but not in GIDS (the adult psychiatrist and psychoanalyst David Bell) as a cause for concern. His report to the Board of Governors warned of several negative implications of a narrow affirmative approach to care that displaced exploratory therapy or deemed it to be transphobic. The tensions in the Tavistock were soon reported in the newspapers and on TV news outlets in 2018, and two years later David Bell was threatened with disciplinary action by his employers. However, the threat was not carried out, and Bell shortly afterwards retired from his post.

Apart from the restrictions on therapeutic freedom for clinicians, Bell also raised the problem of poor outcome data, alongside poor or absent knowledge of the short- and long-term iatrogenic risks of affirmative therapy and bio-medicalisaiton in its wake. Moreover, the disaffected therapists leaving were reporting the clinical complexity of their case load. Children being referred included those with a history of trauma and those from dysfunctional family settings. Some homophobic parents preferred to construe their child to have an inherent pathology, rather than accept they were gay. Some had distinct autistic features (Stagg and Vincent, 2019). That complexity alone warranted, for this group of staff, the need to stop and reflect about the wisdom of the ‘Dutch model’ in principle.

Some of these disaffected staff went on to highlight a new medico-legal challenge on the horizon, about clinical iatrogenesis and proper informed consent (e.g. Butler and Hutchinson, 2020). The promise that gender dysphoria would dissipate with bio-medicalisation, and that mental health gain would be assured, might be turning out to be empty for some patients. This scenario was confirmed by follow-up data from adult transsexuals indicating that overall levels of psychopathology remained little changed after gender reassignment (Dhejne et al., 2011).

These reports of concern from within the Tavistock, and the report by Hilary Cass noted in the introduction, were the direct, maybe at some point inevitable, legacy of the GIDS adopting the Dutch model of care. They represented forms of earnest reality testing, after over 20 years of Pollyanna optimism about the service philosophy transferred from Amsterdam to London.

Elsewhere in the world, the controversy about affirmation versus cautious exploration had produced its career casualties. The one with the highest profile was the dismissal of clinical psychologist Ken Zucker from his role as manager of the Toronto gender identity service in Canada. The service was shut down in December 2015 after his dismissal. His case was dramatic (a dismissal and a service closure) but also noteworthy, given his reputation.

He had been the editor of the Archives of Sexual Behaviour since 2001 and was an acknowledged expert in the field. He was not opposed in principle to the Dutch model but he urged caution, in similar terms to the disaffected staff at the Tavistock Clinic (Zucker, Wood, Singh and Bradley, 2012). He argued for a plurality of approaches, applied judiciously from case to case, and the need for better quality research in the meantime. Transgender activists accused him of championing ‘conversion therapy’, which, by the turn of this century, had come to mean exploratory alternatives to affirmation. Their campaigning was successful when lobbying for Zucker’s sacking. (After an acknowledgement of false claims against him, Zucker’s former employers paid him compensation and damages, though he was not re-instated.) The cases of David Bell and Ken Zucker highlight the career implications for gender-critical clinicians in recent times.

Recent historical reflections and gender activism

The closure of GIDS and the Cass Review were welcomed by gender-critical clinicians. They attributed the failures of the clinic to a bias created by transgender activism and its pressures placed on cautious clinicians. A parallel report from those supporting affirmative care emerged in the same period. Cass reported on an interim basis in March 2022 and made it clear that the GIDS clinic was in various ways problematic in its service philosophy and record keeping. GIDS at the Tavistock Clinic was closed in July 2022. At the time of writing the dispersal of mental health services for gender non-conforming children, recommended by Cass, is occurring, although the ideological character of new services – compared with the discredited Tavistock model, traceable to Amsterdam in the 1990s – is still to emerge.

Another relevant report that appeared around the same time (June 2022) was from the University of Birmingham, which published online and in full, a retrospective review of the work of Feldman and MacCulloch on aversion therapy. This was produced by psychologists and historians employed by the university, but it is not clear from the document how it emerged.

