Conversion Therapy

Should parents, counsellors, doctors, and others be forbidden to help children love the body they are born with?

Recently enacted or proposed conversion therapy bans forbid counselling that helps children and teens love their bodies and feel comfortable in their own skin. They prohibit particular methods of alleviating gender dysphoria, which an astonishing number of children now experience. In 2004, the number of referrals for transgender teens to clinics across Canada was in the single digits. By 2016, in just nine cities, over 1,000 teenagers were referred to “gender clinics”.[1]

Conversion therapy bans also condemn efforts to help someone manage unwanted sexual desires or urges. For example, a person may prefer to diminish feelings of same-sex attraction and enhance feelings of opposite-sex attraction in order to have a traditional family, for reasons of religion or conscience, or for other legitimate personal reasons that the state should respect.

Ontario (2015) and Manitoba (2015) ban “conversion therapy” by health care practitioners. Nova Scotia (2018) prohibits the practice by both health care practitioners and parents or guardians.[2] Vancouver (2018) and St. Albert (2019) have prohibited commercial space from being used for conversion therapy on minors.[3] Proposed bans have been tabled but not yet passed in British Columbia and Canada’s Parliament.[4] All of these bans are overly broad, because all of them are unclear on what “conversion therapy” means.

This report recommends policies that prevent dangerous forms of conversion therapy and respect people’s freedom to seek a variety of counselling supports for struggles related to identity, sexuality, and gender.

What is Conversion Therapy?

Conversion therapy is defined broadly in recent laws to include any efforts to change someone’s sexual orientation, gender identity, or gender expression.[5] Such efforts may include, to quote a British Columbia bill, “any counselling, behaviour modification techniques, administration or prescription of medication, treatment, service, practice, or tactic” to that end.[6] According to this broad definition, conversion therapy may be something offered by medical practitioners or persons in positions of trust or authority (presumably including parents, teachers, counsellors, and pastors).

Body-affirming counselling: talk therapy that uses conversation to explore issues and personal history in order to better understand and address unwanted sexual attraction or manage gender dysphoria Aversion therapy: therapy that uses pain or shame to attempt to modify same-sex attraction or gender dysphoria Sex-change treatments: invasive treatments that modify secondary sex characteristics and reproductive organs by pharmaceutical or surgical means

The stereotype of conversion therapy brings to mind long-discredited practices, such as showing homo-erotic images while inflicting painful electric shocks or shaming rituals to try to “cure” same-sex attraction. In the mid-1900s, some doctors and therapists prescribed medication, performed lobotomies, and practiced electric shock therapy to try to eradicate same-sex attraction.[7] Patients were often coerced or forced to undergo such treatment. It is no wonder, then, that “conversion therapy” is associated with victimization.[8] Such treatments – also known as aversion therapy – are degrading and wrong and should be considered a type of conversion therapy worth banning in legislation.

Present-day discourse lumps beneficial counselling and services with long-condemned, harmful therapies. Proponents of conversion therapy bans take advantage of the well-deserved negative connotations of “conversion therapy” to prohibit other services wrongly labeled conversion therapy, like counselling a young person to resolve or manage gender dysphoria without medically “transitioning”. Such body-affirming counselling is condemned by some for not being “trans-positive” and for failing to accept and affirm a child’s self-reported identity. What such counselling does, however, is respect the child’s biological identity. This is in the child’s best interest – physically, emotionally, and mentally.

Recent conversion therapy bans deprive those who struggle with gender dysphoria or unwanted sexual feelings from getting the help they want and need. Instead, they steer young people down the path of invasive, harmful, and often irreversible medical interventions – these bans explicitly permit (and provincial governments even pay for) medical efforts to physically alter someone’s secondary sex characteristics through the perpetual injection of synthetic opposite-sex hormones and the surgical removal of healthy sex organs or breasts.[9] Such “sex-change” efforts are the most dramatic form of conversion therapy and should be banned.

