Source Laundering (2)

How a handful of activists convinced themselves and the world that therapy was bigotry

The recent release of the Cass Review into healthcare for gender-questioning youth has been welcomed and condemned in equal measure, and the amount of disinformation spread about it by high profile individuals and supposedly reputable organisations is both disappointing and entirely unsurprising. What could have been an opportunity to meet in agreement over the quality of the evidence has instead become an airing of long standing talking points, given fresh life and wider exposure. While some especially egregious gaffes over entirely fictional quantities of evidence excluded have caught the headlines - with Dawn Butler MP ultimately apologising for misinforming parliament and blaming Stonewall for misleading her in turn - there are deeper, more pernicious attacks on the Cass Review that are much harder to unpick.

In recent years, as governments around the world have moved to ban conversion therapy not just of sexual orientation, but also of “gender identity”, some therapists have expressed concern that such moves risk banning the sort of therapy that seeks to understand the roots of an individual’s gender distress. Such concerns have been repeatedly dismissed as groundless - concerns which are once again raised in the Cass Review:

Throughout the Review, clinicians working with this population have expressed concerns about the interpretation of potential legislation on conversion practices and its impact on the practical challenges in providing professional support to gender-questioning young people. This has left some clinical staff fearful of accepting referrals of these children and young people.

Anticipating some of the hostility to the final report, Cass noted in advance the unhelpful and hostile nature of this debate, and the way in which some terms had been “weaponised” for political ends, such as those in the ongoing dispute over appropriate treatment for gender-questioning youth, and the distinctions between “affirmative” and “exploratory” models of care:

The role of psychological therapies in supporting children and young people with gender incongruence or distress has been overshadowed by an unhelpfully polarised debate around conversion practices. Terms such as ‘affirmative’ and ‘exploratory’ approaches have been weaponised to the extent that it is difficult to find any neutral terminology. 

This plea for reasoned debate has not stopped the Cass Review from being condemned for espousing conversion therapy.

Back when the interim report of the Cass Review was released in 2022, WPATH released a statement condemning exploratory therapy as “tantamount to conversion therapy. Now with the final report, WPATH responds again, even more clearly:

The foundation of the Cass report is rooted in the false premise that non-medical alternatives to care will result in less adolescent distress for most adolescents

WPATH considers that anything other than a medical pathway is harmful, and that even trying to suggest other underlying reasons might exist for a child expressing a “trans identity” is not allowed.

WPATH’s affiliated academic journal, The International Journal of Transgender Health, even published a peer-reviewed article laying out all these claims, just prior to the release of the final report, accusing Cass of “cis-supremacy” and “conversion therapy”, that the evidentiary demands are unfeasible, that randomised-controlled trials are unethical, and that “anti-trans professionals” were involved in the process.

These are broad and serious allegations, and they are being repeated over and over by transadvocacy organisations and individuals, believing that there is some weight to these claims. Indeed, if you were to look up Wikipedia for an explanation of what the exploratory approach is, you would be redirected to the page on conversion therapy instead.

In a previous piece, I charted how one tweet was taken out of context and - through a complicated game of telephone - became evidence of a nefarious new form of conversion therapy called “gender critical therapy” in reports to policymakers, despite never actually existing.

In a very similar vein, the phrase “gender exploratory therapy” has become a flashpoint in the debate over conversion therapy, subject to a similar chain of source laundering to give baseless opinion an authoritative gloss. Gossip has been spread as fact, and within activist circles, the notion that exploratory therapy is really conversion is simply a given, circulated and amplified endlessly within echo chambers until we reach the point where the actual basis for the claims is all but forgotten.

Broadly, the chain is as follows:

• 2019: Anastassis Spiliadis’ “Towards a Gender Exploratory Model”

• 2021: Gender: A Wider Lens

• 2022: Health Liberation Now’s “A New Era”

• 2022: Florence Ashley’s “Interrogating Gender Exploratory Therapy”

• 2023: Health Liberation Now’s “SEGM Exposed: Reloaded”

• 2023: Southern Poverty Law Centre’s CAPTAIN report

• 2024: Cal Horton’s “The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children”

Each step along this chain adds its own layer of misinformation and conspiracism, with many more interesting branches along the way, but these are probably the most significant stages. This will hopefully illustrate that the claim is not so simple as something that can be fact-checked and disproved, but is in fact reflective of an entire worldview, a logical consequence of understanding “gender identity” in a particular way, and a perspective that is now supported by a web of interconnected claims that are not easily unpicked.

