Does Reparative Therapy Cure Gender Dysphoria?

A comparison of current therapy for gender dysphoria with religion based reparative therapy alternatives

by Carol F. Milazzo, M.D. (posted in June 2004)

Introduction

Modern mental health science recognizes that gender dysphoria (also known as gender identity disorder or GID) is due to one’s gender identity, i.e., one’s feeling of being male or female, not agreeing with the physical sex of their body.  This results in varying levels of discomfort with one’s own body and with conforming to the gender role expected by society.  Although there are several different suspected inherited and environmental causes of gender dysphoria, one’s “core gender identity” is known to be permanently formed by early childhood–between the ages of three and four years.  Many years of experience have shown that therapy and medications cannot change one’s gender identity.  As a result, the current accepted treatment for gender dysphoria is directed toward ways to help one cope with this stress, and may include cross-gender hormones, part-time or full-time cross-living, supportive counseling and/or surgical sex reassignment.  These treatments are outlined in the Standards of Care of the World Professional Association for Transgender Health.

Reparative therapy alternatives

Parakaleo

There are some individuals who disagree with the current model and who claim that psychotherapy is part of an effective treatment for GID.  This is an extension of a religious fundamentalist movement to convert and reorient homosexuals that is promoting a school of thought called conversion or reparative therapy.  An individual named Keith Tiller who claims to be a recovered transsexual founded and directs one such reparative therapy program called Parakaleo.[1]In his personal testimony page[2], Mr. Tiller reveals the following basically faulty tenets inherent in the school of reparative thought.He characterizes transgender identity as “self determined” when core gender identity is accurately known to develop by very early childhood before an individual can make such a choice.Here Mr. Tiller incorrectly states:

“[G]ender identity disorder … is largely a product of the twentieth century. It is only in the last eighty years or less that an understanding of the work of hormones etc. and the necessary surgical skills have developed to enable sex re assignment surgery to occur.”

He characterizes cross-gendered expression as an “addiction” and “false comfort.”In fact gender variant expression has been known to be inherent in the expression of transgendered individuals from their earliest ages throughout history and across cultures.[3]Gender dysphoria in individuals is a product of their living in cultures that are hostile and oppressive.Mr. Tiller cites Scripture to assert a dogmatic dichotomy of sex while this same source provides evidence for the historical recognition and acceptance of natal intersexuality and the practice of surgical gender modification.

“For some are eunuchs because they were born that way; others were made that way by men; and others have made themselves eunuchs because of the kingdom of heaven. The one who can accept this should accept it.”[4]

Although our modern word “transgender” does not occur in Scripture, in its language the modern transgendered would be called “eunuchs which have made themselves eunuchs,” either through surgical castration (orchiectomy or oophorectomy) in sex reassignment surgery or through medical castration by the use of hormones (the treatment of sexual offenders with hormones is commonly called chemical castration). 

It would be ingenuous to presume that transgender expression was not found among eunuchs of biblical times.  There is evidence from ancient historians that at least some of these eunuchs displayed gender expressions similar to modern day transgendered people:

“First-century Jewish commentators, such as Josephus, ...regarded eunuchs as unnatural ‘monstrosities’ who must be shunned on account of their gross effeminacy and generative impotence (Antiquities IV 8,40), and Philo, who classified eunuchs as various ‘worthless persons’ banned from the sacred assembly because they ‘debase the currency of nature and violate it by assuming the passions and the outward form of licentious women.’ (Special Laws I 324-35).”[5]

These eunuchs obviously did not present themselves as men.The negative reactions of these commentators reveal that these eunuchs of antiquity struggled with many of the same prejudices that transgendered people face in modern times.

The account of Philip’s encounter with the Ethiopian eunuch demonstrates that the early Christian church openly welcomed the inclusion of gender variant individuals.[6]Mr. Tiller selectively cites Deuteronomy 22:5 as an interdiction for crossdressing, but fails to justify our culture’s failure to conform to the adjacent rules in the context of that historical code of conduct.

