Last year conservative media began been touting a new “study” which purports to prove that sexual orientation and gender identity are not innate and immutable characteristics, but are instead things that can be “cured” with, well, something. Therapy of some sort. They’re deliberately vague on this part. The problem is that this is neither a study, nor does it prove what it claims to. Instead, it throws a handful of cherry-picked results from a hodge-podge of sources, ignores other contradictory studies, and then comes to the conclusion “more study is necessary.”
This is exactly the same tactic used by the religious right to fight marriage equality in courts, which makes sense. A Conservative Catholic organization is the common factor in both this “study” and the attacks on sociological evidence that same sex parents do as well as straight ones under similar conditions.
Given the length and attention “Sexuality and Gender: Findings from the Biological, Psychological, and Social Sciences” is getting, a more thorough breakdown of how and why this paper is misleading is merited.
This isn’t a study, it’s a very long Opinion-Editorial piece.
First, The New Atlantis is not a peer reviewed journal. It eschews the normal processes used in academia to ensure shoddy or dubious work isn’t published. The paper also doesn’t actually introduce any new research, which would make it more of a meta-study (if it were a study at all). As such, this has all the scientific weight of an op-ed or a blog, especially since both authors have a long history of bias against LGBT people. Treating this paper as new evidence or proof on a par with a peer reviewed study from an academic institution is sloppy journalism.
The New Atlantis is a religious publication, with clear biases.
The New Atlantis is ideologically in lock step with the most orthodox portions of the Catholic Church, including opposition to access to birth control for all women (not just Catholics), and abortion under all circumstances. Some of its main contributors teach at Catholic Universities. For example, they published an article decrying how evil and awful birth control is, titled “The Population Control Holocaust.” Considering most US Catholics use birth control at some point in their lives, it should tell you a lot about the publication’s social positions.
The New Atlantis is also published by the Ethics & Public Policy Center (EPPC), a conservative Catholic organization. On its web page, the EPPC states, “the Ethics and Public Policy Center is Washington, D.C.’s premier institute dedicated to applying the Judeo-Christian moral tradition to critical issues of public policy.”
As such, this paper is less about new information, as it is a set of apologetics for religious positions on gender and sexuality. The contrarian claims made in the paper should be treated with the same skepticism one would give other similar scientific outliers, such as papers by American Tobacco Institute which claim that smoking doesn’t cause cancer or American Petroleum Institute’s attempts to cast doubt on climate change.
The authors of the paper have strong biases.
Doctors Paul McHugh and John’s Hopkins University both have long histories of religiously motivated antipathy towards transgender people. Mayer is more of a newcomer, but also came from John’s Hopkins.
McHugh is a self-described culturally conservative religiously orthodox Catholic. He has a long history of moral opprobrium towards LGBT people, and has always held a position that being LGBT can (and should be) cured. He filed an amicus brief arguing in favor of Proposition 8 (against marriage equality) on the basis that homosexuality is a “choice,” and called transgender people “caricatures of women.” While on the United States Conference of Catholic Bishops’ (USCCB) Review Board, McHugh pushed the idea that the Catholic sex abuse scandal was not about pedophilia but about “homosexual predation on American Catholic youth.” He opposes abortion under all circumstances, including that of an 11 year old girl raped by an adult relative whose life was in danger.
McHugh has also been a long-time proponent of reparative therapy, is a leader at a designated anti-LGBT group that was designated a hate-group by the Southern Poverty Law Center, and has accepted invitations to speak at conferences hosted by anti-LGBT hate groups promoting reparative therapy.
Dr. Mayer is relatively new to the fray. However, his first big anti-LGBT contribution was writing a report mirroring the one in The New Atlantis for Governor Pat McCrory defending HB2 in court (see exhibit K in the link). In it he claims that gender is too nebulous a concept to be used in court, that “biological sex” is real and gender isn’t, transgender people don’t really exist, and that creating a legal environment where people are encouraged to not be transgender is optimal for everyone. In other words, a legal climate more like Iran or Saudi Arabia is in the best interests of transgender people.