The Mutability of Sexual Orientation and Gender Identity

At the heart of the debate over conversion therapy is the question of whether sexual orientation, gender identity, or biological sex can or ought to be changed. This question is difficult to answer, due to a lack of an objective definition of sexual orientation or gender identity.[10] Sexual orientation, for example, is a multifaceted phenomenon that includes sexual attraction, sexual arousal, sexual fantasy, sexual behavior, and sexual self-concept.[11] The idea of an innate and immutable (trans)gender identity or sexual orientation is a cultural and legal construct.[12] These are not naturally existing categories like male and female.[13]

There is a strong scientific consensus that sexual orientation and gender identity naturally vary during one’s life. Researchers Diamond and Rosky, for example, find “unequivocally” that sexual attraction changes over time, especially for women and for people who experience same-sex attraction. Young people in particular exhibit great mutability.[14] In one study, over 80% of teens who originally reported same-sex attraction and sexual activity reported exclusively heterosexual attraction and sexual activity within 6 years.[15]

In another longitudinal cohort study, young females in the “lesbian” category averaged 3 orientation changes over 8 years.[16]  A multitude of studies demonstrate that 80-90% of all children suffering from gender dysphoria “desist” and identify their gender in accordance with their biological sex by adulthood.[17] Both the American Psychiatric Association and the American Psychological Association recognize that gender identity fluctuates, and the vast majority of gender dysphoric minors will eventually accept their biological sex.[18]

Counselling or talk therapy can influence sexual orientation (particularly with respect to controlling or changing feelings and behaviours) and gender identity, although the rates of “success” cannot be precisely determined.[19] Douglas Haldeman, a skeptic of such therapies, estimates that they have a success rate (changing sexual orientation or gender identity to align with biological sex) of approximately 30%.[20] A study by Jones & Yarhouse finds that 23% of their participants changed sexual orientation.[21] Even many of those who do not fully change sexual orientation reported some benefit from obtaining help to address undesired same-sex attraction. In the Jones & Yarhouse study, an additional 30% lived chaste lives after therapy, which was their goal.[22]

The Immutability of Biological Sex

Unlike sexual orientation and gender identity, biological sex is both objective and immutable. Aside from rare intersex conditions (0.05-0.067% of infants),[23] each person is born with a set of XX or XY chromosomes within the DNA of each cell. This chromosomal reality objectively identifies each person as either male or female and generates secondary sex characteristics. Although sex-change treatments (cross-hormone injections, surgical removal of body parts) may alter the appearance of a person’s sex, these measures simply mask the immutable, biological reality of sex.[24] As Dr. Ryan T. Anderson states, “Changing sexes is a metaphysical impossibility because it is a biological impossibility.”[25]

Self-described “queer feminist lawyer” Barbara Findlay compares sex-change treatment to the metamorphosis of a caterpillar into a butterfly: both transformations take something ugly and turn it into something beautiful.[26] Such a metaphor is horribly misleading. Not only is a sex-change treatment unnatural (unlike a caterpillar’s metamorphosis), the metaphor implies that a pre-treatment transgender person is somehow ugly. Rather than disparaging gender dysphoric individuals who have not attempted to change their sex, Canadian law should affirm that every person is already a beautiful masterpiece, a Mona Lisa in their own right. Trying to change one’s biological sex is akin to painting a new portrait over the Mona Lisa.

Sexual orientation and gender identity may be subjective and fluid, but sex is a biological, immutable reality. Undesired discrepancies between someone’s subjective identity and their biological sex should be resolved in favour of their biological sex.

Counselling for Gender Dysphoria or Undesired Sexual Attraction Can Be Beneficial

Researchers Phelan, Whitehead, and Sutton cite numerous academic studies performed in the mid-1900s that demonstrated the success of the lamentable methods then in use (described above) to reduce same-sex attraction.[27] However, the harms inflicted far outweighed the perceived benefits of being “cured” of same-sex attraction. Such practices have rightly been discredited, rejected, and abandoned.[28] People should never be treated like lab rats.

Modern bans on conversion therapy, however, ban body-affirming counselling along with these body-degrading therapies. Body-affirming counselling is behavioral, psychological, or religious counselling. It is voluntarily sought and received. It may be provided by clinical psychologists, psychiatrists, licensed counsellors, or (though in a different form) religious leaders.[29] It typically takes the form of talk therapy.[30] Body-affirming counselling is thus distinct from conversion therapy, but recent bans on conversion therapy wrongly lump the two practices together.

