The Irish MoU on Conversion Therapy: A Concession amidst Ideological Persistence?

By Jaco van Zyl, Clinical Psychologist

On Friday, 12 July 2024, three organisations – The College of Psychiatrists of Ireland, The Irish Association for Counselling and Psychotherapy, and The Psychological Society of Ireland – signed the Memorandum of Understanding (MoU) on Conversion Therapy on the Island of Ireland. This document was compiled with supporter organisation, LGBT Ireland, and its handover to the Minister for Children, Equality, Disability, Integration and Youth, Roderic O'Gorman, took place at Trinity College Dublin. As in the UK, suggestions of legislation against conversion practices have been made in recent years, particularly by activist organisations. Such suggestions must be based on solid evidence, real threat, and established social and psychological theory. In the spirit of open inquiry, let’s examine how the Irish MoU on Conversion Therapy measures up.

At first glance, there are a few positive features of the Irish MoU on Conversion Therapy. These appear to be in response to the best available evidence at present, quite possibly even the Cass Review of April 2024, which reflects similar evidence-based stances in Finland (COHERE Finland, 2020) and Sweden (National Board of Health and Welfare, 2022). While the Cass Review did not explicitly investigate the issue of conversion therapy, it spoke to the urgent need for ethical, evidence-based assessment and treatment of gender dysphoric minors. One of the recommendations in the Cass Review was a holistic assessment to understand the gender dysphoric young person and their family, followed by a comprehensive formulation explaining the child's presentation, a list of diagnoses, and a treatment plan. As many now know, due to the sheer lack of evidence base in gender-affirmative practice, and its runaway popularity due to activist overreach, the Gender-Identity Development Service (GIDS) in the UK was rendered inadequate and had to close down.

According to the doctrine of gender-affirmative practice, anything other than affirmation amounts to potential harm, including gender-exploratory therapy. It was therefore encouraging to see that the MoU (CPsychI et al., 2024) had the following to say regarding exploratory therapy:

The MoU explicitly supports healthcare providers to provide appropriately informed and ethical practice when working with clients who wish to explore, experience conflict with, or are in distress regarding their sexual orientation or gender identity (p. 1).

And,

This MoU supports therapists to provide ethical and competent practice when working with a client who wishes to explore, experiences conflict with or is in distress regarding, their sexual orientation or gender identity (p. 2).

Over the past several years, the mental health field has been infiltrated by radical identity practitioners, and professional bodies have been pressurised by activist groups to adopt ideological stances that had no grounding in evidence or psychological theory. Many of these practitioners resorted to intimidation tactics if ethical therapists strove to do evidence-based therapy, especially with gender-dysphoric minors. This exclusive, dogmatic adherence to gender-affirmative practice has had a chilling effect on critical discussion and adequate treatment for affected youth (Jenkins & Panozzo, 2024). Given the above statements in the Irish MoU, ethical mental health professionals can have greater confidence in assessing, diagnosing and treating gender-distressed individuals.

While the clarification on exploratory therapy is stated in no uncertain terms, there remain a few serious concerns with the MoU, suggesting the persistence of ideological commitment:

Illusory equivalence of gender identity and sexual orientation

Historically, conversion practices were mostly performed on same-sex attracted men, using frightening aversion techniques like electrical shocks and sniffing ammonia salts, to extinguish same-sex erotic attraction, and encourage opposite-sex attraction. Due to the endurance of homosexual attraction, and the psychological harm these practices had on individuals and their loved ones, these practices were discontinued and legislated against. Conversion practices, or sexual orientation change efforts (SOCE), were always associated with sexual orientation.

But in recent years, primarily due to the overinvolvement of activist groups like Mermaids and Stonewall in the mental health field, as well as the ingress of ideological zealots as practitioners, conversion therapy was expanded – without evidence – to include gender-identity-related issues. This is what the MoU has to say:

Conversion therapy is the term for therapy that assumes certain sexual orientations or gender identities are inferior to others and seeks to change or suppress them on that basis. [C]onversion therapy in relation to gender identity and sexual orientation (including asexuality) is unethical, potentially harmful and is not supported by evidence (p. 1).

And,

‘[C]onversion therapy’ is 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 suppress an individual's expression of sexual orientation or gender identity on that basis (p. 1).

