Evaluating James Caspian’s critiques of UKCP’s revised Memorandum of Understanding on Conversion Therapy

The UK Council for Psychotherapy published its revised Memorandum of Understanding on Conversion Therapy on October 16th. I mentioned in my last blog post that I wanted to see the MoU myself before I assessed James Caspian’s critiques of it. Now that I have, I would say that Caspian’s criticisms were mostly overexaggerated, but the UKCP’s hesitance to refusal to use the word “detransition” injected a lot of ambiguity in their statement that could end up making it harder for detransitioning people to get supportive mental health care.

First, let’s recap Caspian’s critiques. I’m going to focus on the quotes from James Caspian directly, rather than Rebecca Hardy’s summary of his view.

“Any ethical therapist wouldn’t try to impose their view of how a client should be — but surely they should be able to explore if gender identity is truly the psychological issue,” he says.
“We need a framework that allows therapists to freely explore other underlying issues that may be present before they start gender reassignment treatment, without the fear of being accused of conversion therapy if they do so.”
“The Memorandum of Understanding is saying we must accept whatever gender identity a client says they are without question.”
“[P]eople are afraid it might not be safe to work with someone who wants to detransition, i.e. reverse their sex change.”
“Let’s say a trans female, who is no longer happy in their gender, goes to a counsellor to say they want to go back to living as a man. Could that counsellor be accused of conversion therapy if they help them?”
“I kept arguing for specific wording to say, ‘We do acknowledge some people do regret their transitions and reverse them, or change their minds.’ But every time I tried to put that wording in it was rejected.”

Caspian claims that the MoU dissuades therapists from engaging in differential diagnosis of gender dysphoria, because it requires clinicians to accept a client’s gender identity without question. He also claims that the MoU makes therapists worried about helping those who are detransitioning because it does not specifically affirm that possibility.

Now, let’s look at the revised Memorandum of Understanding. It expresses a “commitment to ending ‘conversion therapy’ in the UK,” defining conversion therapy as:

an umbrella term for a therapeutic approach, or any model or individual viewpoint that demonstrates an assumption that any sexual orientation or gender identity is inherently preferable to any other, and which attempts to bring about a change of sexual orientation or gender identity, or seeks to supress an individual’s expression of sexual orientation or gender identity on that basis.

The emphasis here is on neutrality: clinicians should view all sexual orientations and gender identities as equally preferable. Therapists also should not try to change a client’s sexual orientation or gender identity, but the MoU does not state that changes in sexual orientation or gender identity must not occur within the context of therapy. The goal of the therapist must not be for these changes to happen. Similarly, limiting the “individual’s expression of gender identity” by denying them certain medical interventions is only seen as conversion therapy if it is done because of a bias towards one gender identity or another.

Along these same lines, it states that, “[N]either sexual orientation nor gender identity in themselves are indicators of a mental disorder.” Note the phrase “in themselves” here — it suggests that sometimes gender identity is associated with a mental disorder, even though it is not a mental disorder itself. This implicitly references the conceptual distinction between gender dysphoria, which leads individuals to seek treatment, and gender identity, which is not a disorder “in itself.”

The next part of the MoU specifies what is not implied by these statements:

This position is not intended to deny, discourage or exclude those with uncertain feelings around sexuality or gender identity from seeking qualified and appropriate help.
This document supports therapists to provide appropriately informed and ethical practice when working with a client who wishes to explore, experiences conflict with or is in distress regarding, their sexual orientation or gender identity.
Nor is it intended to stop psychological and medical professionals who work with trans and gender questioning clients from performing a clinical assessment of suitability prior to medical intervention.

The MoU explicitly acknowledges that some people experience uncertainty about, conflict with, or are in distress regarding their sexual orientation or gender identity, and affirms “appropriately informed and ethical practice” for these people. According to the previous passages, presumably this means any therapist working with such clients should not have a specific goal regarding the end state of the client’s sexual orientation or gender identity.

The passage also explicitly allows clinical assessment before medical intervention.

For people who are unhappy about their sexual orientation or their transgender status, there may be grounds for exploring therapeutic options to help them live more comfortably with it, reduce their distress and reach a greater degree of self-acceptance. Some people may benefit from the challenge of psychotherapy and counselling to help them manage dysphoria and to clarify their sense of themselves. Clients make healthy choices when they understand themselves better.