Body-affirming counselling involves the counsellor and client collaboratively exploring the issue and together defining the problem, the desired outcomes, and the path they will take to achieve those outcomes. Some people freely seek to change their identity (e.g. to change the belief or feeling that one is transgender), while others seek to manage only their behavior (e.g. overcoming a perceived need for “sex-change” treatment). If they disagree with their counsellor’s assessment, methods, or outcome(s), they are free to stop participating.

Chemical and Surgical Attempts to Change Biological Sex are Harmful

Unlike body-affirming counselling, sex-change treatments are physically invasive, and worryingly reminiscent of the pharmaceutical and surgical forms of conversion therapy practiced in the mid-1900s. They do irreparable physical and psychological harm. One longitudinal study, headed by Swedish researcher Ebba Lindqvist, found that health outcomes deteriorate just one year after receiving a sex-change operation. By the fifth year, post-operative transsexuals had poorer outcomes in 7 of 8 measured categories: mental health, vitality, bodily pain, social function, emotional functioning, physical functioning, and general health.[31] While some studies show that such treatments may provide short-term psychological relief (six months to one year), longitudinal studies show that overall health continues to decline.[32]

One explanation as to why sex-change treatments have poor outcomes is that they are based on a misdiagnosis. At root, gender dysphoria is a psychological condition. Moreover, comorbid psychological conditions, especially anxiety and mood disorders, exist in approximately 61% of adolescents suffering from gender dysphoria.[33] These comorbid conditions amplify a person’s gender dysphoria and often go unaddressed while the dysphoria is treated with puberty blockers, opposite-sex synthetic hormones, and surgery. Thus, the lack of mental health improvement post-treatment should not surprise us. In many cases, sex-change hormones and surgeries exacerbate, rather than alleviate, gender dysphoria and comorbid issues. Many men and women regret the injections and surgery and choose to de-transition. Left with scarred bodies and psyches, they typically receive little support from those who had encouraged their transition.[34]

Impact on Parents and Children

So far, most legislation regulating conversion therapy bans the practice only for minors.[35] These bans purport to protect vulnerable children by silencing those who say their biological sex matters. These proposals assume that children and youth understand the ramifications of embracing a dysphoric identity. Furthermore, expressly permitting (and publicly funding) chemical and surgical transition implies that minors understand the ramifications of sex-change treatments.[36] This is a dangerous assumption with respect to children and most adolescents.

Conversion therapy bans encourage children to unquestioningly embrace their self-perceived gender identity or sexual orientation, despite the fact that these identities are likely to change through adolescence. Instead of banning helpful alternatives to medical transition, public policy in this area should promote these alternatives over irreversible medical interventions.

The most natural guides to help children navigate questions regarding sexuality and gender are their parents. Parents should be free to lovingly affirm that biological sex is inextricably linked to sexuality and identity. Regrettably, bills like British Columbia’s M-218 and Nova Scotia’s ban on conversion therapy disrespect parents. Parents love their children, have an intimate knowledge of their unique personality, history and needs, and seek what is best for them. Public policy should respect, rather than override, the role of parents.

A Normative View of Sexuality, Sexual Orientation and Gender Identity

Underlying conversations about sexuality, sexual orientation, and gender identity are normative questions about what it means to be human. Implicit behind recent, overly broad bans or proposals to ban conversion therapy is the presupposition that our internal sense of gender or sexuality is more important than the objective reality of our sexed bodies. Some claim that a person’s “true” identity as male or female (or both or neither) depends on their self-concept, not his or her body. With respect, that is based on an irrational faith of a disembodied, yet gendered, self. Meanwhile, people rarely ask what it means, for example, for a male to “feel” or “know” he is female. How could a male know what that feels like? The explanation given with respect to young children is often shockingly shallow, such as noting that a boy prefers (stereotypically) feminine toys, colours, and clothes.

