David Pilgrim posts….
Although no one yet has responded to my earlier piece on this blog, there has been some Twitter activity of relevance passed on to me by Pat Harvey. Two historians (Dr Sarah Marks and Dr Kate Davison) have offered criticisms of my arguments about the Birmingham University report. Here are my responses to their claims that my critique of the report was, in some ways, flawed.
1 My piece reflected activism. This is a fair and correct accusation. We are a group of activists concerned primarily with misgovernance in the BPS, with child protection being implicated as a result. My piece was not a journal submission (it would have been stylistically different) but neither was the Birmingham University report, as it was generated for external consumption by paid employees. Both reflect interest work but we are being explicit about our campaign aims. By contrast, the Birmingham group offered a report that was seemingly disinterested – but was it? Cue the next point…..
2 Dr Marks conceded that historians ‘have an agenda’. Indeed they do, and more so in this case. In my view the Birmingham historians were remiss in not making a reflective declaration. Moreover, Marks defends her colleagues in Birmingham for conveniently ‘grouping’ conversion therapy and aversion therapy as an ‘analytical device’. She concedes explicitly that this might well be anachronistic in its logic. If this is so, who exactly then is benefiting from this tolerance of anachronistic thinking from professional historians? Surely they should be the very people who are careful to steer us clumsy amateurs away from anachronisms. I interpret this break from professional methodological convention as a reflection of the virtue-signalling priorities, which now dominate the zeitgeist of identity politics in neoliberal times. (I elaborate that point at length in my recent book Identity Politics: Where Did It All Go Wrong?).
3 Dr Davison noted that in the wider aversion therapy literature, although homosexual men were overwhelmingly the main focus, there were smaller numbers of research subjects of lesbians, transvestites and transsexuals, as well as exhibitionists and fetishists (Bancroft, 1969; Bancroft and Marks, 1968). This does not alter the fact that homosexual men were the focus of the Feldman and MacCulloch work, which was allegedly the very point of the Birmingham report about disgraced ex-staff, and accordingly my piece stayed with that focus. Moreover, that work was research; it did not reflect contemporary clinical routines, cueing the next point.
4 The norm emerging in the 1970s for adult transsexuals was for them to attend for regular monitoring by psychiatrists, while living as the opposite sex, in order to obtain referrals for hormones and surgery. The psychiatric consideration then was on the psycho-social adjustment of adult transsexuals. It is crucially important to note here that the focus was adults, not children who are the focus of recent health policy controversy. This was about the use of mental health assessments of adults prior to their bio-medicalisation, not routine aversion therapy. The BBC2 documentary in 1979, called A Change of Sex, illuminated well this typical psychiatric surveillance of the time. (It had a medical assessor with an unforgivably persecutory professional style when he was interrogating the MtF transsexual, and a poor mistreated patient, Julia Grant). At that point children were not implicated in protocols about transgender care, but that was to change (see point 7 later).
5 For emphasis (for those who are not clinical psychologists) behaviour therapy was about behaviour and it was behavioural criteria that were used to check efficacy. The intention of the research intervention by Feldman and MacCulloch was to displace same-sex arousal with heterosexual arousal. This emphasis on altering sexual interest was aligned epistemologically with methodological behaviourism (hegemonic at the time but, note, not today). By contrast, the concern of transgender activists now is all about identity. This is a much wider existential matter (e.g.‘Who is the real me?, ‘Can I be my true self?’, ‘Will medicine cooperate in my preferences for body modification to make me feel better about life?’). It is simply dishonest to conflate these two matters of the scenario of defunct aversion therapy with recent therapeutic encounters about gender confusion, especially when children, not adults, are the clinical focus. The closure of GIDS and the Cass Report should be our point of reflection today about child protection, not what happened in 1970 to adult homosexuals.
