One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria

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Archives of Sexual Behavior
https://doi.org/10.1007/s10508-020-01844-2
LETTER TOTHEEDITOR
One Size Does Not Fit All: In Support ofPsychotherapy forGender
Dysphoria
RobertoD’Angelo1,2 · EmaSyrulnik2· SashaAyad2· LisaMarchiano2· DiannaTheadoraKenny2· PatrickClarke2
Received: 4 November 2019 / Revised: 17 September 2020 / Accepted: 19 September 2020
© The Author(s) 2020
Turban, Beckwith, Reisner, and Keuroghlian (2020) pub-
lished a study in which they set out to examine the effects of
gender identity conversion on the mental health of transgen-
der-identifying individuals. Using the data from the 2015
U.S. Transgender Survey (USTS) (James etal., 2016), they
found that survey participants who responded affirmatively
to the survey question, “Did any professional (such as a
psychologist, counselor, religious advisor) try to make you
identify only with your sex assigned at birth (in other words,
try to stop you being trans)?” reported poorer mental health
than those who responded negatively to the question. From
this, Turban etal. concluded that gender identity conversion
efforts (GICE) are detrimental to mental health and should
be avoided in children, adolescents, and adults. The study’s
conclusions were widely publicized by mass media outlets
to advocate for legislative bans on GICE, with the study
authors endorsing these calls (Bever, 2019; Fitzsimons,
2019; Turban & Keuroghlian, 2019).
We agree with Turban etal.’s (2020) position that thera-
pies using coercive tactics to force a change in gender identity
have no place in health care. We do, however, take issue with
their problematic analysis and their flawed conclusions, which
they use to justify the misguided notion that anything other
than “affirmative” psychotherapy for gender dysphoria (GD)
is harmful and should be banned. Their analysis is compro-
mised by serious methodological flaws, including the use of
a biased data sample, reliance on survey questions with poor
validity, and the omission of a key control variable, namely
subjects’ baseline mental health status. Further, their con-
clusions are not supported by their own analysis. While they
claim to have found evidence that GICE is associated with
psychological distress, what they actually found was that those
recalling GICE were more likely to be suffering from serious
mental illness. Further, Turban etal.’s choice to interpret the
said association as evidence of harms of GICE disregards the
fact that neither the presence nor the direction of causation can
be discerned from this study due to its cross-sectional design.
In fact, an alternative explanation for the found association—
that individuals with poor underlying mental health were less
likely to be affirmed by their therapist as transgender—is just
as likely, based on the data presented.
Arguably, even more problematic than the flawed analy-
sis itself is the simplistic “affirmation” versus “conversion”
binary, which permeates Turban etal.’s (2020) narrative and
establishes the foundation for their analysis and conclusions.
The notion that all therapy interventions for GD can be cat-
egorically classified into this simplistic binary betrays a mis-
understanding of the complexity of psychotherapy. At best,
this blunt classification overlooks a wide range of ethical and
essential forms of agenda-free psychotherapy that do not fit
into such a binary; at worst, it effectively mis-categorizes eth-
ical psychotherapies that do not fit the “affirmation” descrip-
tor as conversion therapies. Stigmatizing non-“affirmative”
psychotherapy for GD as “conversion” will reduce access to
treatment alternatives for patients seeking non-biomedical
solutions to their distress.
We originally raised our concerns about the quality of
Turban etal.’s (2020) study and the validity of their conclu-
sions in a Letter to the Editor of JAMA Psychiatry, where the
study had been published. However, our letter was rejected,
apparently due to space limitations. In the ensuing months,
as we observed Turban etal.’s unsupported claims of the
harms of psychotherapy for GD taking root globally (United
Nations, 2020), we felt compelled to write a more detailed
critique of the study, which we present here. Our aim is to
put the spotlight on the more problematic areas of Turban
etal.’s analysis and to illustrate how heeding their recom-
mendations will limit access to ethical psychotherapy for
* Roberto D’Angelo
roberto@robertodangelo.com
1 Institute ofContemporary Psychoanalysis, LosAngeles,
CA90064, USA
2 Society forEvidence-Based Gender Medicine, TwinFalls, ID,
USA

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individuals suffering from GD, further disadvantaging this
already highly vulnerable population.