“If you come across a bird's nest beside the road, either in a tree or on the ground, and the mother is sitting on the young or on the eggs, do not take the mother with the young.You may take the young, but be sure to let the mother go, so that it may go well with you and you may have a long life.When you build a new house, make a parapet around your roof so that you may not bring the guilt of bloodshed on your house if someone falls from the roof.Do not plant two kinds of seed in your vineyard; if you do, not only the crops you plant but also the fruit of the vineyard will be defiled.Do not plow with an ox and a donkey yoked together.Do not wear clothes of wool and linen woven together.Make tassels on the four corners of the cloak you wear.”[7]

In his web page titled “Frequently Asked Questions about: Transvestism, or Transsexuality/Transsexualism”[8] Mr. Tiller states that “Psychiatric evidence indicates that gender ambiguity can be responsive to therapies without recourse to surgery.”Although gender dysphoria may be alleviated in some individuals through hormones,therapy and transition without recourse to surgery, there is no evidence that such therapy can alter a firmly established core gender identity.He claims that that pre-operative counseling is increasingly dispensed with exposing increasing numbers of individuals to inappropriate surgery.In fact, the establishment and implementation of standards of care requiring such counseling has been accompanied by a significant observed decrease of post-surgical regrets.

Reality Resources

Reality Resources is another reparative therapy program that Jerry Leach, also claiming to be a cured transsexual, promotes through his website.[9]   The materials he sells include the Reality Resource Manuals #1 & #2, a videotape of an interview with Jerry Leach from a Christian television program called “Straight Talk”, and 3 audiocassette series: one for the wives, one called “Breaking Free of Gender Confusion” consisting of lectures by Jerry and Charlene Leach, and “Men of Destiny”–a series of testimonies of men who have attended a “Break Away” weekend workshop.  (The following information on Mr. Leach's program is taken from these sources.) Here are some comments on his program that address some of the issues common to reparative therapy.

First, as far as Mr. Leach’s credentials are concerned, they consist of his pastoral career and training, having earned a Master of Divinity after attending bible college and seminary.  He had a minimal level of training in the health profession, having been a Hospital Corpsman in the U.S. Navy, roughly equivalent to a medical assistant.  This requires a high school diploma and a few months of training directed toward first aid and performing the simpler tasks of a hospital environment, such as taking vital signs and administering injections and cardiopulmonary resuscitation.  He would also have become familiar with some medical terminology.  The Navy discharged Mr. Leach from the service when he sought help for his cross-dressing, indicating an assessment that determined him unfit for duty.

In his Reality Resource Manuals #1 and #2, Mr. Leach shows some familiarity with gender dysphoria, and intersperses some facts with controversial alternative theories on its causes, descriptions of the emotional trauma suffered by some who have undergone sex reassignment surgery, and some testimonies of individuals who claim to be former homosexuals and cross dressers.  Notably, the theories that Mr. Leach proposes fail to address female to male transgenderism. From his personal biography, it is unclear whether Mr. Leach is a transsexual or transvestite–although the latter is suggested according to the classic definition since he mentions an addiction to masturbation with his cross-dressing.He might be considered an autogynephile according to the controversial theory of Ray Blanchard.[10]Some argue that autogynephilia is a narcissistic phase through which some gender dysphorics pass.Mr. Leach departs from current accepted knowledge and does not differentiate transvestism from transsexuality.  He claims that one progresses from one to the other as if one’s core gender identity can shift, and that it is all addictive and potentially controllable behavior.

The theory of arrested development

Mr. Leach also differs on the issue of GID being due to an immutable core gender identity.He asserts that one’s gender identity is absolutely dictated by the presence or absence of a Y chromosome.The discovery of female individuals with Y chromosomes during IOC mandated gender verification testing disproves this concept.[11]He also asserts that the transsexual’s “self” is a correctable false identity which results from an arrest in personal emotional growth and which is manifested especially in times of stress.  Like other proponents of reparative therapy, Mr. Leach considers consider GID and homosexuality to be manifestations of this same underlying treatable cause.