To me, this passage is ambiguous. The term “transgender status” is different from the term used throughout the rest of the MoU, “gender identity.” One reading of this term is that it refers to whether someone is identifies as cisgender or transgender, in which case it’s basically a different way of saying “gender identity.”

Another possibility is that the term “transgender status” is meant to reference the state of having gone through medical transition. If so, the following sentence would opens up, in a very roundabout way, the possibility for detransition care, for “therapeutic options to help [people distressed by their medical transition] live more comfortably with [the fact of having undergone medical transition]…,” etc. Mentioning that there are a number of options in this context seems to open the door to, for example, going off of hormones.

The next sentence supports this interpretation, by affirms the possibility that therapy can help “manage dysphoria and to clarify their sense of themselves.” The word dysphoria is used no where else in the MoU, and in the context of the previous sentence, I would interpret this sentence as supporting therapy as an alternative way for people who detransition to manage gender dysphoria. Importantly, in this paragraph the client themselves is the agent of this process, and not the therapist themselves.

However, the wording is so ambiguous that you could interpret this passage a different way: “For people who are unhappy about being transgender, there may be ground for exploring therapeutic options to help them live more comfortably with the fact that they are transgender… and reach a greater degree of self-acceptance about the fact that they are transgender.” But I think the following sentence about therapy as helping clients “manage dysphoria and clarify their sense of themselves” is hard to fit into this interpretation. After all, if you are claiming transition is always a one-way process, what clarification is there to be had?

I suspect people in the detransition community will find the framing of this passage somewhat problematic. My intent is not to speak for the detransition community, but to outline potential points of agreement and disagreement there might be regarding the MoU’s statement.

Based on my experience listening to people in the detransition community, most would not frame their experience as having been “unhappy about their transgender status,” whatever that means. Detransitioning people typically don’t continue to identify as transgender or as having a “transgender status.” They tend to emphasize returning to a more accepting stance regarding their bodies and reframing their experience of gender dysphoria as resulting from societal/political pressure. The idea that therapy can help detransitioning people “manage [gender] dysphoria and to clarify their sense of themselves” is in line with the views of many detransition community, though finding therapists willing and capable of providing such therapy is reportedly quite difficult, at least here in the US.

Caspian’s two main claims, that the MoU would prevent therapists from engaging in differential diagnosis before medical intervention and would bar therapists from helping clients who want to detransition, are unfounded. However, he was right when he said that the MoU did not explicitly state that other mental health problems may present as gender dysphoria, and that it did not explicitly mention detransition.

I would argue that the lack of a statement about other mental health problems is unnecessary, because the MoU does support the “clinical assessment of suitability before medical intervention.” This statement seems clear to me. Furthermore, the MoU nowhere claims that therapists must view medical intervention as equally desirable to non-intervention. Instead, the emphasis is on having a neutral perspective towards the client’s gender identity itself.

According to the MoU, a therapist who believes having a transgender gender identity is a false delusion that must be cured is engaging in conversion therapy, while a therapist who explores different possibilities for alleviating gender dysphoria in clients with an uncertain gender identity is not. As I mentioned previously, the MoU implies it is okay to deny access to medical interventions, as long as it is not done because the therapist wants their client to identify a certain way. (It’s worth noting that some in the transgender community may, as a result, find the MoU unsatisfactory in this regard.)

I agree with James Caspian that the MoU should have used the word “detransition,” even though I believe the MoU does not prevent therapists from helping clients who want to detransition. Using the term “detransition” or “voluntary detransition” or something along those lines would have made the goal of this passage more clear and made it easier for therapists to understand.

As it stands, I think it’s possible that the interpretative ambiguities of that passage may make organizations that follow it more cautious about providing care for those who are detransitioning. Because detransition is so rare, it’s important that organizations have clear guidelines about the importance of providing good detransition care. The relative invisibility of detransition and its associated struggles compounds the problems with having such an ambiguous statement in the UKCP’s Memorandum of Understanding.

It’s important to remember, however, that the MoU states, “The memorandum is not intended to and does not create any contractual obligations between these parties.” There is nothing binding about this statement, as the term “memorandum of understanding” suggests. There is a lot of flexibility in how organizations choose to put the MoU into practice, and I hope they do so in a way that makes it clear that detransitioning people deserve supportive, quality care, too.