Biased Sample
Turban etal.’s (2020) analysis used data from the 2015 USTS
survey of transgender-identifying individuals (James etal.,
2016). This survey used convenience sampling, a methodol-
ogy which generates low-quality data (Bornstein, Jager, &
Putnick, 2013). Specifically, the participants were recruited
through transgender advocacy organizations and subjects
were asked to “pledge” to promote the survey among friends
and family. This recruiting method yielded a large but highly
skewed sample. While Turban etal. acknowledged that the
USTS may not be representative of the U.S. transgender
population, they treat it as a valid source of data for major
policy recommendations, disregarding the significant bias in
the underlying data.
To demonstrate this apparent bias, we have constructed
Table1, which compares the demographic characteristics of
the USTS participants to those of transgender participants
from a high-quality probability sample collected by the Cent-
ers for Disease Control Behavioral Risk Factors Surveillance
System (BRFSS) (Baker, 2019; CDC, 2014–2017). As Table1
illustrates, even after applying weighting to correct for known
survey biases, the USTS participants were far more likely to be
young (42% vs. 22% were 18–24years old) and educated (47%
vs. 14% had completed post-secondary education) than BRFSS
participants. They were far less likely to own a home (16% vs.
55%) or to be married or coupled (18% vs. 46%). They were
also much more likely to have a non-binary identity (38% vs.
22%) and a markedly different self-reported sexual orientation:
Only 15% of the USTS participants reported a heterosexual
orientation, compared to 69% of the BRFSS participants. (It
is not clear if sexuality in either case was reported relative to
one’s sex or gender identity.)
A number of additional data irregularities in the USTS
raise further questions about the quality of data captured by
the survey. A very high number of the survey participants
(nearly 40%) had not transitioned medically or socially at
the time of the survey, and a significant number reported no
intention to transition in the future. The information about
treatments received does not appear to be accurate, as a num-
ber of respondents reported the initiation of puberty blockers
after the age of 18years, which is highly improbable (Biggs,
2020). Further, the survey had to develop special weighting
due to the unexpectedly high proportion of respondents who
reported that they were exactly 18years old. These irregu-
larities raise serious questions about the reliability of the
USTS data.
In addition to these demonstrable data problems, there are
a number of other biases in the USTS data that likely skewed
the responses. By targeting transgender advocacy groups,
the survey underrepresented the experiences of transgender
individuals who are not politically engaged. The emphasis
on the survey’s goals to highlight the injustices suffered by
transgender people during the recruitment stage and in the
introduction of the survey instrument itself made it vulner-
able to overreporting of adverse experiences due to “demand
bias” (also known as the “good subject effect”). This form of
bias occurs when the researchers reveal their hypothesis and
aims, which encourages participants to support the inves-
tigator’s aims with their answers (Nichols & Maner, 2008;
Orne, 1962; Weber & Cook, 1972). Finally, the experiences
of detransitioners and desisters were not included, as they
were disqualified from completing the survey. Failure to
include detransitioned and desisted individuals in research
regarding psychological interventions for GD is a serious
oversight. These individuals, whose transgender identifi-
cation was transient, may have been hurt by therapies that
affirmed them as transgender, and may have benefitted from
therapies that helped them successfully ameliorate their GD
(D’Angelo, 2020b).
These serious limitations of the USTS survey greatly
undermine the validity of the findings it produced. It is
imperative that any analysis based on this low-quality biased
sample is validated using a high-quality probability sample
before any recommendations stemming from the analysis of
these data can be used to shape clinical or policy decisions.