Thus, it should come as zero surprise that the conclusions of this paper are completely in line with Catholic doctrine, which has grown increasingly hostile to transgender people in recent years. McHugh has denied that his religious beliefs played a role in the paper, but this should be taken with a great deal of skepticism. He has put his religious beliefs front and center in previous social issues, the publisher has a Conservative Catholic view point, the state of North Carolina paid for this research to support an anti-LGBT law, and McHugh has actively supported conferences run by anti-LGBT hate groups (as defined by the Southern Poverty Law Center).
There’s actually a lot of data supporting biological origins, Mayer and McHugh just deliberately ignored it.
While Mayer and McHugh claim that there’s “no evidence” for the biological origins of gender identity or sexual orientation, this is simply untrue. For example, here are 93 legitimate papers, dissertations, and peer-reviewed journal articles on how hormone exposure affects gender identity and sexual orientation in humans, and 26 more on animals. There have also been 11 showing genetic links in humans, and 16 in animals. Boston University conducted a meta-study (peer reviewed, by the way) which reached the conclusion that there is a biological mechanism for gender identity. It concluded that, “Medical care of transgender patients, including surgical and hormonal treatment, has largely been met with resistance by physicians in favor of psychiatric treatment, owing to misconceptions that gender identity can be changed.”
Even Scientific American (a more reputable and non-partisan publication than the New Atlantis) looked at the issue this spring, and concluded, “Overall the weight of these studies and others points strongly toward a biological basis for gender dysphoria. “
Indeed, Mayer and McHugh completely fail to address the question their paper brings to mind: if sexual orientation and gender identity are so malleable, impermanent, and without underlying biological basis, why has no one ever demonstrated a way to change them under controlled, clinical conditions?
The paper draws unsupportable conclusions.
The paper makes the “no biological basis” conclusions because while acknowledging that studies have hinted at causes, none have proven to be a smoking gun that demonstrates unequivocal cause and effect. This is the same sort of logic used in the past by the American Tobacco Institute to deny that smoking causes cancer. It is also a logically fallacious conclusion. For example: we don’t know the exact biological mechanisms that cause autism, but any researcher who claimed that there is no biological basis for autism because of this knowledge gap would be a laughingstock, and their paper never make it past peer review.
Similarly, pointing to things like MRI studies with a negative result as “proof” that there is no biological basis is also unsupportable. The MRI is a relatively coarse tool, much like an optical microscope is in biology. Claiming that MRI’s prove there’s no biological basis is like looking for the cause of the flu (a virus) with an optical microscope, failing to find the virus, and declaring that the flu is psychosomatic.
Finally, the paper does a hand wave at the new field of epigenetics, which shows great promise, and provides a potential explanation to many of the observations previously made about biological origins. Dismissing the possibility with a casual dismissal of “it’s too complicated to be understood,” and then making a conclusion after throwing out evidence you don’t like or don’t understand is poor scholarship.,
This is why their paper is in The New Atlantis: it would never make it through a legitimate peer review process.
The paper conflates bisexuality with sexual orientation change.
One of the central points they try to make is that people express same-sex attractions when younger, but then end up identifying as heterosexual. This is a form of bisexual erasure, and completely ignores external effects (e.g. sociological pressures to be heterosexual). Again, it does a hand wave at the high variance seen in the data due to “joke” answers, and the fact that adolescents are just beginning to sort out how they define their relationships.
It is also a form of deliberate obfuscation: concluding that you can deliberately change a person’s sexual orientation based on this study is unsupportable.
They recycled the talking point that people are gay due to sexual abuse.
The authors of the paper bring up some studies which they purport to show that maybe sometimes in males, but not females, childhood sexual abuse causes people to be a little bit more likely to end up gay. Most of these studies don’t answer the temporal question of whether the people involved were abused because they were lesbian, gay, or bisexual. One applied a really strange standard to a cohort of abused children, where that a single legal consensual sexual encounter with a person of the same sex puts them in the really, totally 100% gay forever column.
Even with this (strange) standard for sexual orientation, only 8% of the cohort was “gay”. This is, however, almost exactly the same as the general population. The latter is ignored by the New Atlantis article.
