Reparative Therapy is Bad Medicine, even if it “works”.

In a recent Op-Ed for the New York Times, Dr. David Friedman, a professor of clinical psychiatry at Weill-Cornell Medical School, asserts that transition does not help transsexuals, and going one step further rails against parents and professionals helping children transition earlier and earlier, and then makes a case for “reparative therapy” for transgender kids.

Dr Friedman,

I have also shared your concern with children transitioning, probably because my own transition occurred in my early 20’s, and I felt I had more tools to understand gender roles, and what I was willing and not willing to conform to. I was lucky, I had an amazing therapist, who challenged my assumptions, made it her job to inform me as to what issues transition and ultimately surgery would help alleviate. She also made it her job to inform me that transition or surgery was not a “cure all” .

In terms of education, I am more educated than the norm. Besides forays into sociology and psychology, philosophy, computer science,  music/sound engineering, and physics; I decided at a late age to go to grad school for Biomedical Engineering and Pharmacology. I know a little knowledge can be dangerous, but I want to focus on some bioethics questions, while focusing on my personal experience as a transgender woman.
It feels like you are starting with a set of assumptions. You know what they say about assumptions; We all know what they say about them, right? Well, it’s that the premise that the assumption is based has to be true for the assumption to be of any use. What did you think I was going to say?

Now some of my own assumptions may be wrong, but I think there’s a few that must be challenged, even if only to challenge public perceptions of what you wrote. If I can misunderstand, especially in terms of some of what might have come off as passive-aggressive language, referring to transgender identity as a “cherished belief”; then so can many others. I can tell you, my gender identity had been written in stone from about the age of 4. After having some bad experiences, a child of my intelligence quickly learns never to say anything about it; Of course. Up until it got more safe to do so.

The first assumption is that transition is considered a final step. Transition is not the end game. Transition is a beginning. That first step to standing on our own as an individual. Life just began when I was transitioning. Transition isn’t easy. In fact I’d say that the process of such, is one of the most difficult journeys anyone can take in their lives. Even 20 years later, I have difficulties in society because I am a transgender woman. I learned how to cope with them. I learned how to have confidence in my own ability to survive what the world threw at me. I am happy I got the actual transition part done early though… it made things a lot easier as a transgender 41 year old (especially because I am also autistic, preparation can be key) . Thats for sure. My therapist certainly put me on notice that it would not solve my problems, except those of not feeling at home in a body that was in-congruent to my personal identity. That is a pretty big problem, one worth solving. However, it brings to mind one of the things I would look for in a followup study to the Swedish study you mentioned, I would also start asking some harder questions, ones about intake treatment to gender transition. While I have spent a fair amount of time criticizing WPATH for being gatekeepers, I think they are right in one sense, therapy – with emphasis on certain things, including managing expectations about post-transition, is extremely helpful.

Having a lot of knowledge about how socio-economic conditions effect the same things, I’d like to point out that correlation does not equal causation. You’ll notice that they point out a point in the historical period they studied where things changed, hospitalizations dropped, etc. Those years were between 1989-2003 – where something obviously changed. When I notice that there is a change in expected variance in my own research, I look for some other potential cause. I am am running a series of benchmarked statistics, and something drastically changes, the first thing I would look at is a variable I didn’t take into account.

I was a transgender teenager who dare not come out at that time, in the 80’s and early 90’s. I remember what it was like to think that transitioning and the ostracism that came with it would be more destructive to the self, than transitioning. A few years later I changed my mind. What could change my mind? Well one was the advent of the Internet. The Internet became a life line for a lot of transgender people. Suicide rates of those who transitioned were not significantly higher, during the period we all started leaning on each other. So maybe, what’s needed is more support.

The other factor in changing my mind, was the results after having experienced “reparative therapy”.

You are absolutely right about one thing. Transition does not solve any problem but one we feel with ourselves. It doesn’t change how others feel about us. It doesn’t change the fact that many transgender individuals are disowned by their families, or simply not accepted by them (honestly, being called by my “dead name” by my family hurts more than if I was just not a part of them anymore).

It doesn’t change the long term stress and trauma of how the rest of the world treats us. However, what you don’t get is that historically, even in cultures that revered those who were gender-variant, there was no real changing one’s gender identity. Even when accepted, one knew the role they were meant to play in terms of their society, and while changing the body was not always possible, they did live, work, and carry relationships as their non-birth assigned gender. They still had identity based around gender – even if there were potential 3rd and 4th genders available to them in society. If I identify as female, and I want to carry on relationships, especially romantic ones as such, sometimes physical transition makes us much more secure in those personal exchanges. I cannot overemphasize the value of this. I am a bisexual transwoman. I certainly feel more accepted as who I am and have less questions about how a partner may see me, because I am post-transition. I wish I could take it one step further, but health conditions have led to me not being able to have surgery. This is ok, I’ll take what I can get; however I don’t underestimate the value of this.

Yes, if people were more understanding, this would be less painful, but people are in fact as attracted to genitals, or unattracted to them, as they might be attracted to the person. I’ve had many situations where my lack of surgery was potentially an issue, for both male and female partners. If I had the power to change that right now, I definitely would.

