Tue 7 May 2024 — 28 min

Recommendation 3 of the Cass Review contains a smoking gun for conversion abuse in the NHS. One of the sources cited in support of the recommendation is a 2022 research article by a group of Tavistock clinicians describing their attempts to treat ‘gender-related distress’ with CBT (cognitive behavioural therapy). The authors take great pains to distinguish their approach from conversion therapy, but they nonetheless suggest that they may be able to help some young people ‘manage their distress without physical intervention.’ CBT-based conversion therapy in the NHS has a long, sordid, and little-known history. In the light of that history, both the Tavistock’s therapies and Cass’ recommendations look shockingly familiar.

CBT and Conversion Therapy

UK histories of conversion therapy often focus on the 1950s, 60s and 70s, a time when the state notoriously worked closely with the NHS to force violent aversive therapies on gay men¹. The decriminalisation of some gay sex did not, however, spell the end of NHS conversion therapy. While Clockwork Orange-style aversives fell out of favour with clinicians in the 1970s, new approaches took their place. One such approach was cognitive behavioural therapy². The British Association for Behavioural and Cognitive Psychotherapies (BABCP) was founded in 1972, and acts as the accrediting body for CBT therapists in the UK and Ireland. When, in 2022, the organisation celebrated its 50th birthday, the podcast Let’s Talk About CBT held a retrospective, featuring several founding members of the organisation. One of the founders, Howard Lomas, reflected on how important the founding of the BABCP in 1972 was to CBT’s subsequent success. By the 1970s, behaviourism had lost its sparkle. “Behaviour therapy”, Lomas said, “was known very much as behaviour modification, which has got an involuntary feel about it.” Aversive behavioural therapy was “being used for trying to change homosexuality in people”. But following a “big scandal” at Napsbury Hospital and a major government enquiry, the BABCP came together and formed new good practice guidelines. Public backlash against aversive behaviour therapies had set the stage for something new - and as the years went by, CBT would become a perfect rebrand for the increasingly unpopular behaviourists. But the backlash was primarily against aversives, not against therapists trying to make patients straight and cisgender - and the new CBT had not given up on this.

“There’s a few things I think are real problems in the history of our therapy. And probably the one that stands out the most is the role of behaviour therapy predominantly in conversion therapy for people that are LGBT identities. And if you look back at conference proceedings from BABCP conferences 30, 40 years ago this was something that was seen as unproblematic.”
— Andrew Beck, former president of the British Association for Behavioural and Cognitive Psychotherapies, July 2022, on the Let’s Talk About CBT podcast

In the 1980s, conversion therapy had a new look. Behaviourists had become cognitive behaviourists, and choice and flexibility were their watchwords. In 1986, seminal US sex therapist Helen Kaplan published an article covering treatment options for ‘ego-dystonic homosexuality’.³ The piece opens: “The patient coming in with a dysphoria over his or her homosexual feelings, fantasies or behavior must be given the choice of working through the homophobia or the heterophobia”. If the patient chooses homosexuality, the treatment is simple - work on reducing shame. If, however, ‘a move toward greater heterosexuality is chosen’ then psychoanalysis, time-limited psychodynamic psychotherapy, and behavioural techniques may all be used. The goalposts had shifted, but the game remained the same. Aversives were a barbaric mistake of a past age, but ‘dysphoria’ over ‘homosexual feelings’ could be alleviated with CBT. Who wouldn’t want to alleviate a patient’s distress?

The same thing was happening in the UK, seemingly on the NHS. In 1987, Patricia Gillan published Sex Therapy Manual, to a glowing BABCP journal review.

“Nowadays the attitude towards therapy for homosexuals has changed and the days of aversion therapy are more or less a thing of the past. [...] Nowadays, when a client wants to change his or her sexual orientation, other methods like ‘orgasmic reconditioning’ are used.
Orgasmic reconditioning methods are more flexible as at the end of therapy the homosexual can make a decision himself and remain totally homosexual or try bisexuality. He has a choice.”
— Patricia Gillan, Sex Therapy Manual, (Oxford, 1987), p. 29.