Decades of research and theorising have shown that sexual orientation tends to be anchored and resistant to change. However, the same onset and treatment outcomes are not observed with gender identity. With the previous cohort of mostly pre-adolescent gender dysphoric children of the 80s and 90s, the desistance rate was between 61% and 98% (Drummond et al., 2008; Steensma et al., 2013; Singh, Bradley & Zucker, 2021). One of the problems with gender-affirmative practice is that there is no way of ascertaining whether trans-identification will persist. With the current cohort of rapid-onset gender dysphoria (ROGD), certain common environmental factors have been identified that influenced sudden declarations of dysphoria and “transgender” identification. These factors include peer influence, social media and online communities, pre-existing psychiatric issues, stressful family dynamics and a general culture of transgender promotion (Littman, 2018). Similar findings with a much larger research sample have been published by Littman and Bailey (2023). Gender identity foreclosure, moratorium or diffusion – either because of defensive operations to reduce underlying unelaborated psychic pain, or in response to social pressure – are bound to dissipate when the underlying cause is resolved. Treatment outcomes and expectations are therefore different for sexual orientation and gender dysphoria. The former is resistant to change, the latter leads to eventual resolution.

It is for this reason that Hilary Cass wrote the following:

Previously, a diagnosis of gender dysphoria has been the basis for initiating medical treatment, however, this is not predictive that the individual will go on to have longstanding trans identity. (Cass, 2024, p. 146).

This necessary evidence-based distinction is noticeably absent in the MoU's definition of conversion therapy. Practitioners familiar with the psychodynamics of sexual orientation (Friedman, 1988) and paraphilias (Benvenuto, 2016) know that these are resistant to change, and sexual orientation change efforts of yonder years have shown this conclusively. This is not the case with gender identity – not historically, nor with the current cohort who have shown a presence of significant psychiatric, social and neurodevelopmental comorbidities. The inclusion of gender identity under conversion therapy is, therefore, a form of concept creep, informed by ideological activism, and not research.

No distinction between minors and adults

In addition to the problematic inclusion of gender identity under the definition of conversion therapy, we see no distinction between adults and minors. It goes without saying that the identity stability and reality testing of children and adolescents are not as stable or mature as that of the average adult. Identity exploration in minors and severely compromised adults would be clinically indicated. However, the MoU specifies that such gender identity and sexual orientation exploration would only be reserved for “clients who wish to explore, experience conflict with, or are in distress regarding their sexual orientation or gender identity.” In today's climate of affirmative practice and transgender promotion, even among young children, gender and sexual orientation exploration may be clinically indicated, but culturally and defensively prohibited:

For some, initial gender questioning created a sense of urgency, much of which focused on accessing medical pathways. These young adults acknowledged that their original response was to “fix” the problem. This became less important to them as they grew older. Some explained that discovering different ways to express gender identity was one of the most important things they had learned. They wished this had been explained to them when younger but remain uncertain about the extent they would have listened to such advice. (Cass, 2024, p. 148).

The extensive research underpinning the Cass Review demonstrates the necessity of evidence-based and clinically-informed therapeutic practice in relation to gender dysphoria in children. Without the distinction between minors and adults in the Irish MoU, the false impression is created that their presentations and aetiologies are identical.

Moreover, while Cass recommended that prescribing puberty blockers and cross-sex hormones to minors should be limited to an experimental regime under specific ethical design requirements, the same caution is not specified in the Irish MoU:

This position is not intended… to stop medical professionals from prescribing hormone treatments to transgender patients and people experiencing gender dysphoria (p. 2).

It is nothing short of alarming that, despite the recent gender-identity-related crisis in the UK, the exceptional Cass Report, and the subsequent policy changes that followed, the Irish MoU does not reflect the same caution on gender-affirmative practices. This blasé stance on potentially harmful gender-affirmative practices is bound to have similar results as in the UK, particularly for minors.

A rivalry of identities and sexual orientations

In addition to the problematic conversion therapy definition, we find the following peculiar statements:

Conversion therapy is the term for therapy that assumes certain sexual orientations or gender identities are inferior to others (p. 1)

'[C]onversion therapy' is 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 (p. 1)

In terms of definitions, “sexual orientation refers to the sexual or romantic attraction someone feels to people of the same gender, opposite gender more than one gender, or to experience no attraction (p. 2).” And gender identity “is interpreted broadly to include binary (male or female), non-binary and gender fluid identities (p. 2).”

It is unclear on what psychological theory or model they base the above statements. It is an essential part of psychoanalytic theory and practice to approach the vast domain of sexuality as a treasure trove, revealing aspects of a person's defensive strategies, extent of regression, psychological maturity and pathology. Sexual orientation is directly implicated. But what we also know is that there has been a concerted effort among those of certain ideological convictions to sacralise identity, to create novel sexual and gender identities, and to gain from the immunity identity sacralisation affords them. The mere notion of possible psychological pathology underlying sexual orientation can induce outrage and retaliatory vindictiveness among ideologues. True, there is no ethical basis to withhold human dignity from those with paraphilic disorders presented as a protected gender identity (like autogynephilia or kink). But affording basic human dignity to individuals and uncritically affirming their paraphilias as if these would have no bearing on their psychological health is a misconstrued equivalence.