6 If the Birmingham report authors or any other historians, such as Drs Marks and Davison, are inclined to offer us a longer and fuller historical context that is fine and would be welcomed, but that would need to report what has happened since 1980. This has included: the postmodern turn; the gap between second and third wave feminism; the claims from Queer Theory and its neologisms, like ‘cis’; the risky introduction of the provisional Dutch protocol elsewhere as a standard service philosophy; 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; the shift from ‘women’s studies’ to ‘gender studies’; and the new norms of rapid ‘clictivism’, created by social media. To miss out this long list of important details affords a false conflation of aversion therapy, pre-1980, and exploratory psychological therapy of today. This post-1980 scenario has involved the LGB Alliance splitting off from Stonewall. Why has that happened? Why has equality now been displaced by identity? These are pertinent historical questions which cannot be answered by looking narrowly at the long-gone discredited work of Feldman and MacCulloch (or for that matter, Marks and Bancroft). Yes, let us have history; we need much more of it not less. However, it must also consider what happened after 1980 to account for current transgender activism. In other words, why was 1980 different from both 1970 and 2020? It also should consider the wider picture circa 1970, cueing the next point……
7 Professional historians such as Drs Marks and Davison might also help us to ‘get the story right’ about the 1970s. By focusing on the alleged unbroken link between then, when aversion therapy for homosexuality predominated, and now, when the matter in dispute is the reasons for the closure of GIDS, a key feature of the 1970s is then ignored. The care of transsexual adults in the 1970s and beyond was not routinely governed by the goal of the patient accepting their natal sexed body (with or without the use of aversion therapy) but instead in permitting its bio-medical manipulation after a period of psychosocial assessment (see point 4 earlier). Psychiatrists then were gatekeepers for access to other medical specialists (endocrinologists and cosmetic surgeons), not therapists. The later mission creep of this gatekeeping function of mental health services, increasingly implicating psychologists, from adults to children, came originally from the work of Harry Benjamin in the 1960s (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. Here then is the link with the affirmative approach of GIDS (now closed) which, quite properly, remains the focus of a post-mortem.
Implications
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 both from transsexualism and eroticised transvestism. The latter was to be later conceptualised as one aspect of variegated transgender phenomena, ‘autogynephilia’ (Blanchard, 1991).
The mission creep of transgender activism, supported during the postmodern turn by Queer Theory and Third Wave feminism, from adults to children should be at the centre of any historical understanding of why the Cass Report emerged. It also explains why thirty five disaffected therapists left GIDS between 2016 and 2019, with some of them warning of the upcoming medico-legal challenge of de-transitioners suffering iatrogenic symptoms (Butler and Hutchinson, 2018).
There is now a clear link to be made (diverted from our needed attention by focusing on homosexuality and aversion therapy) between the Benjamin care regime for adults in the 1970s and children in the past twenty years. The Center of Expertise on Gender Dysphoria in Amsterdam and then GIDS in London in the 1990s began to experiment with the impact of puberty suppression, while affirming credulously the child’s subjective identity. From the outset no one knew whether this would be effective in creating mental health gain 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). That Pollyanna optimism is now facing some earnest reality testing in the wake of the internal report at the Tavistock Clinic in 2018 from David Bell and, more importantly, the Cass Review in 2022.
In case the above points from me are dismissed as merely of academic interest, we know that the young are exposed to social media reports that healthcare professionals today supposedly torture gender non-conforming children. This preposterous myth will continue to be reinforced and legitimised, unless we make some important honest distinctions. Homosexuality is not transsexualism and it does not require any self-doubts about the ontology of our sexual anatomy. Children are not adults. Mainstream secular mental health services are not fundamentalist religious organisations.
All these distinctions are important politically right now, if we are to discern what connects the past and present, but also how things have changed and for what reason. The work of Harry Benjamin has much more to offer us in terms of clarifying the role of history than that of Feldman and MacCulloch.
At the heart of the standoff now between gender critical clinicians and transgender activists is the meaning of the term ‘conversion therapy’. The first emphasise that putting healthy sexed bodies, with immutable chromosomes at risk of iatrogenic damage is a form of ‘conversion’. The second emphasises that to offer a cautious exploratory alternative to that bio-medicalisation is a form of ‘conversion’, because it prevents children who believe that they were born in the wrong body having their current desire fulfilled. We can all have a view about which case is more persuasive on empirical and ethical grounds.
References
Bancroft, J. (1969). Aversion therapy of homosexuality: A pilot study of 10 cases. British Journal of Psychiatry, 115(529), 1417-1431.
Bancroft, J. and Marks, I. (1968). Treatment of sexual deviations. Proceedings of the Royal Society of Medicine. 61 (8): 796–79
Benjamin, H. (1966) The Transsexual Phenomenon New York: Julian Press.
Blanchard R. (1991) Clinical observations and systematic studies of autogynephilia. Journal of Sex and Marital Therapy. 17, 4, 235-5.
Biggs, M. (2022). The Dutch protocol for juvenile transsexuals: origins and evidence. Journal of Sex and Marital Therapy. 19, 1-21.
Butler, C. and Hutchinson, A. (2020), Debate: The pressing need for research and services for gender desisters/detransitioners. Child and Adolescent Mental Health, 25: 45-47.
de Vries, A. and Cohen-Kettenis, P. (2012) Clinical management of gender dysphoria in children and adolescents: The Dutch approach. Journal of Homosexuality, 59 (3), 301-320.
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