Its relevance relates to the sequencing of sections in the report. It begins with a health warning and the offer of help to anyone affected detrimentally as a result of targeted ‘conversion therapy’. This is followed by an apology from the vice-chancellor of the university about the work of Feldman and MacCulloch and then by the report from the employees about aversion therapy. The first paragraph of the executive summary (quoted here in full) states:

The University of Birmingham agrees wholeheartedly with the British Psychological Society and the Royal College of Psychiatry [sic] and numerous other organisations and professional bodies, which state that there is no moral or ethical support for activities aimed at changing sexual orientation or gender identity (often called ‘conversion therapy’). The Memorandum of Understanding on Conversion Therapy in the United Kingdom is endorsed by 26 prominent health and therapy organisations, including NHS England and NHS Scotland: https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Memorandum%20of%20Understanding%20on%20Conversion%20Therapy%20in%20the%20UK.pdf. Crucially, there is no robust scientific evidence to support the use of ‘conversion therapy’. This report places that term in inverted commas, precisely because these interventions have no form of therapeutic value. Efforts to suppress same-sex desire or enforce conformity to social expectations of gender do not ‘work’ as intended; in fact there is substantial evidence that shows how harmful it is. ³

This report is important because the last and substantive part alludes specifically to the role of aversion therapy c.1970 and it is critical of ex-staff members Feldman and MacCulloch, noted earlier. However, it fails to distinguish clearly, for empirical and ethical consideration, adult research subjects from gender-confused children, who might be patients of mental health services today.

For example, it makes clear that its focus is on Feldman’s and MacCulloch’s work on aversion therapy with homosexual men, as their main empirical interest. However, it refers often to gender identity and conversion therapy, viz: ‘The focus of this report, as stated at the outset, is on research into and related to “conversion therapy” that was conducted and disseminated by members of staff at the University of Birmingham.’ Aversion therapy when used is not put in speech marks but conversion therapy is, raising a question about what is being alluded to specifically and operationalised c. 1970, and what is being connoted for rhetorical purposes in today’s context of transgender activism.

It is analytically questionable to group aversion therapy historically in relation to adults with exploratory therapy today with children. Of most importance throughout the report is the elision or amalgam of sexuality and gender identity, as a combined unwelcomed target of the umbrella term ‘conversion therapy’, which offers the reader a form of anachronistic reasoning. For example, the health warning placed at the start of the report says this (bearing in mind the report is substantively purportedly about aversion therapy for homosexuality 50 years previously):

Note: this report deals with activities aimed at changing gender identity and sexual orientation. It discusses psychological ‘treatments’ used in the past in sometimes graphic detail. Readers affected by this material may wish to make use of this dedicated resource: National Conversion Therapy Helpline If you are currently experiencing abuse aimed at changing, altering, or ‘curing’ your LGBT+ identity, or think this will happen to you if you come out, Galop’s Conversion Therapy Helpline is here for you. So-called conversion therapy can have a long-term impact on LGBT+ people. If this has happened to you in the past and you are still struggling with it, you can reach out to Galop’s support services. The helpline can provide a safe, confidential listening and information service to any LGBT+ person aged 13+. There are different ways to contact us. All of them are free: Phone [phone] Email [e-mail] The helpline is open: Monday to Friday 10am – 4pm. Calls will last 40 minutes.

Note the privileging of gender identity at the opening of the report, even though it was not the main concern of the Feldman and McCulloch research, the purported focus of retrospective criticism from the employees of Birmingham University today.

In the previous paragraph cited, sexual orientation is privileged, suggesting that in the minds of many now (lay people and professionals) sexual orientation and gender identity are self-evidently alloyed, as the targets of ‘conversion therapy’. However, when and if they are thought of interchangeably, this is misleading. They are orthogonal concepts. Homosexuality is simply about same-sex attraction, whereas transgender individuals can report being gay, straight, bisexual or even asexual.

The risks of anachronistic reasoning and of adding gender identity to sexual orientation

The history traced so far in this paper shows that aversion therapy for adult homosexuality was not the same as the exploratory approach for gender non-conforming children. The early work of Benjamin on responding sympathetically to the expressed needs of adult transsexuals has more of a pertinent historical resonance. The rationale today of enabling gender non-conforming children to begin a pathway of biomedical transition to the opposite sex represents a form of mission creep beyond the specific concerns of responding to adult transsexualism. For this reason, any discussion today about what is meant to be ‘conversion therapy’ in relation to children should begin there, with the Benjamin rationale, and not with the aversion therapy literature about homosexuality.

A failure to recognise these different historical lineages has led to a confusing ‘mixing of apples and oranges’ in the Birmingham report, and other documents common today, which elide sexual orientation and gender identity. A recent example of the implication of this elision, and the stand-off it has afforded between transgender activists and their gender-critical opponents, is the modification of the Memorandum of Understanding on Conversion Therapy (MoU), mentioned for the purpose of legitimisation in the introduction in the Birmingham report quoted above.

The MoU was agreed initially in 2015 and alluded specifically to same-sex attraction. There was absolutely no evidence that the work of those such as Marks, Bancroft, Eysenck, Feldman and MacCulloch had left any legacy of clinical practices in mental health services in the UK. However, there was evidence of conversion practices being present in some conservative Christian groupings, at times known as ‘reparative therapy’.