In support of this theory, Mr. Leach lists the following traits as common to “homosexuals and trans-gender men.”[12]

1.Poorly developed same-sex adult relationships

2.Poorly developed same-sex parent relationships

3.Poorly developed same-sex peer relationships

4.Poorly developed relationships with heterosexual males

5.Overly-attached with the mother

6.Feeling more secure in mother’s love

7.Ambivalence about their own sexual identity

8.Attracted to and emulating the feminine in mannerisms, temperament, etc.

9.Envy and jealousy of the attention females receive

10.Instinctively drawn to mother’s side in times of stress to find comfort

11.Feels more understood and loved by mother

12.Disengagement and defensively-detached from father

13.Early childhood experimentation with cross-dressing

14.Incessant obsession with fantasy and pursuit of sexualized-idol

15.Labeled a sissy, effeminate, momma’s boy

16.Temperamentally more inclined to arts, music, nurturing, sensitive

17.Tormented by the bitterness and cycles of shame and guilt

18.Lured into roles of the opposite sex

19.Growing ambivalence toward God

20.Paranoid personality as a result of toxic shame

21.Desire to be taken care of and protected

22.Growing dissatisfaction with own body & appearance

23.Victimized by sexual abuse

24.Made to feel different by personal mannerisms, temperament, personal preferences, choice of interests

25.Growing self-contempt

Here is my analysis that shows that each of these traits describe situations that are prevalent among much of modern Anglo-American culture including heterosexuals, homosexuals and transgenders:

1.Poorly developed same-sex adult relationships.  This is common among all oppressed, stigmatized and discriminated groups due to fear and mistrust of a society that is often hostile toward them.  This is also common among mainstream heterosexual males due to social pressures that discourage men from emotional intimacy and that encourage superficial and stereotypical relationships.

2.Poorly developed same-sex parent relationships.  These exist among all groups including mainstream heterosexual males and females.  Unknown if there is any significant difference in the prevalence of this condition among homosexuals, heterosexuals and transgenders.

3.Poorly developed same-sex peer relationships.  This also appears to be common among mainstream heterosexual males due to social pressures that discourage men from emotional intimacy and that encourage superficial and stereotypical relationships.  Males may be open to improved peer relationships when they choose not to conform to this stereotypical male role.

4.Poorly developed relationships with heterosexual males.  Same as number 1 above.

5.Overly-attached with the mother.  This occurs among heterosexuals, homosexuals and transgenders.  The cultural expectation is that the mother is more affectionate, empathetic and nurturing than the father.  Unknown if there is any significant difference in the incidence among homosexuals, heterosexuals and transgenders.

6.Feeling more secure in mother’s love.  Commonly true among all groups.  The expectation is that the mother is more affectionate, empathetic and nurturing.

7.Ambivalence about their own sexual identity.  Heterosexuals, homosexuals and transgenders are generally well established in their gender identity.  Ambivalence may occur among some in all groups.  Unknown if there is any significant difference in the level of conviction of sexual identity among homosexuals, heterosexuals and transgenders.

8.Attracted to and emulating the feminine in mannerisms, temperament, etc.  Temperament is inborn and mannerisms are learned social behaviors.  Social stigma suppresses and discourages “feminine” temperaments and mannerisms among heterosexual males.  Homosexuals and transgenders often reject this suppression and express their various innate traits regardless of their classification as typically “masculine” or “feminine.”  Heterosexual females experience greater freedom from social disapproval when diverging from their gender role expectations.

9.Envy and jealousy of the attention females receive.  All individuals desire attention.  Desire for attention as a female is appropriate for all who identify as female.  Frustration of this desire is a cause of poor self-esteem and depression.

10.Instinctively drawn to mother’s side in times of stress to find comfort.  Same as number 6.  Commonly true among all groups.  The cultural expectation is that the mother is more affectionate, empathetic and nurturing.

11.Feels more understood and loved by mother.  Same as number 6.  Commonly true among all groups.  The cultural expectation is that the mother is more affectionate, empathetic and nurturing.