ARPA Canada rejects the legal and medical prioritization of shifting cultural concepts of sexual and gender identity over innate biological sex. Humans were created binary – male and female.[37] Rare disorders of sexual development do not change that reality.[38] When some people struggle to connect their self-perception to their biology, the answer is not to disregard the body or to chemically or surgically alter it. Rather, we should help those struggling with gender dysphoria to be comfortable with their bodies. This approach minimizes harm and respects the body as integral to the human person.

Cultural stereotypes or expectations related to gender may deserve to be challenged and changed. But rejecting the natural reality of the male-female binary is folly rooted in an ideological commitment to human autonomy. ARPA Canada’s view is that our existence as male and female creatures is not meaningless or oppressive. Rather, our bodies are intrinsically meaningful. ARPA rejects body-mind dualism. ARPA affirms the body-mind integrity of the human person. We are not ghosts in machines. Our bodies are not raw materials for us to impose our will on. Our bodies are the good creations of a loving God, who made us male and female.

Recommendations

Based on the foregoing, ARPA Canada opposes recently passed bans on conversion therapy in Canada, and any further attempts to implement such bans. While bans on conversion therapy prohibit harmful forms of conversion therapy, they also prohibit beneficial forms of counselling. Therefore, we make the following recommendations to address the inherent flaws of these recently passed or proposed laws:

1. Respect the liberty of individuals to address unwanted sexual feelings or impulses or to resolve gender dysphoria (subject to Recommendations 2 – 6).
2. Tighten the definition of conversion therapy in legislated bans to include only coercive and aversive therapies. The definition should exclude body-affirming counselling.
3. Ban attempts to change minors’ secondary sex characteristics, including puberty blockers, cross-sex hormones, and the removal or destruction of sex organs or breasts.
4. Ensure the rights and role of parents are respected. Parents should never be prohibited from helping children manage unwanted desires or understand their biological identity.
5. Likewise, children and adults should have the freedom to access professional counsellors and spiritual guides to help them with matters of identity and sexuality.
6. As a prerequisite to providing sex-change treatments to adults, require that a patient receive a comprehensive psychological assessment by an independent third party. Such an assessment should determine whether comorbid factors – such as anxiety or past sexual abuse – are contributing to the patient’s gender dysphoria. Such comorbid factors must be addressed and resolved before considering chemical or surgical transition.

Legislation regulating conversion therapy should restrict coercive and aversive efforts to change sexual orientation and gender identity and ban efforts to change biological sex. Such forms of conversion therapy are harmful and unethical. “Sex-change treatment” presupposes that subjective identities trump objective reality and ignores the fact that sex is immutable. Consensual counselling that encourages children, teenagers, and adults to accept the biological basis for gender and sexuality – to love the body they are in[39] – should be permitted and encouraged for medical practitioners, professional counsellors, or persons in other positions of trust and authority. Conducted appropriately, such counselling respects patient autonomy, limits potential harms, and respects the reality and integrity of biological sex.

Endnotes

[1] Jen Beard, “Spike in Demand for Treatment of Transgender Teens,” CBC, March 4, 2019; Trans Youth Canada, “A New Study of Medical, Family, and Social Outcomes for Trans Youth Referred for Hormone Therapy,” Trans Youth CAN! (blog), 2019.

[2] Ontario Legislative Assembly, Bill 77 – An Act to Amend the Health Insurance Act and the Regulated Health Professions Act, 1991 Regarding Efforts to Change Sexual Orientation or Gender Identity (2015); Nova Scotia Legislature, Bill 16 – Sexual Orientation and Gender Identity Protection Act – RA, (2018); Province of Manitoba, “Position on Conversion Therapy,” (accessed October 3, 2019).

[3] City of St. Albert, “Council Briefs,” 2019; Vancouver City Council, “Motion B3,” 2019.

[4] Parliament of Canada, Bill S-260 – An Act to Amend the Criminal Code, (2019); Legislature of British Columbia, Bill M 218 – 2019: Sexual Orientation and Gender Identity Protection Act, (2019).