Invalid Measure ofGender Conversion
Therapy
Turban etal.’s (2020) conclusions rest on the assumption
that they have a valid way of determining whether or not a
respondent was exposed to the unethical practice of conver-
sion therapy. Yet, the USTS question they relied on (Ques-
tion 13.2) is too non-specific to serve as a valid measure
of gender conversion therapy. Firstly, the question conflates
mental health encounters with interactions with other types
of professionals. Secondly, there is no information about
whether the recalled encounter was self-initiated or coerced.
Thirdly, it does not differentiate between diagnostic evalua-
tions or a specific therapeutic intervention. There is also no
information about whether the focus of the encounter was
gender dysphoria or another condition. And finally, it does
not determine whether shaming, threats, or other unethical
tactics were utilized during the encounter. This lack of con-
text and detail renders the question incapable of differentiat-
ing between ethical non-affirmative (neutral) encounters and
unethical conversion therapy.
Consider a common situation where the patient is seek-
ing approval for medical treatment for GD, where the role
of the therapist is to assess the individual’s mental health to

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ensure that GD is not secondary to another condition. Such
encounters can be experienced by patients as an attempt to
withhold the treatment they so desperately want (Chiland,
1997). Further, patients with psychiatric diagnoses, highly
prevalent in transgender-identifying populations (Gijs, van
der Putten-Bierman, & De Cuypere, 2013; Goodman &
Nash, 2018; Wanta, Niforatos, Durbak, Viguera, & Altinay,
2019), can potentially experience or misinterpret neutral
Table 1 Comparison of
demographic characteristics
of transgender-identifying
individuals in the 2015 US
Transgender Survey (USTS)
and the Behavioral Risk Factor
Surveillance System Survey
(BRFSS) 2014–2017
a US Transgender Survey, 2015 (James etal., 2016). Weighted data
b CDC BRFSS Survey, 2014–2017 (Baker, 2019). Weighted data
c Sexual orientation reported based on the respondent self-identification
d Combines all the response options other than “homosexual,” “lesbian/gay,” or “bisexual.”
e Calculated using 2014–2017 BRFSS data (CDC, 2014–2017). Weighted data
USTS, 2015a
Transgender (n = 27,715)
BRFSS,
2014–2017b
Transgender
(n = 3075)
Characteristic
Gender identity
Transgender women (male to female) 33% 48%e
Transgender men (female to male) 29% 30%e
Non-binary/gender-non-conforming 38% 22%e
Sexual orientationc
Heterosexual 15% 69%
Lesbian or gay 16% 10%
Bisexual 14% 15%
Otherd55% 7%
Age
18–24 42% 22%
25–44 42% 30%
45–64 14% 32%
65 + 2% 17%
Race/ethnicity
White, non-Hispanic 62% 55%
Black, non-Hispanic 13% 16%
Asian, Native Hawaiian, or Pacific Islander 5% 5%
Other, non-Hispanic 3% 5%
Hispanic 17% 19%
Education level
Did not graduate high school 2% 21%
Graduated high school 11% 33%
Some college or technical school 40% 32%
Graduated college or technical school 47% 14%
Annual household income
< 25,000 38% 39%
25,000–49,999 24% 24%
50,000 + 38% 37%
Home ownership
Own 16% 55%
Rent 44% 35%
Other arrangement 40% 10%
Marital status
Married or coupled 18% 46%
Divorced, separated, or widowed 10% 21%
Never married 72% 33%

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interpersonal interactions as invalidating or rejecting (Bar-
now etal., 2009; Beck & Bredemeier, 2016; Gotlib, 1983).
Not only does the survey question provide no detail to help
discriminate between these essential therapy encounters and
unethical conversion therapy, but it arguably biases the recall
of neutral encounters toward recall of conversion by using
emotionally charged language (e.g., “stop you being trans”)
and by conflating recall of religiously motivated encounters
with clinical ones.