Regrettably, the recent infiltration of various spheres of Western society by subversive hybrid theories of Critical Social Justice has apparently not spared the signatory organisations of the MoU:

It is impossible for a group founded on ideology not to proselytize. It will try to destroy not only its enemies and whatever it sets up as the screen of its projection, but also all those people who remain on the outside, unconvinced. By not participating in the game of the illusion they come to represent the failure of illusion itself. In refusing to hand over reality-testing to the worshippers of the illusion they throw it ipso facto into doubt (‘if you're not for us you're against us’). It now becomes vital for the group to control the indifferent and the sceptics and to force them to cede the function of reality-testing to the ‘believers’: ‘Der Führer hat immer recht’; ‘The Party is always right’. (Chasseguet-Smirgel & Grunberger, 1986, p. 18).

The depathologisation of neo-identities that disregard the differences in sex, species and generations has no basis in established psychological theories. And to demand such depathologisation at the threat of legal sanction amounts to the capture of an establishment that tolerates no coexistence with competing perspectives.

Notice, again, that the definition of sexual orientation does not distinguish between children and adults, but merely references “persons.” Part of the depathologisation campaign by queer activists has been the neutralisation of autogynephilia as a trans identity and the normalisation of paedophilia and paraphilic disorders colloquially referred to as “kink.” In many activist circles autogynephilia, paedophilia and kink are regarded as acceptable sexual identities. On what basis would a paraphilic disorder like paedophilia be imagined to be inherently equal to, say, a fulfilling heterosexual relationship? Or someone who compulsively needs to cross-dress and engage in exhibitionistic displays for sexual excitement equivalent to homosexual men or women in respectful, committed relationships? Compare this to the extreme ends of torture enactments in kink. This dogmatic declaration that all orientations are equally healthy is an ideological attack on normality and psychological health. One of the bedrock principles of psychoanalysis is the necessity to mentally elaborate on unconceptualised instincts (Bion, 1992). Immunising sexual orientation from psychological exploration has its roots in envious psychodynamics and subversive ideologies.

The same applies to sociopolitical identities. On what basis should something like a “fluid” gender identity be uncritically accepted as healthy? “If the stability of personal identity is necessary to avoid consequences as bad as psychosis, then fluidity is likely to be personally threatening. The stability of the ego has taken precedence in the treatment situation over the conflicts within it (Hinshelwood, 2017).” Considering identity development in children, which the MoU does not specify, identity consolidation is inherently more preferable to identity foreclosure, moratorium and diffusion. Again, I ask, if any model which considers one identity to be more preferable than others is to be repudiated, on what basis is this demanded if not ideology? And since when do the College of Psychiatrists, the Association for Counselling and Psychotherapy and the Psychological Society of Ireland prioritise novel, seasonal, radical ideologies above established psychological modalities?

To the ideological non-possessed clinician, the question is not whether certain identities or sexual orientations are inherently superior and which not; it is, instead, what this particular sexual orientation and identity reveal about the latent, unspoken and unthought-of content of the client. Since all sexual orientations and paraphilias are developmental, the ethical clinician will ask, given their developmental and relational background, why this individual developed this particular sexual orientation or paraphilia. Likewise, they would ask, what has this person's historical identifications been, such that they feel compelled to identify with the opposite sex, or in extreme cases feel unbearable rage when they are being reminded of their biological sex?

A call to charge at windmills?

In his famous experiment of 1951, Solomon Asch demonstrated that people would disregard what they see with their own eyes just to conform to the expectations of others (Asch, 1951). And Nyhan and Reifler (2010) showed how people knuckle down in their pre-existent beliefs, even when presented with counterevidence (“backfire effect”). This seems to be what is going on in Ireland:

The MoU is based on a report, An Exploration of Conversion Practices in Ireland (Keogh et al., 2023) from Trinity College Dublin, School of Nursing and Midwifery (TCD). There were severe limitations to this research:

• Findings were based on an online survey of 278 participants. None of these responses could be verified.

• Conflict of interest: participants were obtained through the networks the “research advisory group” were connected to, including LGBT Ireland's campaign officer for their Ban Conversion Therapy Campaign. The research advisory group were representatives from activist organisations, including LGBT Ireland, TENI and Gay Project.

• The quality of evidence provided is low. Only 7 persons were interviewed; 5 were exposed to sexual orientation or gender identity change efforts (they do not distinguish) in Ireland and 2 in another country. One “was not sure if what he experienced could be described as conversion therapy (p. 64).” Another argued that assigning the “gender she was born [for surgery] was a form of conversion therapy (p. 66).”

• The research contains no reports of investigated complaints to regulatory bodies.

• Treatment outcomes for persons with gender dysphoria and same-sex attraction are confounded. While sexual orientation and paraphilias in adults remain anchored, the same is not observed among persons with gender dysphoria. Despite this fact, the dubious practice of affirmative practice is recommended as the only acceptable approach to treat gender dysphoria.