[5] James E Phelan, Neil Whitehead, and Philip M. Sutton, “What Research Shows: NARTH’s Response to the APA Claims on Homosexuality: A Report of the Scientific Advisory Committee of the National Association for Research and Therapy of Homosexuality,” Journal of Human Sexuality 1 (2009); Jacob M Victor, “Regulating Sexual Orientation Change Efforts: The California Approach, Its Limitations, and Potential Alternatives,” The Yale Law Journal 123 (2014): 55; Marie-Amélie George, “Expressive Ends: Understanding Conversion Therapy Bans,” Alabama Law Review 68, no. 3 (2017): 61; Canadian Psychological Association, “CPA Policy Statement on Conversion/Reparative Therapy for Sexual Orientation,” 2015.

[6] Legislature of British Columbia, Bill M 218, supra note 4; Nova Scotia Legislature, Bill 16, supra note 2.

[7] George, “Expressive Ends: Understanding Conversion Therapy Bans” Alabama Law Review; Victor, “Regulating Sexual Orientation Change Efforts: The California Approach, Its Limitations, and Potential Alternatives” Yale Law Review; Phelan, Whitehead, and Sutton, “What Research Shows”, supra note 8; Haldeman, “Gay Rights, Patient Rights”, supra note 18.

[8] Andrew Weaver, “Introducing a Bill to End the Practice of Conversion Therapy in British Columbia,” Andrew Weaver, MLA (blog), May 27, 2019.

[9] To change someone’s biological sex is actually impossible. Chemical and surgical advances have made it possible to make a biological male appear very much like a female and vice versa, but a true sex change remains an impossibility. The chromosomal data in each of the approximately 73,000,000,000,000 cells in an adult body will continue to identity the body as either male or female, an immutable characteristic.

[10] Joseph Nicolosi, A. Dean Byrd, and Richard W. Potts, “Retrospective Self-Reports of Changes in Homosexual Orientation: A Consumer Survey of Conversion Therapy Clients,” Psychological Reports 86 (2000): 1071–88; Phelan, Whitehead, and Sutton, “What Research Shows: NARTH’s Response to the APA Claims on Homosexuality: A Report of the Scientific Advisory Committee of the National Association for Research and Therapy of Homosexuality” Journal of Human Sexuality; Lisa M. Diamond and Clifford J. Rosky, “Scrutinizing Immutability: Research on Sexual Orientation and U.S. Legal Advocacy for Sexual Minorities,” Journal of Sex Research 53, no. 4–5 (June 2016): 363–91.

[11] Diamond and Rosky, “Scrutinizing Immutability”, supra note 8.

[12] Heather Brunskell-Evans, “The Medico-Legal ‘Making’ of ‘The Transgender Child,’” Medical Law Review, June 25, 2019. See also Michael Hannon, “Against Heterosexuality”, First Things, (March, 2014).

[13] Paul Sullins, “‘Born That Way’ No More: The New Science of Sexual Orientation,” Public Discourse (blog), September 30, 2019,; Andrea Ganna et al., “Large-Scale GWAS Reveals Insights into the Genetic Architecture of Same-Sex Sexual Behavior,” Science 365, no. 6456 (August 30, 2019) ; Contrary to the wisdom of the children’s book The Gender Fairy by Jo Hirst, it is not true that “Only you know if you’re a boy or a girl. Nobody can tell you.”

[14] Diamond and Rosky, “Scrutinizing Immutability”, supra note 8; see also Douglas C. Haldeman, “The Practice and Ethics of Sexual Orientation Conversion Therapy.” Professional Psychology: Research and Practice.

[15] Ritch C. Savin-Williams and Geoffrey L. Ream, “Prevalence and Stability of Sexual Orientation Components During Adolescence and Young Adulthood,” Archives of Sexual Behavior 36, no. 3 (June 4, 2007): 385–94.

[16] Johnny Berona et al., “Trajectories of Sexual Orientation from Adolescence to Young Adulthood: Results from a Community-Based Urban Sample of Girls,” Journal of Adolescent Health 63, no. 1 (July 2018): 57–61.

[17] Ryan T. Anderson, When Harry Became Sally (New York, New York: Encounter Books, 2018).

[18] Diagnostic and Statistical Manual-Fifth Edition, p. 455.

