Introduction
Parents of a child who thinks they are transgender often have difficulty challenging the ideas that lie behind their child’s outlook. In the first instance, any challenge to the child’s world view is seen by them as confrontational and is likely to result in ‘push back’. Even parents who have a good relationship with their trans-identifying child can find sensible discussions hampered by the lack of good science and a preponderance of bad science. Good science is honest; it starts with the idea: ‘We don’t know – let’s see if we can find out.’ Bad science can look like that but, with careful analysis, it can become clear that those behind it think they know and want the results of their research to confirm their point of view.
When a child seems armed with all the answers and claims to back them up with science, it pays to check the science. Those of us who do so will often see the same names crop up on academic papers that seem to support our children’s claims. One of those names is Jack Turban.
Parents first must parent, then they have their own jobs to do, homes to run; and very few of us have the academic background to dissect journal papers, let alone the credibility to have our analyses accepted by our own children – let alone society at large.
Fortunately, there are people who recognise the importance of this task, and they do have the academic background and the credibility to carry it out.
Members of Society for Evidence-Based Gender Medicine Roberto D’Angelo, Ema Syrulnik, Sasha Ayad, Lisa Marchiano, Dianna Theadora Kenny and Patrick Clarke, examined one of Jack Turban’s articles and had their analysis published in the journal ‘Archives of Sexual Behavior’, the official publication of the International Academy of Sex Research.
One size does not fit all: in support of psychotherapy for gender dysphoria
Letter to the editor by D’Angelo et al (2000) in response to a paper by Turban et al (2020)
D’Angelo et al highlighted problematic areas of Turban et al’s study, saying its methodology, data interpretation and conclusions are flawed and that it would limit access to all types of psychotherapy and stifle research.
Original article by Turban et al
Turban et al concluded ‘lifetime and childhood exposure to ‘gender identity conversion efforts’ (GICE) are associated with adverse mental health outcomes in adulthood’ and that anything other than ‘affirmative’ psychotherapy for gender dysphoria (GD) is harmful.
They also said exposure to GICE ‘was significantly associated with increased odds of severe psychological distress during the previous month and lifetime suicide attempts’.
In their paper, conversion therapy is that which does not affirm the patient’s transgender identity.
Read the reports
Turban JL, Beckwith N, Reisner SL, Keuroghlian AS. Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults. JAMA Psychiatry. 2020;77(1):68–76. https://doi.org/10.1001/jamapsychiatry.2019.2285
D’Angelo R, Syrulnik E, Ayad S et al. One size does not fit all: in support of psychotherapy for gender dysphoria. Arch Sex Behav. 2020. https://doi.org/10.1007/s10508-020-01844-2
Shortened version of Angelo et al (2020)
Simplistic view of therapy
Turban et al view psychotherapy through a crude binary of ‘affirmation’ versus ‘conversion’, a ‘blunt classification’ that ‘betrays a misunderstanding of the complexity of psychotherapy’. This simplistic approach stigmatises non-affirmative psychotherapy as conversion and is potentially harmful.
Study design
Turban et al’s results are based on the 2015 US Transgender Survey.
This asked participants whether they had experienced GICE – ie if any professional had tried to make them identify with their birth sex, ‘in other words, try to stop you being trans’.
Turban et al found an association between GICE and poor mental health, and said this showed GICE was harmful. However, the study had a ‘cross-sectional’ design which, by definition, cannot show cause and effect.
Bias in data
The USTS survey sample (the people taking part in the survey) was highly skewed.
The sampling method (convenience sampling) generates low-quality data.
Participants were recruited through transgender advocacy organisations, so people who were not involved in transgender politics were excluded. The study goal of highlighting injustices was made clear, making it more likely people would overreport bad experiences. In addition, participants were asked to ‘pledge’ to promote the survey among friends and family, a recruiting method that would result in a large but skewed sample.
The participants were different from those surveyed by the Centers for Disease Control, which is more likely to reflect the general transgender population in several respects including age (many said they were exactly 18 years old, which is unlikely), education level, sexual orientation and intimate relationships.
They were far more likely to identity as non-binary. Nearly 40% had not transitioned medically or socially, and many did not intend to transition.
Some said they started puberty blockers after the age of 18 years, which is highly improbably.
Detransitioners and desisters were excluded, a ‘serious oversight’ given they may have been hurt by affirmation therapy.
Invalid definition gender conversion therapy
The USTS question is vague on the type of professional involved, the purpose of the consultations (ie they may have been an initial assessment), whether unethical tactics were used and if the person was forced to attend.
The use of emotionally charged language (‘stop you being trans’) could make participants view neutral encounters as conversion.
Patients commonly want to be approved for medical treatment for GD, and can view a therapist starting with a general mental assessment as an attempt to withhold treatment.
Those with psychiatric diagnoses (common in transgender-identifying people) can misinterpret neutral interactions as invalidating or rejecting.
The question did not allow discrimination between agenda-free, ethical therapy and coercive, agenda-driven therapy, which undermines Turban et al’s entire argument.
Misinterpreted mental health measure
USTS participants who remembered GICE were more likely to report severe psychological distress, which was defined as scoring ≥13 on the K-6 scale.
The K-6 was designed to discriminate between psychological distress and serious mental illness, with a score of ≥13 indicating the latter.
The results showed only that people recalling GICE were more likely to be diagnosed with a severe mental illnesses.
Any claim that GICE caused serious mental illness in previously mentally well people is ‘highly speculative and implausible’.
Original mental health
People’s mental health before they experienced GICE is not included, which makes it impossible to show whether mental health or suicidality worsened, stayed the same or improved after the non-affirming consultation.
This undermines the claim that GICE causes poor mental health.
Given the high rate of mental illness in transgender-identifying patients, this is a serious methodological flaw.
It is more likely that poor mental health led to a non-affirming consultation than vice versa.
Inconsistencies in measuring suicidality
Lifetime suicide attempts were higher among the GICE group. However, suicide attempts in the previous 12 months were not significantly different between the two groups.
The relationship between suicidality and the higher levels of serious mental illness among the GICE group was not investigated.
The unclear association between GICE and suicidality was treated as cause and effect and elevated into the paper’s title.
Claim of cause from an association
Turban et al strongly implied GICE causes mental health problems even though they acknowledged there was only an association. This is a serious shortcoming as it could misinform and mislead people.
(Editor’s note: an explanation of why cause and association are different, with examples of spurious associations, here: https://en.testingtreatments.org/association-not-causation-lets-say-association-not-causation/ )
Publicity and debate
Turban et al used their flawed findings in a media campaign promoting legislative bans of GICE.
In contrast, debate regarding this study in the scientific arena was not allowed. Letters to the editor of JAMA Psychiatry, many by respected academics and clinicians, were rejected (some are included as non-indexed comments in the online publication).
This stifles scientific debate and perpetuates the politicisation of transgender healthcare.
Implications for practice and research
Given the absence of robust, long-term evidence, the least-invasive approaches should be pursued first. Ensuring access to therapies to help an individual obtain relief from GD without undergoing body-altering interventions is ethical and prudent.
The endorsement of ‘affirmative’ therapies and framing non- ‘affirming’ approaches as harmful will have a chilling effect on psychotherapists’ willingness to take on complex GD patients. It could stifle future research into psychological interventions for GD.
Informed consent means all treatment options must be considered. Withholding psychotherapy to ameliorate GD non-invasively while promoting affirmation approaches that can lead to medical transition is ethically questionable.
Addendum
This idea of a simplified synopsis (which was seen by two authors of the original letter) proved compelling enough for the authors to produce their own version published in Quillette.