12.Disengagement and defensively-detached from father.  This also exists among mainstream heterosexual males and females.  Unknown if there is any significant difference in the prevalence of this condition among homosexuals, heterosexuals and transgenders.

13.Early childhood experimentation with cross-dressing.  Reported common among many males and females during dress-up play.

14.Incessant obsession with fantasy and pursuit of sexualized-idol.  Also known as fetishism.  This occurs among all groups but in this society is comprised largely of heterosexual males who are the principal consumers of pornography and an advertising industry that exploits sex.

15.Labeled a sissy, effeminate, momma’s boy.  Derogatory language is a common form of emotional violence perpetrated against many minority individuals who differ from a majority ideal of appearance or behavior.

16.Temperamentally more inclined to arts, music, nurturing, sensitive.  Social pressures typically discourage these positive human qualities that are not currently interpreted as typically “masculine”.

17.Tormented by the bitterness and cycles of shame and guilt.  This is the internalization of experienced hatred and stigmatization that is perpetrated by individuals and many organized religious institutions.

18.Lured into roles of the opposite sex.  Experimentation across culturally defined gender boundaries is an expression of diversity that is increasingly stigmatized through childhood and adulthood.  Gender role variance is not a “lure”, but rather an expression of individual diversity.

19.Growing ambivalence toward God.  Lack of a positive relationship with God is common among many males and females in current society.  The hostility and stigmatization of many organized religious institutions toward homosexuals, transgenders and other minorities often provokes a sense of disenfranchisement and difficulty with spiritual matters.

20.Paranoid personality (as a result of toxic shame).  Paranoid feelings are common among all oppressed and discriminated groups due to fear and mistrust of a society that is often hostile toward them.  Fear of bodily harm is reasonable in a hostile environment characterized by discrimination, ridicule, and hate crimes including murder.  These feelings are called “common sense” when considering the risks of females in situations in which they are frequently the victims of violent crime.  “Toxic shame” is the internalization of the hatred experienced from others.  There is no absolute relationship between fear of others and self-hatred.

21.Desire to be taken care of and protected.  This desire is common and normal among all humans.  Theists look to God as Provider and Protector and strive to provide these to each other in caring relationships.

22.Growing dissatisfaction with own body & appearance.  Transsexuals experience dissatisfaction with their physical anatomy from an early age.  Symptoms of dysphoria and depression become aggravated with denial and suppression.  Dissatisfaction with physical appearance is endemic in this society.  It is cultivated and exploited by the cosmetic and esthetic surgery industries that promote unrealistic images of beauty that provoke poor self-esteem and depression among males and females alike.  Heterosexuals and homosexuals, including non-transsexual cross dressers, are typically satisfied with their anatomy.

23.Victimized by sexual abuse.  Occurs among some in all groups, especially perpetrated by heterosexual males upon females.  Unknown if there is any significant difference in the prevalence of sexual abuse among homosexuals, heterosexuals and transgenders.

24.Made to feel different by personal mannerisms, temperament, personal preferences, choice of interests.  This awareness of an alternate identity is characteristic among many individuals of minority groups who show variation from mainstream cultural norms.  This incurs stigmatization and alienation when an individual resists the society's attempts to coerce assimilation.

25.Growing self-contempt.  This is common among socially stigmatized minority groups and is the internalization of experienced hatred.  It may lead to fatalism, addictions and other self-injurious behaviors, self-denial and suppression.

This analysis can lead one to the following conclusion.  Modern Anglo-American society presents an environment which has discouraged diversity and that has allowed the perpetration of discriminatory and violent behaviors by individuals and institutions disproportionately against women and members of sexual and ethnic minorities.  Many established religious institutions have traditionally sanctioned the perpetuation of such oppressive behavior although this may be in contradiction of their proclaimed teachings and philosophies.  One does not logically conclude that arrested emotional development is a common cause of homosexuality and transsexualism.  To the contrary, there exists a pervasive hostile environment in our culture that would probably interfere with the full development of healthy relationships among some members of these discriminated minorities.