Accordingly, when in 2021 the British government made its statement on researching ‘conversion therapy’, this point was made about the relevant setting:

The UK government has committed to exploring legislative and non-legislative options for ending so-called ‘conversion therapy’. In this report the term ‘conversion therapy’ is used to refer to any efforts to change, modify or supress a person’s sexual orientation or gender identity regardless of whether it takes place in a healthcare, religious or other setting. ⁴

Moreover, the report continues (this time with no inverted commas on conversion therapy):

There is no representative data on the number of lesbian, gay, bisexual and transgender (LGBT) people who have undergone conversion therapy in the UK. However, some evidence appears to suggest that transgender people may be more likely to be offered or receive conversion therapy than cisgender lesbian, gay or bisexual people. There is consistent evidence that exposure to conversion therapy is associated with having certain conservative religious beliefs.

The report had little to go on, as far as the UK is concerned (i.e. evidence was lacking), and drew on studies from the USA. Thus we do not know the prevalence of ‘so-called conversion therapy’ in the UK, how it might have changed over time or how it has been constituted in practical terms. We do know that all mainstream therapy organisations condemn it today, and the dominant problem is considered to be with religious fundamentalist organisations.

The US picture is relevant as an Anglophone point of reference that is common in the UK. For example, in the USA, the National Association for Research & Therapy for Homosexuality has contained socially conservative therapists, some with religious affiliations. The organisation seeks to reverse the de-pathologisation of homosexuality, dating back to the change of DSM in 1973, and re-codify it as a form of mental disorder (Nicolosi, Byrd and Potts, 2000).

In the UK, to my knowledge, there is no equivalent of this group of clinical practitioners in the NHS or private practice concerned to ‘cure’ same-sex attraction. Accordingly, it was fairly easy for a range of secular health organisations to endorse the MoU, to ensure the protection of gay people, because religious conversion practices were notable by their absence in mainstream secular psychological therapy.

However, that non-contentious endorsement in 2015, with its singular focus on sexuality, changed two years later with a revised version of the MoU. The group editing the original document were pro-transgender activism and all the paragraphs of the Memorandum were modified pointedly to add ‘gender identity’ to ‘sexual orientation’. This seemingly small, but politically significant, semantic elision was noted above in relation to the Birmingham Report and its alloy phrasing, common now in documentation in public and private organisations.

Thus, the period between 2017 and the present has witnessed the tension between those supporting MoU 2015 and those supporting the second edition in 2017. Those supporting the latter and pushing strongly for a gender-identity focus for now control the MoU Campaign Against Conversion Therapy. This has representatives from the British Psychological Society and Pink Therapy, who strongly support transgender rights, including an affirmative approach to children. Those dissenting from this line of reasoning to inform the revision left the MoU working group. They went on to contribute to two activist organisations of gender-critical professionals, extant at the time of writing (‘Thoughtful Therapists’ and the ‘Clinical Advisory Network on Sex and Gender’). This was also the period when the LGB Alliance split off from Stonewall, disaffected with the distorted priorities created by transgender activism.

A critical realist discussion

The historical summary above, covering the period between the late 1960s and today, reports various changes in the arguments about what might constitute ‘conversion therapy’. In the discussion below, the philosophy of critical realism, which assumes that open human systems are in constant flux, will be used as a hermeneutic resource. What was the world like across those decades to account for the picture described? How did the events and disputes of relevance to the focus of this paper emerge?

Two frameworks of understanding from critical realism will be used to answer variants of these question. The first is about the axioms of ontological realism, epistemological relativism and judgemental rationalism, and the second helpful framework is that of our ‘four planar social being’. Ontological realism refers to the axiom that the world exists with real generative mechanisms operating, which are independent of the way that we understand or describe the world. ‘The map is not the territory’ and so we should not reduce the world to our statements about the world (the error of the ‘epistemic fallacy’) (Korzybski, 1933: 4).

However, we do talk and write about the world every day and in formal codifications, such as academic research. Accordingly, we must also take into consideration competing and shifting accounts (epistemological relativism). Ideas matter because they can be causally efficacious and people will ‘die on a hill’ for their beliefs; hence the important role of political ideology, rhetoric, propaganda and religious preaching (Bhaskar, 1997).