Turban etal. (2020) ignored these issues and instead cre-
ated a veneer of certainty by referring to USTS question
13.2 as GICE and used it throughout the paper as though it
were a valid equivalent of conversion therapy. Not only it the
term itself novel (the lead author referred to the same USTS
question by yet another term, “PACGI,” in a publication
just weeks earlier [Turban, King, Reisner, & Keuroghlian,
2019]), but its equivalency to conversion therapy is highly
debatable, in part due to the fact that the term itself has not
been defined, other than through a circular reference to USTS
question 13.2 itself.1 Accounting for the many gray areas in
the question wording, we propose that GICE is “any profes-
sional encounter which the subject recalls as non-affirmative
of their transgender identity.” As we have demonstrated, it
is not uncommon for agenda-free, neutral therapy interven-
tions to be experienced by the subjects as non-affirmative.
However, non-affirmative is not the same as “conversion,”
as the latter implies a therapist agenda and an aim for a fixed
outcome (American Psychological Association, 2015). In
fact, it is the utter inability of USTS question 13.2, and con-
sequently, GICE, to differentiate between agenda-free ethical
psychotherapy and coercive, agenda-driven therapy, that is
the Achilles heel of Turban etal.’s entire argument.
Misinterpretation ofaKey Scale
A key finding of Turban etal.’s (2020) analysis is that the
USTS participants who recalled exposure to GICE were more
likely to report severe psychological distress, as evidenced
by their score of
≥
13 on the K-6 scale. From this, Turban
etal. concluded that GICE has adverse effects on mental
health. We will address the unsupported claim of causa-
tion in a subsequent section. Here, we would like to further
explore the use of the K-6 scale to make these claims, and
its implications.
The K-6 scale, and its cutoff score of
≥
13, was specifically
developed by Kessler etal. (2003) in order to discriminate
between cases of non-specific psychological distress and
cases of serious mental illness (SMI). Scoring
≥
13 is pre-
dictive of having a DSM diagnosis of schizophrenia, bipolar
disorder, and a range of other major mental health conditions
that cause serious functional impairment (Substance Abuse
and Mental Health Services Administration, 2020). Thus,
Turban etal.’s (2020) finding of an association between the
recall of GICE and scoring
≥
13 actually suggests that the
USTS participants recalling GICE were more likely to have
a severe mental illnesses diagnosis than those not recalling
GICE. Further, any claim of causation, which Turban etal.
continue to suggest throughout the paper (however unsup-
ported by the study design), would imply that exposure to
GICE caused serious mental illness, in previously mentally
well populations. This is a highly speculative and implausible
hypothesis, which further challenges their claims.
Omission ofaKey Control Variable
Turban etal.’s (2020) hypothesis, namely, that GICE expo-
sure (during lifetime, as well as in childhood) causes poor
mental health and contributes to suicide attempts, is further
weakened by a significant flaw in their data analysis: failure
to control for the individuals’ pre-GICE-exposure mental
health status. Not only does this critical omission confound
the association between exposure to GICE and present men-
tal health, but it may mask reverse causation, namely, that it
was the individual’s underlying poor mental health that led
to their experience of GICE in the first place.
Let us revisit the example of a common clinical encounter
in which a person with GD and one or more comorbid psy-
chiatric conditions presents for assessment with the goal of
obtaining approval for cross-sex hormones. An assessment of
such a complex presentation generally requires multiple ses-
sions and involves ascertaining whether the GD is secondary
to another condition. It is also likely that the clinician might
focus on treating the comorbid condition(s) first, before pur-
suing “gender-affirming” interventions. While such a contact
would be recalled by the respondent as non-affirmative and
thus likely classified as GICE, it is the patient’s poor men-
tal health status that led to the non-affirming content of the
encounter, rather than vice versa. If the said individual had
attempted suicide in the past or continued to struggle with
mental illness more recently, Turban etal.’s (2020) analysis
would erroneously conclude that GICE was likely respon-
sible for those difficulties, when, in fact, no such causation
occurred.
In fact, failure to control for the subjects’ baseline mental
health makes it impossible to determine whether the men-
tal health or the suicidality of subjects worsened, stayed the
same, or potentially even improved after the non-affirming
encounter. Given the high rate of co-occurring mental illness
in transgender-identifying patients (Gijs etal., 2013; Good-
man & Nash, 2018; Wanta etal., 2019), failure to control for
prior mental health status is a serious methodological flaw.
