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We would like to take the opportunity to thank the author for their correspondence and critique of our paper.
In response to our conclusion about the “rarity” of the practice, the correspondence may be misleading. Our paper states “We found limited evidence in the research literature of the use of conversion therapies that aimed solely at suppressing or modifying what was considered by the therapist as abnormal gender identity”. Of course (as is the case for reviews of research into conversion treatments for LGB people), this does not presume that practices are not occurring in a wider context.
We would like to further state that as in all systematic reviews, the search strategy must be agreed before the search begins. We spent considerable effort in discussing search terms, and based our search on previous reviews of LGB people and conversion/reparative approaches. This basis did not dictate the only search terms used however; we also used further terms which we believed would increase the yield in papers, these included “reparative” “non-affirming” and “repair”. We also included terms such as “barring” to account for covert attempts at hindering transition.
We disagree that systematic reviews are counterproductive. Our aim was to assess how often and in what form conversion/reparative treatments for transgender and gender diverse people had been studied. We sought to examine critically any claims for effectiveness as well as understand the consequenc...
We disagree that systematic reviews are counterproductive. Our aim was to assess how often and in what form conversion/reparative treatments for transgender and gender diverse people had been studied. We sought to examine critically any claims for effectiveness as well as understand the consequences of undergoing such treatments in terms of psychological health and well-being. We found no instance of a large cross-sectional or cohort design of people undergoing treatments and ended by suggesting the need for investigation of the experiences of transgender and gender non-conforming people at the population level. This is exactly the evidence the correspondent has suggested too. Out of interest, a study is currently underway at Coventry University, which fulfills our recommendation for further research (see: https://www.coventry.ac.uk/research/areas-of-research/innovative-researc...).
We also thank the author for contributing further discussion on Dr. Kenneth Zucker’s work and controversies. However, the other sources the correspondent cites were more at the level of discussion than data.
We thank the correspondent again for their thoughtful critique of our paper. No article is beyond reproach and/or scrutiny, and this correspondence enhances the discourse about conversion therapies in trans and gender diverse people.
Wright, Candy, and King (2018)’s recent systematic review of transgender conversion therapies searched for articles which contained variants of the terms “conversion” and “transgender”. The review only identified four studies on conversion therapy, concluding that the practice was uncommon and reassuring.
I believe that the article severely underestimates the breadth of the conversion therapy literature and of its practice. This is due to the inadequacy of the search strategy, which seeks articles involving variants of the term “conversion”, whereas proponents of reparative practices rarely conceive themselves in those terms. The search strategy was derived from “those used in previous reviews of LGB conversion therapy”. The decision to mirror terms of LGB conversion therapy should have been subjected to greater scrutiny. By the 1990s, the term “conversion therapy” was struck with infamy and associated with religious approaches, creating a pressure to disidentify with the term among secular practitioners who sought to discourage transitude, even if their clinical approaches were very similar to the approach of famous conversion therapists such as George Rekers.
Many articles can be identified which sought to alter the patient’s gender identity or prevent trans outcomes but were not captured by the systematic review. The first author of one of the reviewed articles, Dr. Zucker, is a prolific writer who has written a lot about his approach, which is further de...
Many articles can be identified which sought to alter the patient’s gender identity or prevent trans outcomes but were not captured by the systematic review. The first author of one of the reviewed articles, Dr. Zucker, is a prolific writer who has written a lot about his approach, which is further described in the reviewed 2012 article. In 1995, he co-authored the seminal book on the psychotherapeutic approach (Zucker & Bradley, 1995), which is understood as conversion therapy by Wright, Candy, and King. In 2003, Susan Bradley and him denied accusations that they were promoting practices “disturbingly close to reparative therapy for homosexuals” (Bradley & Zucker, 2003; Pickstone-Taylor, 2003). He has written many case studies and defences of his approach (Zucker, 2006a, 2006b). Despite being opposed by affirmative scholars at conferences (Tosh, 2011), he is commonly invited to speak on trans issues in scientific and clinical settings.
Since the review fails to capture a large section of the literature on transgender conversion therapy, the conclusions of Wright, Candy, and King with regards to the rarity of the practices is severely undermined. However, it bears adding that the absence of peer-reviewed literature on trans conversion therapy does not suggest its absence from clinical practice. Peer animus and protests against practitioners of conversion therapy disincentivizes public identification with the practice through peer-reviewed articles, whereas clinical practices are much less scrutinized. Sociologist Karl Bryant noted that one of the reasons why “nobody ever publishes data about what happens in therapy” is that the stark critiques of George Rekers’ work encouraged clinicians to refocus their work away from descriptions of interventions (Bryant, 2006, p. 34).
Estimating the incidence of transgender conversion therapy is difficult. Nonetheless, it appears uncomfortably common. A large-scale survey of the U.S. adult trans population found that 13% of participants were subjected to conversion therapy, including 9% by non-religious professionals (James, Herman, Keisling, Mottet, & Anafi, 2016). The proportion is higher for trans individuals than for LGB ones (Government Equalities Office, 2018), despite the relative paucity of trans-specific literature.
Wright, Candy and King’s systematic review exemplifies the limits of this type of research, which depends on a distinct shared vocabulary. The strong opposition to conversion therapies creates pressures on clinicians to be less than forthcoming about their approach, relabelling it and redefining it away from traditional depictions of reparative practices. In that context, systematic reviews may be counterproductive and misleading.
Bradley, S. J., & Zucker, K. J. (2003). Children with Gender Nonconformity. Journal of the American Academy of Child & Adolescent Psychiatry, 42(3), 266–267.
Bryant, K. (2006). Making gender identity disorder of childhood: Historical lessons for contemporary debates. Sexuality Research and Social Policy, 3(3), 23–39. https://doi.org/10.1525/srsp.2006.3.3.23
Government Equalities Office. (2018). National LGBT Survey: Research Report. Manchester: U.K. Government Equalities Office.
James, S. E., Herman, J. L., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.
Pickstone-Taylor, S. D. (2003). Children with Gender Nonconformity. Journal of the American Academy of Child & Adolescent Psychiatry, 42(3), 266. https://doi.org/10.1097/00004583-200303000-00005
Tosh, J. (2011). ‘Zuck Off’! A commentary on the protest against Ken Zucker and his ‘treatment’ of Childhood Gender Identity Disorder. Psychology of Women Section Review, 13(1), 10–16.
Wright, T., Candy, B., & King, M. (2018). Conversion therapies and access to transition-related healthcare in transgender people: a narrative systematic review. BMJ Open, 8(12), e022425. https://doi.org/10.1136/bmjopen-2018-022425
Zucker, K. J. (2006a). Commentary on Langer and Martin’s (2004) “How Dresses Can Make You Mentally Ill: Examining Gender Identity Disorder in Children.” Child and Adolescent Social Work Journal, 23(5–6), 533–555.
Zucker, K. J. (2006b). “I’m Half-Boy, Half-Girl”: Play Psychotherapy and Parent Counseling for Gender Identity Disorder. In R. L. Spitzer & American Psychiatric Publishing (Eds.), DSM-IV-TR casebook: experts tell how they treated their own patients (Vol. 2). Washington, DC: American Psychiatric Publishing.
Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York: Guilford Press.