Sex Therapy Manual contains explicit instructions on how to do conversion therapy - but presents itself as a new, kinder therapeutic approach. Gillan’s book draws heavily on case studies from her work in Maudsley Hospital in London, where she co-founded the Maudsley Psychosexual Clinic with Michael Crowe. This clinic, now the Maudsley Psychosexual Service, still exists. Both Gillan and Crowe have retired from public practice. If (as the evidence suggests) orgasmic reconditioning methods were offered for ego-dystonic homosexuality at the Maudsley in the 1980s, it is unclear when they stopped - unsurprisingly, they are no longer advertised as part of their service. ‘Psychological support for people experiencing gender dysphoria’, however, is.

Third-wave CBT and Cass

Gillan’s Sex Therapy Manual gestured towards the possibility of unpathologised gay identity, but it did not extend the same courtesy to trans people. The closest it comes is in the introduction, where Gillan remarks that ‘transvestites’ (grouped here with exhibitionists) are ‘probably regarded with less fear than by previous generations’. The public, we are told, could be ‘beginning to think of them as sick rather than dangerous’. While ‘ego-dystonic sexual orientation’ was finally removed from the World Health Organisation’s International Classification of Diseases in 2019, ‘gender incongruence’ remains. Patient reports suggest that coercive therapeutic approaches were still being forced on trans patients in the NHS throughout the 2000s. So how new is the CBT approach cited in the Cass Review?

The first mention of CBT in the review is in the section titled ‘Specialist Mental Health Conditions’, where ‘exposure-based cognitive behavioural therapy’ is raised as an effective treatment for Body Dysmorphic Disorder (BDD). The review reports that when a patient experiences ‘distress about genitalia or breasts’, it can be ‘difficult to determine whether the distress is due to BDD or gender dysphoria’. After a course of exposure therapy, some patients ‘say they no longer feel ill at ease with their birth-registered gender’, while others ‘may have less distress about their genitalia or breasts but still have marked gender incongruence and proceed to a social or medical gender transition’. Several things stand out here. First, as Elia Cugini has reported, this is not a neutral approach: a trans life is being treated as something to be averted. Perhaps more strangely, this omits a relatively common outcome: CBT not working at all. Even the most positive reports of CBT efficacy for BDD don’t say it works for everyone - and previous studies have found efficacy rates between 46% and 60%.⁴ The possibility of trans patients undergoing distressing exposure therapy focused on their ‘genitalia or breasts’ to no discernible benefit is simply ignored. The source for this information makes this more concerning - this is drawing on what clinicians have told the review, presumably about their existing clinical practice. Have trans children already been subjected to exposure therapies focused on their genitals within the NHS, in the hope this might make them cis?

The Cass Review gestures, in its own way, at this question. Under ‘Current NHS Practice’, the report notes that while some patients in the service have had 1 or 2 appointments, some have had ‘in excess of 100’. The report concludes that ‘this indicates that some practitioners must have been providing therapeutic input to patients, despite the fact that there was not a formal structured programme in place.’ Even with the best-intentioned clinical team, a total lack of transparency is a recipe for abuse. The context of this therapy also points to an unusually extreme power imbalance between therapist and patient. Assessment, according to the report, ‘formed the starting point for a therapeutic relationship which could continue over many sessions’. The report goes on to link this informal therapy with denial of access to medical transition: ‘It appears that, for those young people for whom an endocrine option was not the best option, staff at GIDS were doing their best to provide ongoing support, perhaps because local services were not able to offer this’. Can patients meaningfully consent to therapy carried out under these circumstances? And what does therapy look like when the aims of the patient and the therapist are at odds?

“I am really glad that I didn't go on testosterone, because I realized during like my 17 sessions at GIDS that that wasn't for me.”
— Anonymised ‘young person’ from a lived experience focus group, Cass 11.32

What kinds of ‘ongoing support’ are unavailable through local NHS mental health services? The next point gives us a clue. Cass 11.33 refers to clinicians’ concerns that long waiting lists ‘can be a barrier to having exploratory discussions with children and young people that could provide them with a broader range of options for addressing their distress’. This language is eerily evocative of exploratory therapy, a paradigm that is repeatedly defended in the Cass Review, and has been critiqued for its lack of specific parameters, ethical issues, and material links to conversion therapy groups.⁵ The report goes on to make the purpose of this therapeutic intervention explicit: ‘by the time young people are seen they have often made their minds up that an endocrine pathway is their chosen option and do not want to consider other approaches’. The Cass Review is concerned about the efficacy of these therapies, but not the risk of adverse effects, or the potential for abuse.