So, lets add prolonged stress to the issue, both before and after transition. Sometimes traumatic stress. Just because someone may have had surgery, does not make them better able or not able to address the ostracism that can go with transition. Before transition we have the stress of not presenting who we are honestly to the world. Afterwards, we have the stress of people thinking we’re freaks, “faggots”, and crazies. It might be enough to drive some…. well…. crazy. Higher incidence of depression than cisgender counterparts, higher incidence of PTSD, Higher incidences of sexual violence lead to similar issues, you leave out so much from the holistic equation here. While there is definitely a correlation between certain things, you’ve left out the causes, even while citing them as something that should change in our society much earlier in your Op-Ed. As a result, I am not sure using cis-gender individuals as a control group in the Swedish paper would prove or disprove anything about transgender people and the incidence of mental health and physical health effects leading to an earlier death. It only establishes a correlation between being transgender and higher incidence of mortality, even after transition.

The second assumption you seem to be starting with is that there is no data at all on whether reparative therapy for gender dysphoria works, so we should try it on transgender people.  I’m going to quote you, as I understand you might have been criticizing the (honestly a bit illogical jump) that other trans activists claim the “wait and see” attitude, is like reparative therapy. However, and you can correct me, you seem to advocate for getting data on the efficacy of “reparative therapy” on gender dysphoric patients. Which means of course, using those methods to treat a subset vs. another method.

“I think that criticism is misguided. First, there is abundant evidence that reparative therapy is both ineffective and often harmful, while there is no comparable data in the area of gender dysphoria. Second, unlike sexual orientation, which tends to be stable, gender dysphoria in many young people clearly isn’t. Finally, when it comes to gender dysphoria, the evidence for therapeutics are simply poor to start with: There are no randomized clinical trials and very few comparative studies examining different approaches for this population.”

Yes, for one, it would be difficult to get some of these numbers, as there are probably less transgender people willing to be tortured and brainwashed. However, as a person who has been through it, I would say – to even go there, and suggest that it may be a solution is unethical at best, it’s advocating for worse torture, and a lifetime of post-traumatic stress.

In case you didn’t realize, most reparative therapy is achieved through a combination of things, including shame, humiliation, physical abuse (including sleep deprivation and starvation), and in some cases even sexual abuse. These things aren’t always publicized, but as someone who has been through it… I can tell you, it took nearly 20 years to be able to reconcile what had happened to me in the name of treatment. We don’t need numbers to say that this type of treatment (of any child – or adult for that matter!) is even more unethical than letting kids transition earlier and earlier.

I have another suggestion all together.; you mentioned other interventions; how about trained therapists who aren’t there to judge, or even guide, but to prepare kids for transition; if they so choose. Maybe minimizing potential issues of keeping tabs on hormone levels and only using anti-hormonal regimens when it is obvious that puberty is imminent. I still think the value of not having to deal later with the effects of secondary sex characteristics (as in body hair) is worth it in the long term for a child who may decide to transition. A lot of the difficulties adults who transition have are because of that.

We all know treatment modality regarding psychiatric and even physical conditions, can yield vastly different results, ABA vs. things like DIR in autism are hotly discussed and debated, much hinging on debate about whether certain parts of ABA are ethical, though they may produce results in the short term, is the nature of ABA more harmful long term? I think the contrast between coming up with an effective therapy guide and modality that stays within ethical boundaries, or using methods that are considered “reparative therapy” is much more stark and obvious than the ABA vs. DIR question. You are essentially advocating concentration camps for transgender children.

To advocate for reparative therapy over preparation for the potential transition, at which point you make it their choice, when they are old enough to make that decision for themselves,which may solve some of the issues you point out, is unethical simply based on method. How can we say a harmful method is ethical? How can we say what amounts to torture is ever ethical?  By the way, old enough to make that decision for themselves, includes a maturity that with some kids is present fairly early, it’s not with others, we shouldn’t give a hard and fast age. With adults, we shouldn’t be playing gatekeeper at all.

This preparation may help mitigate a lot of what your concerns are psychologically; and you are correct to be concerned medically.

However, the last assumption you make is another one of moral and ethical obligation of the professionals in our lives.

It’s my body. If I have been notified about potential risk vs. benefit in a currently available treatment, and I decide to go through with it, then I will avail myself of such treatment. While I do believe your heart is in the right place, outcomes with the currently accepted treatment still seem to be better than those without, and certainly much better than the several (6) outcomes I have seen of transgender people being subjected to so-called “reparative therapy”, including myself, all as teens and young adults. In fact in all six cases I have seen of transgender people being subjected to such, all experienced long term post-trauma symptoms; and with the exception of myself and one other, a struggle with gender identity long term, because of the struggles they had gone through. Even if it did work to achieve a goal (which for some was very short term, of “identifying” as their assigned birth gender) – the methods are so heinous as to lose any moral high ground in terms of treatment… PTSD and Gender Dysphoria are bad independent of each other. But to cause one while attempting (probably unsuccessfully) to treat the other is just Bad Medicine.


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