[19] For studies which suggest that conversion therapy is not effective, see Phelan, Whitehead, and Sutton, “What Research Shows”, supra note 8; Nicolosi, Byrd, and Potts, “Retrospective Self-Reports”, supra note 8. For studies which suggest that conversion therapy is effective, see Canadian Psychological Association, “CPA Policy Statement on Conversion/Reparative Therapy for Sexual Orientation”; Judith M. Glassgold et al., “Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation” (American Psychological Association, 2009); Haldeman, “The Practice and Ethics of Sexual Orientation Conversion Therapy”, supra note 12.

[20] Douglas C. Haldeman, “Gay Rights, Patient Rights: The Implications of Sexual Orientation Conversion Therapy,” Professional Psychology: Research and Practice 33, no. 3 (2002): 260–64.

[21] Stanton L. Jones and Mark A. Yarhouse, “A Longitudinal Study of Attempted Religiously Mediated Sexual Orientation Change,” Journal of Sex & Marital Therapy 37, no. 5 (October 2011): 404–27. Such a success of 23-30% rate is comparable to programs that deal with other undesired but deeply-engrained behaviors. Alcohol recovery programs, for instance, have an average success rate of only 24%. See W R Miller, S T Walters, and M E Bennett, “How Effective Is Alcoholism Treatment in the United States?,” Journal of Studies on Alcohol 62, no. 2 (March 2001): 211–20.

[22] Jones and Yarhouse, “A Longitudinal Study of Attempted Religiously Mediated Sexual Orientation Change”, supra note 19.

[23] Intersex Society of North America, “How Common Is Intersex?,” (accessed September 16, 2019).

[24] Anderson, When Harry Became Sally, supra note 15, at p. 100.

[25] Robert P. George, requoted in Anderson, supra note 15 at p. 100.

[26] See transcript of oral arguments in A.B. v C.D & E.F at the British Columbia Court of Appeal (2019).

[27] Phelan, Whitehead, and Sutton, “What Research Shows”, supra note 8.

[28] George, “Expressive Ends”, supra note 25.

[29] George, “Expressive Ends”, supra note 25; Victor, “Regulating Sexual Orientation Change Efforts”, supra note 25; Canadian Psychological Association, “CPA Policy Statement on ConversionTherapy”, supra note 17.

[30] Victor, “Regulating Sexual Orientation Change Efforts”, supra note 25.

[31] Ebba K. Lindqvist et al., “Quality of Life Improves Early after Gender Reassignment Surgery in Transgender Women,” European Journal of Plastic Surgery 40, no. 3 (June 1, 2017): 223–26.

[32] Cecilia Dhejne et al., “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden,” PLOS ONE 6, no. 2 (February 22, 2011): e16885; Henk Asscheman et al., “A Long-Term Follow-up Study of Mortality in Transsexuals Receiving Treatment with Cross-Sex Hormones,” European Journal of Endocrinology 164, no. 4 (April 2011): 635–42.

[33] Joost à Campo et al., “Psychiatric Comorbidity of Gender Identity Disorders: A Survey Among Dutch Psychiatrists,” American Journal of Psychiatry 160, no. 7 (July 2003): 1332–36; U. Hepp et al., “Psychiatric Comorbidity in Gender Identity Disorder,” Journal of Psychosomatic Research 58, no. 3 (March 2005): 259–61.

[34] See a multitude of such stories in Anderson, When Harry Became Sally, supra note 15.

[35] The age of minority is defined differently in different provincial legislatures, ranging from 16 to 19. See Nova Scotia, Bill 16, supra note 2; Ontario, Bill 77, supra note 2; British Columbia, Bill M 218, supra note 4.

[36] See Sikkema, John “B.C.’s highest court says 14-year-old can continue hormone treatment, despite gaps in risk disclosure”, for a discussion on serious omissions in medical consent forms for adolescents considering transition.

[37] See Genesis 1:26-31 for an account of what it means to be human. 

[38] Intersex Society, “How Common Is Intersex?”, supra note 21.

[39] For a thorough and compassionate critique of our cultural moment’s deeply religious commitment to gender transitions and identity questions, see Nancy Pearcey, Love Thy Body: Answering Hard Questions about Life and Sexuality (Grand Rapids, MI: Baker Books, 2018).