Judgemental rationalism indicates that we use rationality and good faith to establish what is true. Truth is accepted by critical realists as being provisional and revisable (the need for ‘epistemic humility’), but it is also defensible. That defence of truth by critical realism means that it rejects the common assumption today, since the postmodern turn, of judgemental relativism, with its connecting notions of ‘perspectivism’ or ‘positionality’, traceable to the metaphysics of Nietzsche. He averred that ‘there is no such thing as facts, there are only interpretations’ (cited in Pojman, 1998: 1015).

If we apply these general axioms from critical realism to the historical account offered above, we can start with the implications of ontological realism. Bhaskar makes this point of relevance to the disputes between second- and third-wave feminists and Queer Theorists:

. . . God makes the spectrum, man makes the pigeon holes; so that genera, species, essences, classes and so on are human creations. I can find no possible warrant for such an assumption. Taken literally, it would imply that a chromosome count is irrelevant in determining the sex of an individual, that the class of the living is only conventionally divided from the class of the dead, that the chemical elements reveal a continuous gradation in their properties, that tulips merge into rhododendron bushes and solid objects fade gaseously away into empty spaces . . . (Bhaskar, 2008: 213)

This citation, as with the point made by Sontag about natural life not being stylish, points up the difference between discursive and non-discursive aspects of reality, even though both can have causal powers. Biology does fix our sex because our genes are immutable, and that is a fact. A man cannot become a woman, any more than lead can be turned into gold. However, human beings, as language-using and meaning-seeking animals, can describe, desire and imagine in a vast range of ways. Thus, a man may want to be a woman or believe that they are so already. They may then seek ways to approximate to that existential state phenotypically (from dress and make-up to hormonal and surgical alterations with the cooperation of medicine).

Given this commitment to the belief in becoming who a person really is (pace the Mock citation above), then the non-discursive aspect of material reality renders claims based solely upon identity (‘self-identification’) open to legitimate challenge from philosophical realists. For this reason, we can reflect on the relationship between ontological realism and epistemological relativism in this case. A critical realist understanding of the contention outlined above is that the 1970s were characterised mainly by realist presuppositions, whereas the postmodern turn rejected them in favour of perspectivism, re-animating the Nietzschean tradition; hence the difference between second- and third-wave feminism (Watkins, 2018).

By the 1990s, realist presuppositions, including judgemental rationalism, were in tension with new forms of both epistemological and judgemental relativism, with their tendency to background material ontology. For this reason, it is logically unsound to depict a simple grouping of aversion therapy with exploratory therapy, under the common rubric of ‘conversion therapy’. This assumes that there has been an unbroken arc of service philosophy or patient type over time, which is not the case. Around 1970, not only were adult homosexuals and transsexuals different from one another (one referred to sexual attraction and the other to identity), but they were also different from gender non-conforming children. Adults have assumed capacity and children do not, so the meaning of informed consent, when bio-medicalisation is in the offing, has different ethical implications. Not surprisingly those moral hazards were pointed up emphatically by gender-critical clinicians and parents.

Another reason that ontological realism and epistemological relativism should be considered in relation to one another, rather than one or other being considered automatically superior, is that there were real changes in medical technology during the twentieth century to afford the prospect of a ‘sex change’ (Gherovici, 2010). Genital surgeries and the prescription of sex hormones made such a prospect possible and could even start, if deemed wise, with child patients.

The Dutch model represented the continuing sense of optimism about a technological fix for existential distress, but extending it now to children, with the inevitable concerns that this would probably provoke. Indeed, the optimism was so appealing that the enthusiastic adopters in London saw little point in checking on what it would mean in practice. The negative implications of this stance were then pointed out, first by the internal report from David Bell in the Tavistock Clinic, and then by the external report of Hilary Cass, commissioned by NHSE.

Moving from the prospects and risks of modern medicine to the social context of their emergence, the second framework from critical realism helps our understanding. Critical realists assume that any phenomenon emerges, is maintained, and then might change as a result of laminated reality and its variety of generative mechanisms acting in synergy or opposition. Bhaskar (1993) used the notion of our ‘four planar social being’ to depict this layered complexity in slow or fast flux. The first layer refers to our emergence from nature, the second to our relationships with one another, the third to our socio-economic context and the fourth to our unique personhood. Within the discourse of healthcare, this view of laminated reality is aligned with the ‘biopsychosocial model’ (Bhaskar, Danermark and Price, 2018).

These four metaphysical abstractions all have a practical relevance for the historical picture (see above) of a 50-year period which was, and remains, full of controversy. As I have already noted, biological sex is immutable (plane 1). This being the case, gender-critical writers consider that the real conversion therapy is taking a healthy sexed body, male or female, young or adult, and artificially turning it into the appearance of its opposite.