The theory of wounded masculinity

Mr. Leach claims that male homosexuals and male to female transgenders suffer from a “wounded masculinity” that precludes these individuals from achieving a full emotional development that would result in heterosexuality for each one.  (This logic can lead one to the absurd conclusion that female to male transgenders develop from an immature female state into an inherently emotionally mature male gender identity.)He provides a list of resource readings that deal with topics such as male homosexuality, sexual addictions, addictions to pornography, unfaithfulness in marriage, healing the male spirit, etc.  These readings do not address issues directly relevant to gender dysphoria, but present an image of men who engage a broad spectrum of behaviors, some of which depart from mainstream cultural norms, some of which are seen as harmful to women and families although they are often tacitly condoned by cultural gender role expectations. Males are conditioned from childhood to be “manly”, i.e., to conceal and suppress their feelings, to objectify those around them, and to devalue emotional and physical intimacy in people as a sign of weakness. Add to these the effect of a constantly heightened libido from elevated testosterone levels and it is no surprise that many men tend to behave towards others primarily on an animal impulse level for self-gratification. It is a small wonder that any men survive all these assaults to retain any vestige of humanity. One should probably not regret the failure to be assimilated among those of this mindset.  Exposure to such pervasive conflicting influences is undoubtedly detrimental to men's development.

Contrast this macho image of masculinity with the biblical presentation of Jesus of Nazareth whose life the Christian church has always held as the role model for humanity.  Jesus regularly transgressed religious taboos and social gender stereotypes.  He modeled mature spirituality, kind, nurturing and empathic relationships toward others and preached peace and love of neighbor in a society dominated by a rigorous sexist and legalistic religious patriarchy and where many advocated for violent rebellion against foreign domination.  The religious authorities rebuked him for associating with outcasts, e.g., publicans and sinners (Matt. 9:11), (Matt. 11:19), (Mark 2:16), (Luke 5:30), (Luke 7:34), (Luke 8:39), (Luke 15:2), Zaccheus (Luke 19:7), and the Samaritan woman at the well (John 4:9,27).  Were Jesus exercising his ministry in modern times, no doubt he would be preaching reconciliation and inclusion to gender dysphorics and others whom many of today's dogmatic religious institutions now condemn and abandon in the tradition of the Pharisees.

The claims to recovery

With respect to the efficacy or lack thereof of reparative or conversion therapies, one prominent controversy revolves around the testimony of Michael Bussee, a founder of Exodus International, who resigned decrying a high rate of depression and suicide attempts among individuals who had gone through their program.  Bussee stated that although the program did effect changes in outward behaviors in some individuals, it failed to demonstrably change sexual orientation in anyone.[13]  Joe Dallas, president of Exodus International, responded that the program has never made claims to the degree of the change of homosexual attraction.[14]  The Exodus International FAQ web page also follows its claims to 30-50% conversion with a disclaimer that “success rates” vary considerably and the measurement of change is problematic.[15]  In a personal conversation, Dr. Benjamin Kaufman, a prominent psychiatrist and Chairman of the Board of the National Association for Research and Therapy of Homosexuality (NARTH), stated that a major goal of therapy was the suppression of gender variant behaviors and to bring behaviors into conformity with the social norm.  This individual offered as a reference the work of George A. Rekers, who himself reported that “severe sexual problems of adulthood such as transsexualism and homosexuality (Rekers, 1985b; Rekers & Kilgus, 1995) ...are highly resistant to treatment.”[16]

Mr. Leach's claim to being “cured” may be questioned as he admits to still having recurring desires to cross-dress although he suppresses these with medications, intensive counseling, reinforcement by like-minded peers, and a conscious effort to redirect his thoughts through prayer and meditation.  Even if Mr. Leach truly has GID, it is known that in some its symptoms may be mild and may respond to minimal measures, or it can be cyclical, with its severity waxing and waning over periods of years[17]–it remains to be seen for how long Mr. Leach maintains the control that he now claims to have.

When it has been scientifically demonstrated that therapy does not reverse gender identity, how does one explain these claims to be a recovered transsexual? Supposing that one truly has gender dysphoria, what may be involved is a defense mechanism called “Reaction Formation.”