1 Psychological Attempts to Change Gender Identity.

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Internal Inconsistencies inMental Health
Measures
Turban etal.’s (2020) finding that mental health outcomes
of persons exposed to GICE are worse than those whose
encounters were “gender-affirming” is weakened by inter-
nal inconsistencies in the mental health outcome meas-
ures. We have already discussed the fact that the threshold
chosen by Turban etal. on the K-6 scale detects serious
mental illness, rather than distress. Another measure of
psychological distress chosen by Turban etal.—substance
misuse—was not significantly different between GICE and
the non-GICE group. More importantly, there is a lack of
consistency in the suicide measures. While lifetime sui-
cide attempts were elevated among the GICE group, total
suicide attempts in the prior 12months, as well as suicide
attempts requiring hospitalization, which generally indicate
more serious attempts rather than non-suicidal self-injury,
were not significantly different between the two groups.
Turban etal. did not address this inconsistency. Nor did
they explore the relationship between suicidality and the
higher levels of serious mental illness among the GICE
group, despite the well-documented link between serious
mental illness and suicide (Bertolote, Fleischmann, De
Leo, & Wasserman, 2004). Turban etal. did not heed their
own warning not to attribute the increased lifetime suici-
dality entirely to GICE since “other factors are also likely
to be associated with suicidality among gender-diverse
people.” Instead, they treat the inconsistent and unclear
association between GICE and suicidality as causative and
infuse it with an air of certainty by elevating it into title
of their paper.
Claim ofCausation When Only
anAssociation Has Been Found
Although a causative relationship between recalled GICE
and adverse mental health status is possible (even if direc-
tion of the causality is unclear), the cross-sectional design
of the USTS is not capable of determining causation. While
Turban etal. (2020) acknowledged this limitation and cor-
rectly referred to the relationship they found as an asso-
ciation, they strongly implied causation throughout their
discussion, as well as in their “Conclusions and Relevance”
section, which states, “These results support policy state-
ments from several professional organizations that have
discouraged this [GICE] practice.” Presenting a highly
confounded association as causation is a serious error,
given its potential to dangerously misinform and mislead
clinicians, policymakers, and the public at large about this
important issue.
Discussion
The fact that coercive techniques to force unwanted changes
in individuals are unethical and have no place is modern
psychotherapy is self-evident and needs no additional jus-
tification. However, as we have demonstrated, Turban etal.
(2020) failed to prove that GICE, as defined by affirmative
answers to the USTS question, caused poor mental health or
suicide attempts in study subjects. Further, since Turban etal.
failed to establish equivalence between GICE, which likely
subsumes a range of ethical non-affirmative interventions,
and “gender conversion therapy,” which implies unethical
and coercive attempts to force a change in one’s identity,
their use of the study findings in support of a ban on “gender
conversion therapy” is without any foundation.
Rather than appropriately acknowledging the significant
study limitations and calling for more research, Turban etal.
(2020) used their flawed findings to engage in a media cam-
paign promoting legislative bans of GICE. Two of the study
authors penned an op-ed in which they state, “It’s time for
conversion efforts to be illegal in every state, before more
people die” (Turban & Keuroghlian, 2019). Turban, the lead
author, repeated these sweeping, emotive claims on several
highly visible national media platforms (Bever, 2019; Fitzsi-
mons, 2019). In contrast, the debate regarding this study in
the scientific arena was not allowed to occur. To the best
of our knowledge, all of the letters written to the Editor of
JAMA Psychiatry, many by respected academics and clini-
cians who outlined the serious problems in the study, have
been rejected (some of them were later submitted as non-
indexed comments in the online publication). The omission
of these important arguments from the scientific discourse
stifles scientific debate and perpetuates the current politiciza-
tion of transgender health care, where treatment decisions are
increasingly legislated by politicians.