Genspect (2023) compiled a more elaborate critique of this research on their website.

What is the relevance of the Asch experiment and the “backfire effect?” For years responsible and ethical psychologists working with gender dysphoric patients have been intimidated by activist organisations and their allies within regulatory bodies. Psychologists and psychotherapists were expected to repudiate their psychologically trained judgment and treat gender dysphoric persons as exceptions to the rules. Many complied and became zealous advocates for a practice that had no experimental or theoretical rigour behind it. Thousands of patients – underaged, autistic and psychotic patients – were subjected to potential and actual harm of medical gender affirmation. Are the researchers at TCD and the signatories of the MoU expecting mental health professionals to ignore what they see with their own eyes and pretend that the problem is not affirmative practice, but the obscure practice of conversion therapy?

What about the “backfire effect” of Nyhan and Reifler? It should come as no surprise that this MoU was adopted a few months after the decisive Cass Review. This MoU does not evidence an abandonment of the assumptions that led to the closed-minded adoption of gender-affirmative practices, or a renunciation of the baseless belief that conversion practices are rampant in Irish society; we see instead the backfire effect in their knuckling down, declaring that the windmills are actually giants. Are these researchers and signatories creating smokescreens, distracting from participating in potentially harmful gender-affirmative practices, and projecting such culpability on imaginary conversion practitioners? Will critiques like this one lead to the integration of difficult criticism, or will it lead to further knuckling down? Time will surely tell.

While the MoU conceded to exploratory practice, the ideological meme that paralysed responsible care for gender dysphoric individuals in the first place, just repositioned itself. This MoU still lacks the necessary evidence-based distinction between sexual orientation and gender identity, in terms of stability and treatment outcomes. A serious drawback is its failure to distinguish between minors and adults. The signatories to this MoU have yet to learn that ideology and time-tested theory cannot coexist. It still bases its definitions and stances on dogmatic statements, demanding that no gender identity or sexual orientation may be regarded as inherently superior to the other. This belief has its roots in politicised postmodern theories, not psychology. And the prominent involvement of activist organisations in both the problematic TCD research and the current MoU, severely compromises its rigour. For these reasons, much more work needs to be done before this MoU should be given the regard it demands.

---

References:

Asch, S. E. (1951). Effects of group pressure upon the modification and distortion of judgments. In H. Guetzkow (Ed.), Groups, leadership, and men. Carnegie Press.

Benvenuto, S. (2016). What are Perversions? Sexuality, Ethics, Psychoanalysis. Karnac.

Bion, W. R. (1992). Cogitations. Karnac.

Cass, H. (2024, April). Independent review of gender identity services for children and young people. https://cass.independent-review.uk/home/publications/final-report/

Chasseguet-Smirgel, J. & Grunberger, B. (1986). Freud or Reich? Psychoanalysis and Illusion. Yale University Press.

COHERE Finland. (2020, June 11). Medical treatment methods for Dysphoria associated with variations in gender identity in minors – recommendations.

Drummond, K. D., Bradley, S. J., Peterson-Badali, M. & Zucker, K. J. (2008). A follow-up study of girls with gender identity disorder. Developmental Psychology, 44(1), 34 – 35.

Friedman, R. C. (1988). Homosexuality – A contemporary psychoanalytic perspective. Yale University Press.

Genspect. (2023, June). Genspect Review of the Trinity College Dublin Research on “Gender Identity Conversion Therapy.” Retrieved from https://genspect.org/wp-content/uploads/2023/06/Genspect-Review-of-the-Trinity-College-Dublin-research-on-Gender-Identity-Conversion-Therapy-2.pdf.

Hinchelwood, R. D. (2017). On Not Thinking Straight. In N. Gifney & E. Watson (Eds.), Clinical Encounters in Sexuality: Psychoanalytic Practice and Queer Theory. Punctum Books.

Jenkins, P., & Panozzo, D. (2024). “Ethical care in secret:” Qualitative data from an international survey of exploratory therapists working with gender-questioning clients. Journal of Sex and Marital Therapy, 1–26. https://doi.org/10.1080/0092623X. 

National Board of Health and Welfare (2022, December). Care of children and young people with gender Dysphoria – national knowledge support with recommendations for the profession and decision-makers.

Nyhan, B., & Reifler, J. (2010). When corrections fail: The persistence of political misperceptions. Political Behaviour, 32(2), 303 – 330.

Singh, D., Bradley, S., & Zucker, K. (2021). A follow-up study of boys with gender identity disorder. Frontiers of Psychiatry.

Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. Journal of Academic Child Adolescent Psychiatry, 52(6), 582 – 590.

---

Genspect publishes a variety of authors with different perspectives. Any opinions expressed in this article are the author’s and do not necessarily reflect Genspect’s official position.

---