Without formal structure or transparency, it’s hard to estimate the nature and extent of these therapies. We can, however, get some insight from the following paragraph, which contains the first and only reference to published research in this section:

“The Review also heard that some staff had looked at how standard evidence-based treatments (in this case third-wave CBT) could be used to help young people to manage their gender-related distress, stressing that this can be achieved without pathologising or changing a young person’s gender identity (Canvin 2022). However, this was not developed into a full research study.”
— Cass, 11.34

‘Gender-related distress’: the new ‘dysphoria over homosexual feelings

The full title of the 2022 article is ‘Supporting young people to manage gender-related distress using third-wave cognitive behavioural theory, ideas and practice’. It was written by Lauren Canvin, Oliver Hawthorne and Holly Panting, a group of clinical psychologists working for the Gender Identity Development Service (GIDS) of the Tavistock, and published by the journal Clinical Child Psychology and Psychiatry.⁶ It describes how the authors have attempted to apply CBT techniques to ‘gender-related distress’ in children referred to the GIDS, using an illustrative case study amalgamated from work done ‘with a number of young people’.

To a reader of the Cass Review, ‘gender-related distress’ will be a familiar phrase. It is used 47 times in the report, and its use has subsequently proliferated widely. At the time of writing, though, it was still very unusual (as opposed to the ‘more commonly used gender dysphoria’) so the authors explain their choice of language.

“In the DSM 5 (American Psychiatric Association, 2013), Gender Dysphoria in Adolescents and Adults is defined as having both ‘A marked incongruence between one’s experienced/expressed gender and assigned gender’ and ‘clinically significant distress or impairment in social, occupational or other important areas of functioning’. (American Psychiatric Association, 2013, p 452).
Our work focuses only on the second of these criteria; we do not believe it is ethical for therapeutic work to focus on changing someone’s experienced/expressed gender but do believe that it is ethically necessary for anyone working in this field to be aiming to reduce distress.”
— Canvin et al, 2022.

While they accept and affirm patients ‘self-reported’ gender identities, the authors seek to ‘bring a broader curiosity to understanding and managing gender-related distress’. Under the canopy of ‘gender related distress’, they group ‘a felt sense of dissonance between body and identity’ and ‘distress related to minority stress’.⁷ This unusual categorisation allows them to position their approach as neither affirmative nor explorative, but instead as a ‘third position’ between the two. Gender identity is sacrosanct, but the expression of that identity is not. The authors take great lengths to insist that they are not doing conversion therapy, but leave room in their model for a love-the-sinner-hate-the-sin approach to medical transition that would not be out of place in an anti-queer religious organisation. As we can see from the history of diagnoses like hysteria and drapetomania, reducing distress and dissatisfaction is not an inherently ethical goal.  Canvin et al pathologize distress caused by social realities - including waiting times in their own service. They justify this with reference to the use of CBT for chronic pain, stating that: ‘third-wave CBT models have been shown to be helpful in other areas where people are experiencing distress in relation to something which is not amenable, possible or ethical to change’.⁸ Put like this, an entire oppressive apparatus is simply an unavoidable ‘material reality’. The question is not what the authors of this study intend with their approach, it’s what could it let in. A definition of gender-related distress that groups frustrated desire for medical transition with minority stress makes space for conversion therapy to be laundered as simply ‘reducing distress’.

The paper presents a series of strategies for increasing distress tolerance using third-wave CBT methods - was this what the Tavistock’s ‘ongoing support’ for patients deemed unsuitable for medical transition looked like?

“The ‘Quicksand’ metaphor (Harris, 2011) can be helpful in thinking about the impact of fighting against thoughts, feelings, and material realities (e.g. waiting times) in potentially perpetuating and magnifying experiences of distress”
— Canvin et al, 2022, p.1249.