Definition of REACTION-FORMATION: The blocking of desire by its opposite. “Reaction-formation” is the term Freud uses to describe the mechanism whereby the ego reacts to the impulses of the id by creating an antithetical formation that blocks repressed drives. For example, someone who feels homosexual desire might repress that desire by turning it into hatred for all homosexuals.

In this case, one would consider a female core gender identity as an inherently evil self-deception that is incompatible with their value system, therefore they may suppress this identity by assuming an opposite role–becoming a leader in a fundamentalist denomination and/or establishing a mission to save others from gender dysphoria. Thus, one may free himself of guilt and distract himself from dysphoria by constructing a situation in which he believes he can exert control and superiority over his gender dysphoria and, by extension, over those who subscribe to his program. As Mr. Leach admits to a recurrent struggle with his dysphoria this defense mechanism is not perfect, but it may be sufficient to maintain suppression of his symptoms for the present.

As guilt is a major motivator in this method of suppression, the individual who chooses it would be at risk for depression associated with relapses due to cyclic variations in severity of dysphoria and inconsistent effort. The results of reparative therapy programs would then not differ significantly from the cycles of purging and relapse that gender dysphorics commonly report with their own efforts.

Conclusion

Reprogramming external visible behaviors arguably does not constitute a valid and satisfactory outcome when such behaviors conflict with the essence of one’s identity.  Likewise, any treatment with a claimed failure rate of up to 70%, exposing subjects to a significant risk of depression and suicide is unethical.For these reasons, the major mental health associations have issued resources[18] and policy statements[19][20][21] advising professionals not to engage in conversion or reparative therapies on ethical grounds due to the harm they inflict on individuals.

If in fact those who promote reparative therapy programs have been able to attain peace of mind, suppression of transgender behaviors and an ability to function as a heterosexual in their birth-assigned gender to their satisfaction and that of their family and peers, then they would understandably want to share this accomplishment through this work.  The crucial question is how effective such treatments may be for others–a claim which the scientific literature to date does not support.



[3] Mollenkott V., “Precedents for Increased Gender Fluidity,” Omnigender: a trans-religious approach, (Cleveland: Pilgrim Press, 2001), 127-163.
[4] Matthew 19:12 (NIV)
[5] Spencer F., Acts, (Sheffield: Sheffield Academic Press, 1997), 93.
[7] Deuteronomy 22:6-12 (NIV)
[10] Blanchard R., The concept of autogynephilia and the typology of male gender dysphoria, The Journal of Nervous and Mental Disease, 177: 616 – 623, 1989.
[11] Genel M, “Gender Verification No More?Medscape Women’s Health, Vol. 5, No. 3, 2000.
[12] Reality resource Manual #1 "Flight Toward Woman" Chapter 8: Homosexual & Transsexual Compared, p. 51.
[14]Davies, B., Setting the Record Straight, Exodus Standard, Vol. 8, No. 1, 1991.
[16] Rekers, G, Gender Identity Disorder, The Journal of Family and Culture, Vol. II, No. 3., 1986.
[17] Marks I, Green R, Mataix-Cols D, Adult gender identity disorder can remit, Comprehensive Psychiatry, Vol. 41, No. 4, July 2000, pp. 273-275.
[18] Just the Facts About Sexual Orientation and Youth, American Academy of Pediatrics, American Psychological Association, National Association of Social Workers, and other organizations.
[19] American Academy of Pediatrics, Committee on Adolescence, “Homosexuality and Adolescence (RE 9332),” Pediatrics, Vol. 92, No. 4, October 1993, pp. 631-634.
[20] American Psychiatry Association, Commission on Psychotherapy by Psychiatrists, “Position statement on therapies focused on attempts to change sexual orientation (reparative or conversion therapies)”, Am J Psychiatry. 2000 Oct;157(10):1719-21.
[21]American Psychological Association Council of Representatives, August 14, 1997, “Resolution on Appropriate Therapeutic Responses to Sexual Orientation.”