While the poor study methodology is unfortunate, argu-
ably, the most problematic aspect of Turban etal.’s (2020)
work is the choice to view psychotherapy through a binary
of “affirmation” versus “conversion,” resulting in a confla-
tion of ethical non-affirmative psychotherapy with conver-
sion therapy. The self-evident crudeness of the GICE versus
“affirmation” binary, promoted by Turban etal., and the
potential harms of such a simplistic view of psychotherapy
are illustrated by the following examples.
Consider a female victim of sexual assault, who sub-
sequently develops an intense discomfort with her female
anatomy and expresses a desire to undergo biomedical inter-
ventions to change her body. It would be unethical for the

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clinician to overlook the contribution of sexual victimization
to this nascent GD. A therapist enthusiastically supporting
this patient’s new male identity would be failing to provide
appropriate treatment for what amounts to a post-traumatic
condition, instead providing an inappropriate treatment
with the potential to harm. Similarly, a boy who has been
traumatized by relentless bullying due to his gender “non-
conformity” (e.g., interest in classical music or fashion and
avoidance of sports) may conclude that if he were a girl then
he would “fit in” and the humiliation would stop. In this case
too, gender-affirming interventions miss the mark when what
this traumatized young person requires is psychotherapy.
Another obvious difficulty arises when same-sex attracted
adolescents report cross-sex identifications. Research shows
that a high number of homosexual adults have experienced
periods of “cross-sex” behaviors and cross-gender identifi-
cation in childhood and adolescence, often to a degree that
is severe enough to warrant the diagnosis of GD, or gen-
der identity disorder, as it was previously known (Bailey
& Zucker, 1995; Bell, Weinberg, & Hammersmith, 1981;
Hiestand & Levitt, 2005; Li, Kung, & Hines, 2017). When
a dysphoric same-sex attracted young person in the midst of
this developmental process presents for mental health care,
a clinician overtly affirming the patient’s cross-sex gender
identity would be failing this patient by not addressing the
patient’s struggle with same-sex attraction and/or internal-
ized homophobia. In fact, some homophobic societies and
indeed families that reject homosexuality among their chil-
dren have embraced the “affirmative” biomedical pathway
(Bannerman, 2020; Hamedani, 2014), which poses a question
as to whether “affirmative” care in some instances serves the
role of gay conversion therapy.
Further, GD can present as a transient symptom that
resolves spontaneously or in the context of developmentally
informed psychotherapeutic treatment. Some common exam-
ples of transient gender-dysphoric states include adolescents
girls, often on the autism spectrum, experiencing distress
around the physical and social changes of puberty or gen-
der-non-conforming young women struggling with shame
about being seen as “butch.” These individuals, searching for
ways to understand and remedy their distress, can incorrectly
attribute their discomfort to being transgender. Several case
reports (Churcher Clarke & Spiliadis, 2019; Lemma, 2018;
Spiliadis, 2019) indicate that the distress of young people
with GD can lessen or resolve with appropriate psychothera-
peutic interventions that address the central issues.
If anything other than “affirmation” is viewed as GICE,
it follows that the provision of psychotherapy in these clini-
cal scenarios would be seen as harmful conversion efforts.
Yet these therapeutic interventions do not aim to convert or
consolidate an identity, but instead aim to help individuals
gain a deeper understanding of their discomfort with them-
selves, the factors that have contributed to their distress, and
their motivations for seeking transition (Bonfatto & Cras-
now, 2018; D’Angelo 2020a). These exploratory questions
are consistent with the principle of therapeutic neutrality—a
cornerstone of ethical psychotherapy (Simon, 1992). In fact,
both “conversion” and “affirmation” therapy efforts carry the
risk of undue influence, potentially compromising patient
autonomy. In contrast, the provision of a neutral, unbiased
psychotherapeutic process that allows these patients to clarify
their feelings and assess the various treatment options, which
range from non-invasive to highly invasive, irreversible pro-
cedures, is arguably the only way that meaningful informed
consent for the latter can be obtained (Levine, 2018).