Distress tolerance is presented as especially important for ‘gender diverse people in the UK’, for a number of reasons. Access to medical transition may take years of waiting - so young trans people must learn to tolerate distress.⁹ Greater distress tolerance, we are told, may allow patients to ‘relate more flexibly’ to ‘safety-seeking behaviours’. Behaviours targeted for intervention include binding (which is presented as risking ‘creating a vicious cycle’ via intensifying ‘self-focus on the chest’), and ‘attempting to hide any indicator of their birth assigned sex’. The risk of pushing patients to abandon behaviours that genuinely keep them safe is acknowledged, but the risk of encouraging a dissociative relationship to feelings and experiences outside the norm is not. The final reason for inculcating distress tolerance is presented almost as an afterthought: ‘other young people may wish to find ways to manage their distress without physical interventions’. Like the second-wave CBT conversion therapists of the 1980s, the authors don’t want to make you live a straight, cis life on their own account - but if you want that, they’re more than happy to try and make it happen.

This paper is not an outlier. In its ‘Broader Reflections’ section, it cites an article by another group of Tavistock clinicians, in support of the statement ‘we would hypothesise that young people be [sic] less distressed about gender in a society which was more open, diverse and accepting of gender diversity’. It’s mostly focused on looking for an evolutionary reason for transition (unsurprisingly - it was written by the Tavistock’s evo-psychotherapy study group), but the section invoked by the citation makes another argument - that in a ‘queer’ society, medical transition might be less popular. With this context, ‘less distressed about gender’ starts to read like a palatable way of saying ‘less likely to transition’. Bernadette Wren, the lead author of the evo-psych paper and former associate head of GIDS, has said elsewhere that: “we knew that for some young people a period of transgender or non-binary identification, coupled with intense body dissatisfaction, would resolve and we could then support them through a process of reconciliation with their birth sex”. A picture is starting to form of what has been happening in the Tavistock..

The Cass Review is critical of the informal and unstructured therapy that has thus-far been administered in the GIDS - but it does not seek to stop it. Instead, it proposes an expansion. All therapies administered to trans children in the NHS, regardless of the reason or the service administering them, should also be assessed on their impact on ‘gender-related distress’, recommends Cass 11.36.¹⁰ The risk of creating a perverse incentive for covert conversion therapy in non-specialist services goes unacknowledged. The formal recommendation makes the Cass position clear:

“Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress and cooccurring conditions. This should include support for parents/carers and siblings as appropriate.”
— Cass Recommendation 3

This is not a pitch for evidence-based medicine. ‘Associated distress’ is broad enough to be readable as ‘gender-related distress’. Fluoxetine is a recommended treatment for depression, OCD, and bulimia, but that doesn’t mean it’s standard and evidence based when prescribed for ego-dystonic homosexuality. Beyond distancing itself from conversion therapy, the Canvin paper did not discuss the ethical context of its research - nor did it mention seeking approval from an NHS Research Ethics Committee. Following an informal enquiry, the editor of Clinical Child Psychology and Psychiatry has stated that a corrigendum will be issued showing that patient and parental consent were obtained prior to publication - that this could have been omitted in the first place tells us something.

“Alex spoke of initially being sceptical about the benefits of a therapeutic approach, as he felt only physical interventions would help to reduce his distress.”
— Canvin et al, 2022, p. 1258.

There are ethical and practical issues that must be addressed when offering therapy to children. How do you manage the greater-than-usual power imbalance between therapist and patient? What happens when a child and their parents or guardians want different things from the course of therapy? What factors might impact the process of obtaining informed consent? These questions are acutely significant to the Canvin study, and go completely unaddressed. It is impossible to tell whether subjects felt that they could refuse this novel therapy without compromising their access to gender-affirming care. In the section ‘setting up the therapy’, the authors say that it is ‘vital’ that ‘therapy is in line with a young person’s hopes and wishes for change’ - but the practical discussion that follows is entirely focused on persuading reluctant patients to take part, and overcoming their mistrust. If the team had devoted as much space to safeguarding against coercion as they did to defending themselves against accusations of coercion, the paper would look very different.