After a lot of hand waving that sexual abuse causes homosexuality, the authors conclude: “the idea that sexual abuse may be a causal factor in sexual orientation remains speculative.”
Minority stress is a well understood phenomena, and the cause of poor outcomes for sexual minorities.
One of the key arguments they try to make in favor of reparative therapy is that LGBT people have worse mental health outcomes than straight people, and should therefore seek to become straight. Mayer and McHugh claim that the effects of social stigma have not been studied in detail, the mechanisms are poorly understood, and that they don’t account for all of the difference between the general population and the LGBT population. The first two are demonstrably untrue, that last comes close.
First, there is a wealth of quantitative studies on how various aspects of discrimination, marginalization, and abuse due to being a sexual minority affects mental health outcomes. For example, here are more than a dozen studies on just the narrow slice of how various stigma factors affect transgender suicide rates. There are more for LGB people looking at how stigma and minority stress affect all sorts of other outcomes such as poverty, drug abuse, depression, etc… (Hint: they pretty much all say that poor social climate makes these worse).
Next, the idea that the mechanisms causing bad outcomes are poorly understood is another example of the authors’ deliberate obtuseness. The figure below shows a process map of the process, which was developed by, Dr. Jae Sevelius of the University of California San Francisco and published in the peer reviewed journal Sex Roles. Each of the bullet points, connections, and conclusions has peer reviewed articles backing them up.
Diagram from “Gender Affirmation: A Framework for Conceptualizing Risk Behavior among Transgender Women of Color” by Sevelius JM. DOI: 10.1007/s11199-012-0216-5
Finally, there are a number of studies showing that even transgender people, when having passing privilege and living in supportive environments, have mental health outcomes not statistically different than the general population. This conclusion is supported by other recent studies (Murad 2010 and Ainsworth 2011) that found that adults who receive treatment not only are better-off than those who didn’t but are not significantly different in daily functioning than the general population. Another recent study of transgender children living in supportive homes found they “have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group.”
One of the religious right’s favorite studies to misuse is Dr. Cecilia Dhejne’s from 2010. While Mayer and McHugh note that the elevated suicide rate only applies to transgender people who transitioned before 1989, they left out the conclusion that Dhejne herself made about the reasons why younger transgender people had better outcomes:
“In accordance, the overall mortality rate was only significantly increased for the group operated on before 1989. However, the latter might also be explained by improved health care for transsexual persons during 1990s, along with altered societal attitudes towards persons with different gender expressions.”
McHugh and Mayer attempt to confuse the issue by stating that we cannot definitively prove that minority stress accounts for all of the bad outcomes. However, reducing social stigma seems much more likely to achieve positive results than funneling LGBT people into reparative therapy or the closet via legislation, law, and moral opprobrium. Indeed, the negative outcomes observed seem to be primarily due to these factors.
Thus, it is difficult to see how this proposed “remedy” would improve the lives, and mental health, of LGBT people. The article also ignores the conclusion by the psychological and medical communities that attempts to change sexual orientation or gender identity are harmful, ineffective, and unethical.
The overwhelming preponderance of the evidence supports affirming care for transgender people.
One of the central attacks the paper makes on transgender people is on their access to affirming care as adults, claiming that there is no substantive evidence that medically affirming care is beneficial. This is another case of the authors cherry picking the evidence for negative evidence, and dismissing that which they don’t like as “poor quality.”
In a comprehensive review of 34 studies on the effects of affirming medical care for transgender people 79% of the studies surveyed showed positive changes from transition, 15% showed weak improvement or mixed or ambiguous results, and only 6% showed negative changes from transition.
This is why every major medical and mental health organization has issued position statements supporting the necessity and efficacy of affirming care for transgender people. None of them have signed off on a model of rejecting identities. Indeed, World Professional Association of Transgender Health (WPATH), the foremost body of experts on transgender health in the world, has this to say about what Mayer and McHugh propose:
“Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success (Gelder & Marks, 1969; Greenson, 1964), particularly in the long term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical.”