Turban etal.’s (2020) unproven assertion that non-affirming
therapies are dangerous stands in contrast to the documented
risks and uncertainties associated with hormonal and surgi-
cal interventions that are a core part of the “affirmation” treat-
ment path. Until recently, puberty blockers were considered
safe and fully reversible, but there is now emerging evidence
of their adverse effects on the bone and brain health (Klink,
Caris, Heijboer, van Trotsenburg, & Rotteveel, 2015; Joseph,
Ting, & Butler, 2019; Schneider etal., 2017). Additionally,
since almost all of the children treated with puberty blockers
proceed to cross-sex hormones (de Vries etal., 2014), concerns
have been raised that puberty blockers may consolidate gender
dysphoria in young people, putting them on a lifelong path of
biomedical interventions.
Cross-sex hormones are associated with cardiovascular
complications, including a fourfold increased risk of heart
attacks in biological females, and a threefold increase in the
incidence of venous thromboembolism in biological males
(Alzahrani etal., 2019; Nota etal., 2019). “Gender-affirming”
surgeries can cause urethral stricture, neo-vaginal stenosis
and prolapse, and long-term post-mastectomy pain (Larsson,
Ahm Sørensen, & Bille, 2017; Manrique etal., 2018; Rashid
and Tamimy, 2013; Santucci, 2018). The effects of “gender-
affirmative” care on fertility have not been adequately stud-
ied, but infertility is a likely outcome, depending on the spe-
cific treatments pursued. It remains unclear whether fertility
concerns will be important to this group of patients as they
mature, but increasingly, gender centers are recommending
fertility preservation procedures prior to undergoing hormo-
nal interventions.
Given the absence of robust long-term evidence that the
benefits of biomedical interventions outweigh the potential
for harm, especially among young people (Heneghan & Jef-
ferson, 2019), it is self-evident that the least-invasive treat-
ment options should be pursued before progressing to more
risky and irreversible interventions. To the extent that psy-
chological treatments can help an individual obtain relief
from GD without undergoing body-altering interventions,
ensuring access to these interventions is not only ethical and
prudent but also essential.

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The importance of continued access to non-affirmation –non-
conversion, agenda-free evaluation, and treatment is further
underscored by the increasing numbers of detransitioning
patients speaking out in social media forums following gen-
der transitions they have come to regret (Entwistle, 2020).
The rate of regret, detransition, and desistance from transgen-
der identification is largely unknown (Butler & Hutchinson,
2020). The majority of patients with classical, childhood-
onset gender dysphoria (61%-98%) desist from transgender
identification some time in adolescence or young adulthood
(Korte etal., 2008; Steensma, McGuire, Kreukels, Beek-
man, & Cohen-Kettenis, 2013; Zucker, 2018). The minority
who persist with their transgender identification into adult-
hood and undergo “gender-affirmative” surgeries have been
reported to have low rates of regret (van de Grift, Elaut, Cer-
wenka, Cohen-Kettenis, & Kreukels, 2018) and detransition
(Dhejne, Öberg, Arver, & Landén, 2014). However, these
studies may understate true regret rates due to overly strin-
gent definitions of regret (i.e., requiring an official applica-
tion for reversal of the legal gender status), very high rates of
participant loss to follow-up (22%-63%) (D’Angelo, 2018),
and an unexplored relationship between regret and high rates
of post-transition suicide (Dhejne etal., 2011).
The novel cohort of young GD patients increasingly pre-
senting for help is poorly understood. It is overrepresented by
adolescent females with recent-onset GD and with comorbid
mental health and neurocognitive issues (Bewley, Clifford,
McCartney, & Byng, 2019; de Graaf, Giovanardi, Zitz, &
Carmichael, 2018; Kaltiala-Heino, Bergman, Työläjärvi, &
Frisen, 2018; Littman, 2018; Zucker, 2019). The trajectory of
GD among these young patients, including the rates of desist-
ance and detransition, remains unknown. However, many of
us, along with our colleagues, are seeing increasing numbers
of detransitioners with adolescent-onset GD who regret not
having received exploratory psychotherapy to help them
understand their distress and the desire to transition before
they underwent irreversible medical and surgical treatments.