Only at the end of the article is the distorting pressure of the relationship acknowledged. A question is raised for clinicians, about where this type of therapy should take place: ‘would additional difficulties arise due to the gender service’s role in decision making around physical interventions?’ No answer is given. We don’t know how safe the young trans people whose experiences were amalgamated into this preliminary study felt. We don’t know whether they believed that taking part improved their chances of accessing transition-related care. We don’t even know how widespread this practice was in GIDS. But we know that the authors didn’t think to tell us. The Cass Review and many of its sources share a profound disinterest in autonomy, agency, or even the prevention of abuse.

Flexibility and Choice

The ‘voluntary’ conversion therapy of the 1980s was not ethical. Mark, a private patient included as a case study in Patricia Gillan’s Sex Therapy Manual, had never been attracted to women - but he wanted to be. ‘I’ve never had a male partner,’ he confessed. ‘It’s too late now with the AIDS scare. I don’t even want to try’. Mark’s deeply-religious fiancée did not know he was gay - she wanted to wait until she was married to have sex. But advances in therapy were here to help, and after a round of orgasmic reconditioning therapy, the two got married. No news was good news, and the case went down in the handbook as a resounding success.

The pressures on Mark’s decision were not unknown to Gillan - she comments earlier in the book that ‘since the arrival of AIDS many gay men have been increasingly worried about their behaviour patterns and have sought therapy’ - but they are treated as neutral, or even positive, perhaps heralding a cultural change. The therapist’s neutrality doesn’t quite hold - only heterosexual intercourse is treated as a goal, and Gillan’s language exposes her value judgments. ‘Many gay men’ she concedes, ‘do not indulge in sexual intercourse’.

It’s hard not to see parallels, reading about ‘homosexual dysphoria’ and ‘the need to be a biological parent and raise a family in the usual way’ and ‘homosexual arousal’ as ‘a persistent source of distress’ in Kaplan’s 1986 state of the field.¹¹ Against a background of hostility to queer life, therapists offer a ‘neutral’ therapy, directed by the needs of the client, that treats recloseting in short-term case studies as a kind of success.

But Mark was an adult - the stakes are different. The Cass Review has shown that children referred to the GIDS have been subjected to experimental therapies as the price of entry for seeking medical transition. Whether Hilary Cass wants conversion therapy to be institutionalised on the NHS again is immaterial: her recommendations have made space for it. Therapy is a caring profession, and despite the crueller parts of its history, good work happens under its banner - but so does violence. The NHS must set out a clear and actionable plan to keep conversion therapy out of its services, and investigate instances where it may have been allowed to take place. Anything else is complicity.

Footnotes

Bibliography

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Zoya Raza-Sheikh, ‘Conversion Therapy’: A guide to its harmful history’, Gay Times (2022)

Alexandra Topping, ‘Countless lives damaged’: UK’s dark history of gay conversion practices, The Guardian (2022)

Jules Gill-Peterson, ‘A Trans History of Conversion Therapy’, Sad Brown Girl (2021)

Judith S. Beck and Sarah Fleming, ‘A Brief History of Aaron T. Beck, MD, and Cognitive Behavior Therapy’, Clin Psychol Eur (2021), doi: 10.32872/cpe.6701.

Howard Lomas, ‘The Development of the BABP’, Behavioural and Cognitive Psychotherapy (1991), doi.org/10.1017/S0141347300012246.

Lucy Maddox, ‘How has CBT changed over the last 50 years?’, Let’s Talk About CBT (2022)

H. I. Lief, H. S. Kaplan, ‘Ego-dystonic homosexuality’, Journal of Sex and Marital Therapy, DOI: 10.1080/00926238608415412.

Padmal De Silva, ‘Sex Therapy Manual - Patricia Gillan, Oxford: Blackwell Scientific Publications Ltd., 1987, pp. Viii + 344, £27.50 hardback, £14.95 paperback.’, Behavioural and Cognitive Psychotherapy (1987), DOI: 10.1017/S0141347300012970.

Patricia Gillan, Sex Therapy Manual (Oxford, 1987).