However, the biology of this dispute is not the only matter: how we relate to one another (sexually) or recognise one another (our presentation of self) are also part of the above story (plane 2). One reason noted as to why aversion therapy for homosexual adults is not the same as conversion therapy, used in its pejorative sense by transgender activists, was that sexual relationality was its narrow focus. By contrast, the relational aspects of transgenderism are much wider and varied. The emergence of the notion of ‘cis’ is an artefact of transgender ideology, as is the notion that a person might be ‘misgendered’, a rule infraction today that could not have existed 50 years ago.

When we turn to plane 3 a number of considerations apply, from the profits of drug companies to the career interests of cosmetic surgeons and mental health workers committed to an affirmative approach to child patients. The emergence of norms of neoliberalism in late capitalism after the 1980s emphasised choosing consumers and the sovereignty of their experience. Moreover, the social context of that period included important ideological, not just commercial, questions. In particular, these related to a factor that does connect the politics of Gay Liberation with that of gender identity today, as well as second- and third-wave feminisms: the valorisation of personal experience as the touchstone of oppression or victimhood.

That emphasis on unique personal experience is central to all forms of identity politics and to plane 4. Since the 1980s, they have been the main focus of defining social justice, and so diversity and inclusion have now tended to displace equality as the relevant criterion. This has had major divisive consequences (in particular gender-critical feminists and some gay activists being at loggerheads with transgender activists), as well as new-found concerns about the loss of respect for freedom of expression.

A particular relevant aspect of this has been the emergence of ideological monovalence: this is the correct way to think and speak about gender, and all other ways are wrong and reflect irrationality and bigotry. The latter are now connoted in social media exchanges by dismissive terms such as ‘transphobia’, ‘anti-trans’ and ‘TERF’ (trans-exclusionary radical feminist). These terms indicate that bigotry requires contempt, not serious engagement; hence recent shifts in the gender dispute towards ‘no debate’ and ‘cancellation’ from transgender activists.

Other changes in the discursive rules since the 1980s have included self-censorship in academia and the inverted status of ad hominem statements. Prior to the growth of identity politics and neoliberal consumerism, such statements were disvalued and considered the very weakest form of rhetoric, and even a taboo, in academic reasoning. Today, instead, they have been afforded a very high status (‘lived experience’ and ‘epistemological privilege’).

These multi-layered considerations suggest that it is both simplistic and anachronistic to conceptually and empirically amalgamate aversion therapy for adult homosexuals, c. 1970, with cautious exploratory therapy with gender non-conforming children today. In addition, ‘conversion therapy’ is being connoted in different ways by different allied or opposing factions within the current Zeitgeist of identity politics.

Those discrepancies of understanding are apparent when we read the current advice of the British Psychological Society (2019) on affirmative practice and the position of the ‘MOU Coalition Against Conversion Therapy’, ‘Stonewall’, ‘Mermaids’ or ‘Gendered Intelligence’, on the one hand, and the competing stance of groups such as ‘Thoughtful Therapists’, ‘Clinical Advisory Network on Sex and Gender’, ‘Women’s Place’, the ‘LGB Alliance’ and ‘Transgender Trend’ on the other.

Today the unresolved culture war about sex and gender is being played out in the politics between these groups. This ongoing form of politics reminds us to check in which ways the past explains the present, but is also different from it. It leaves arguments about how mental health services should respond properly, in an evidence-based and value-based way, to gender non-conforming children unresolved at the time of writing. That failure to agree, for now, reflects the historical legacy of the twists and turns of contention, beginning in the 1960s and described above.

Conclusion

I have outlined the clinical and ideological changes that have emerged since the late 1960s in response to adult homosexuality and gender non-conforming children. Those changes shifted the focus from adults to children on the one hand and sexuality to gender identity on the other.

Critical realism was then used as a resource to examine the implications of considering ontological realism and epistemological relativism for a fuller understanding of this complex topic. This offers a better understanding of social and historical complexity than the strong social constructivist claims from the postmodern turn, with its characteristic third-wave feminism and Queer Theory. Our four-planar social being was also applied to emphasise complexity and flux, especially in the ways in which identity politics valorise relationality and unique personal experience, while backgrounding biological and socioeconomic determinism.

This critical realist account leaves the very notion of ‘conversion therapy’ as problematic. For now, it means different things to different factions, within our recent Zeitgeist of identity politics. For this reason, it is unwise to conflate, without reflection and anachronistically, aversion therapy for adult homosexuality (now defunct in mainstream mental health services) with cautious exploratory psychotherapy offered to gender non-conforming children today.