Equally concerning, a number report that when doubts about
their own transgender status arose, their therapists contin-
ued to affirm them as transgender, attributing their doubts to
internalized transphobia, and encouraging them to continue
medical interventions, which, in turn, unnecessarily exacer-
bated the psychological and physical harms.
Advocates of “affirmative care” tend to downplay the risks
of iatrogenic harms resulting from inappropriate transitions
and minimize the seriousness of the resulting harms by
describing them as merely “cosmetic” (Turban & Keurogh-
lian, 2018). In stark contrast to these assertions, we are seeing
increasing numbers of patients who feel deeply traumatized
by inappropriate transitions. They suffer from irreversible
physical changes, including alterations to their genitals and
sexual function, sterility, painful vaginal atrophy, chest/breast
alteration and scarring, deepening of the voice, unwanted
permanent changes to facial hair growth, male-pattern bald-
ness, urinary incontinence, and other lasting effects. Apart
from the distress that these changes cause, they also nega-
tively impact many areas of their lives, including their ability
to form a stable gender identity (many feel trapped in a “gen-
der no-man’s land”), to find romantic partners and supportive
social networks, to bear children, or to secure employment.
The process of coming to terms with these consequences of
their transition is psychologically difficult and can be pro-
foundly painful.
Given the risky and irreversible nature of “gender-affirm-
ing” treatments, it is concerning that for many years now,
there has been a lack of systematic research into the role that
developmentally informed psychotherapy can play in the ame-
lioration of GD, especially among young people. The need
for the continued development and evaluation of non-invasive
psychological treatment alternatives for GD has never been
more urgent, given the fact that over 3% of young people report
transgender identification or ideation (Johns etal., 2019).
Given the sheer magnitude of this change, and the potential
for exponential growth in the number of individuals who are
medically harmed, it is time to raise the bar on science and to
heed the first and most fundamental tenet of medicine: “First,
do no harm.”
Conclusions
Turban etal.’s (2020) singular endorsement of “affirmative”
therapies, which their data failed to substantiate, contrib-
utes to the alarming trend to frame any non-“affirming”
approaches as harmful. We are deeply concerned that this
false dichotomy, reinforced by Turban etal.’s unproven
claims of the harms of GICE, will have a chilling effect on
the ethical psychotherapists’ willingness to take on com-
plex GD patients, which will make it much harder for GD
individuals to access quality mental health care. We main-
tain that availability of a broad range of non-coercive, ethi-
cal psychotherapies for individuals with GD is essential to
meaningful informed consent, which requires consideration
of the full range of treatment options, from highly invasive to
non-invasive. Further, given the potential of agenda-free psy-
chotherapy to ameliorate GD non-invasively among young
people with GD, withholding this type of intervention, while
promoting “affirmation” approaches that pave the way to
medical transition, is ethically questionable.
We believe that exploratory psychotherapy that is neither
“affirmation” nor “conversion” should be the first-line treat-
ment for all young people with GD, potentially reducing the
need for invasive and irreversible medical procedures. This
is especially critical now, when we are witnessing an expo-
nential rise in the incidence of young people with GD who

Archives of Sexual Behavior
1 3
have diverse and complex mental health presentations and
require careful assessment and treatment planning.
We are concerned about the deficit in our knowledge base
about psychological interventions for GD, beyond a few suc-
cessful but small case studies, and we fear that the erroneous
conclusions presented by Turban etal. (2020) will make it
less likely that such research will be carried out in the future.
We call on the scientific community to resist the stigma-
tization of psychotherapy for GD and to support rigorous
outcome research investigating the effectiveness of various
psychological treatments aimed at ameliorating or resolving
GD. The outcomes of psychotherapeutic treatments must
be compared to those of biomedical interventions, so that
evidence-based standards of care that allow patients and cli-
nicians to make fully informed decisions about how best to
alleviate GD can be developed and put into practice.
Open Access This article is licensed under a Creative Commons Attri-
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tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
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permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/.
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