NHS South London and Maudsley Psychosexual Service, ‘How our service can help you’

World Health Organization, ‘Gender incongruence and transgender health in the ICD’

Geoffrey M. Reed, Jack Drescher, Richard B. Krueger, Elham Atalla, Susan D. Cochran, Michael B. First, Peggy T. Cohen-Kettenis, Iván Arango-de Montis, Sharon J. Parish, Sara Cottler, Peer Briken and Shekhar Saxena, ‘Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations’, World Psychiatry (2016), doi: 10.1002/wps.20354.

Elaine Scattermoon, ‘Desistance therapy’ thread on Twitter (now X) (2022)

Elia Cugini, ‘Do no harm? The trouble with Cass’ therapy recommendations’, Trans Safety Network (2024)

E. Hogg, P. Adamopoulos, G. Krebs, ‘Predictors and moderators of treatment response in cognitive behavioural therapy for body dysmorphic disorder: A systematic review’, Journal of Obsessive-Compulsive and Related Disorders (2023), DOI: 10.1016/j.jocrd.2023.100822.

American Psychiatric Association, ‘What is Exposure Therapy?’, Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (2017)

The Cass Review, Independent review of gender identity services for children and young people: Final report (2024).

Florence Ashley, ‘Interrogating Gender-Exploratory Therapy’, Perspectives on Psychological Science (2023), DOI: 10.1177/17456916221102325.

Erin Reed, ‘Unpacking ‘gender exploratory therapy,’ a new form of conversion therapy’, Xtra Magazine (2023)

Mallory Moore, ‘NHS Trust uses “Gender Exploratory” training materials promoting conversion therapy lobbyists’, Trans Safety Network (2022)

trickyspoons, ‘Asked if I was dom or sub during assessment years ago’ thread on Reddit

Lauren Canvin, Oliver Hawthorne and Holly Panting, ‘Supporting young people to manage gender-related distress using third-wave cognitive behavioural theory, ideas and practice’, Clinical Child Psychology and Psychiatry (2022), DOI: 10.1177/13591045211068729.

Tom Nash, ‘The Church’s Position on “Transgenderism”’, Catholic Answers

May El Mantawy, ‘Hysteria: The Persistence of Patriarchy’, The History of Emotions Blog (2021)

Oxford Reference, ‘Overview: drapetomania’

Sannisha Dale, ‘Using Cognitive Behavioral Therapy to Assist Individuals Facing Oppression. [Web article]’, Society for the Advancement of Psychotherapy (2018)

Alana Saltz, ‘How CBT Harmed Me: The Interview That the New York Times Erased’, Disability Visibility Project (2021)

Raphael B. Stricker and Derek F. H. Pheby, ‘The Updated NICE Guidance Exposed the Serious Flaws in CBT and Graded Exercise Therapy Trials for ME/CFS’, Healthcare (2022), DOI: 10.3390/healthcare10050898.

Natalie Grover, ‘UK Health standards body delays new ME guidance in therapy row’, The Guardian (2021)

Bernadette Wren, ‘Epistemic Injustice’, London Review of Books Diary (2021)

Bernadette Wren, John Launer, Michael J Reiss, Annie Swanepoel, Graham Music, ‘Can evolutionary thinking shed light on gender diversity?’, BJPsych Advances (2019), DOI:10.1192/bja.2019.35.

Katrina Roen, ‘The Body as a Site of Gender-Related Distress: Ethical Considerations for Gender Variant Youth in Clinical Settings’, Journal of Homosexuality (2016), DOI: 10.1080/00918369.2016.1124688.

James L. Elmore, ‘Fluoxetine-Associated Remission of Ego-Dystonic Male Homosexuality’, Sexuality and Disability (2002), DOI: 10.1023/A:1019834512443.

Kathryn Geldard, David Geldard and Rebecca Yin Foo, ‘Ethical Considerations when Counselling Children’, in Counselling Children: A Practical Introduction (5th Edition), (London, 2018).

Thumbnail by Nik Shuliahin 💛💙 on Unsplash

Tags:

• Conversion Therapy
• CBT
• NHS
• Psychiatric abuse

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