McHugh and Mayer completely misrepresent models of care for transgender youth.
The paper follows many of the same scare tactics as the right wing media when it comes to transgender children. However, despite these scare tactics and outright lies, the model of affirming therapy is not “encouraging” children to be transgender. No one is pushing blockers, hormones, and surgery on six year olds (as the paper claims without citation). Using Leuprorelin to block puberty is not new: the FDA approved it in 1993, 23 years ago, as treatment for precocious puberty. Transgender children identify with their gender as strongly as cisgender children, and children are entirely capable of knowing their gender at two or three.
What is known is that children in supportive homes are at far less risk of negative outcomes, and transgender people whose identities are at far higher risk of suicide, depression, poverty, and drug use. Negative outcomes for transgender youth are strongly linked with rejection of their gender identity. One recent study found that children whose parents reject their identities are 13 times more likely to attempt suicide. Over and over again, familial rejection has been linked to suicidal thoughts and behavior.
They also ignore the fact that even Dr. Kenneth Zucker, the primary proponent of non-affirming therapy and the desistance narrative, believes that if cross gender identity persists past 13 or 14 the individual’s gender identity is extremely unlikely to change, and believes transition is usually the best option for the health of the patient at that point. He has also prescribed puberty blocking drugs to such youth as well.
Mayer and McHugh state without a trace of self-awareness or irony that, “we are deeply alarmed that these therapies, treatments, and surgeries seem disproportionate to the severity of the distress being experienced by these young people,” in the same paper where they take great pains to illustrate all the horrible life outcomes transgender people face. They fail to acknowledge that the distress transgender people feel makes these outcomes less painful than not transitioning. Mayer and McHugh seem deliberately unaware of the experiences of parents of transgender children, who describe suicidal 4 year olds, and children who attempt to cut off their own genitals.
The fact that affirming models have shown great promise and a massive reduction in harm in comparison with the general population of transgender youth also seems to escape them. Instead, they seem more concerned about this being only partially charted territory, and not knowing what the unknowable outcome in 10, 20, or 30 years will be while ignoring that the patient is healthy and happy now.
Dr. Colt Keo-Meier is former Chair of the American Psychological Association Committee for Transgender and Gender Diverse People, a former WPATH Board, and author of the APA’s Gender Diversity and Transgender Identity in Adolescents fact sheet. He described his reaction to the article’s misrepresentation of the affirming model:
“After reading McHugh and Mayer’s writing, I’m left wondering if they’ve ever worked clinically with this population. They do not seem to have a grasp on the difference between gender expression and gender identity or how the Gender Affirmative Model is practiced with young people. Further, no medical or surgical interventions are offered to prepubescent children. No children are encouraged to become transgender, they are supported in developing their true gender self, something that should be true for all children. Some children happen to be transgender and know it from a young age and others come to discover this later, sometimes around puberty.”
Conclusion
In the end, we must answer why McHugh and Mayer went to such lengths to produce such a long and deeply flawed paper for a journal that isn’t even peer reviewed. First and foremost, it is likely to be used to provide a scientific veneer for the legal and public policy goals of their church. Ultimately this paper is about using cherry-picked science to justify religious views rather than an actual review of what the research suggests should be best practice. This utility of this paper to conservative lawmakers can already be seen in how this work was used to defend North Carolina’s HB2 in court.
They have also somehow contorted themselves to twist the commonly accepted answer of, “it is complex” into “there’s no evidence.” In this they have gone against all current medical wisdom, standards of care, and practice. There does not appear to be any awareness or concern that such a contrarian position which could cause so much harm to so many people requires an extraordinary level of proof.
This paper does not suffice as a true study when it cuts so many corners, resorts to logical fallacies, and makes sweeping claims without either evidence or citation. A solution of “more reparative therapy” is completely unsupported by peer-reviewed literature, and their claim that there is no evidence for the biological origins of sexual orientation or gender identity is demonstrably false a hundred times over.
In the end, they have forgotten their vow to “do no harm,” while advocating against both civil and human rights for highly vulnerable minorities.