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2019 - Towards a Gender Exploratory Model

In July 2019, Anastassis Spiliadis - a clinician at the Tavistock GIDS - published a paper titled “Towards a Gender Exploratory Model: slowing things down, opening things up and exploring identity development”. In it, he describes a polarisation in therapeutic approaches, between those focused on affirming, validating and facilitating a trans identity in gender questioning youth, and those seeking to prevent one.

Broadly speaking, we can conceptualise competing theoretical approaches in working with young people with GD, as loosely connecting to two different polarities: one that would affirm (often perhaps confirm) a young person’s subjective gender(ed) experience and related hopes (for instance, for medical interventions) in the context of ‘authentic self-knowledge’ (Lopez, Marinkovic, Eimicke, Rosenthal, & Olshan, 2017) or on the basis of their ‘privileged access’ (Wren, 2014); and, on the other hand, one that would posit that offering active therapeutic intervention will effect a change / desistance in the young person’s identification and therefore lead to congruence with their natal sex.

Neither of these is uncontroversial, as approaching therapy with a set outcome in mind (either facilitating or preventing) forecloses other options, and the latter - when coercive or “reparative” methods are employed - is indeed tantamount to the sort of conversion therapy perpetrated against gay people historically.

However the point of Spiliadis’ paper is to chart a third way - an exploratory model that is open, curious and undirected, not seeking impose a particular normative mode of self-expression, but at the same time not shying away from exploring why a young person might wish to be the opposite sex.

He presents a case study of a boy who was adamant he wished to be a girl, but through a process of exploration revealed a same-sex attraction that was suppressed due to homophobic bullying, and that was later reconciled by this undirected and open therapy, to the point of embracing a more fluid identity, encompassing both masculine and gender-neutral pronouns. The boy simply could not understand himself as a boy, in a relationship with another boy, and probing the roots of that enabled alternative understandings of how it was possible to be, without resorting to drastic experimental medical interventions in pursuit of becoming something he could never truly be at all. An affirmative approach would not have explored these roots in such a questioning fashion, and what was otherwise a same-sex oriented boy would likely have been set on a medicalised path in a quest to appear to the world as a heterosexual girl.

This paper reveals the tension between sexual orientation and the medicalisation of gender nonconformity. Taking a gay boy and making him appear “straight” to the world is conversion therapy - but to advocates of the affirmative model, taking a “trans girl” and cruelly denying her medical interventions while insisting on talking therapy to “convince” her she’s simply a gay boy is conversion therapy, denying a fully realised trans identity that a medical pathway would facilitate.

It also reveals the tension within GIDS itself over appropriate therapeutic practice, with some clinicians favouring a slower, exploratory approach, while others held to overly-affirmative practices which have since been criticised in the Cass Review.

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2021 - Gender: A Wider Lens

In May 2021, Spiliadis’ paper was discussed on the Gender: A Wider Lens podcast, with Sasha Ayad and Stella O’Malley:

Sasha Ayad says:

This term was first used by a therapist called Anastassis Spiliadis, and he has an excellent paper called “Towards a Gender Exploratory Model: slowing things down, opening things up and exploring identity development”, and he's a colleague of ours and he's written about his gender exploratory model which is brilliant.

And Stella O’Malley responds:

What I am is I'm curious and I'm compassionate and I'm exploratory and trying to find out the person and where they're at, and so if you want to call it gender exploratory, yeah that would suit me better, but I'm just effectively client exploratory you know?

Stella O’Malley went on to found the organisation Genspect a month later, with a live webinar on June 19th:

During this event, other organisations were promoted, including the Society for Evidence-based Gender Medicine (SEGM). At one point, Sasha Ayad mentioned a sentence from the film “Transmission”, by the Centre for Bioethics and Culture:

If you’re the sort of person who is open, curious, resistant to ideological purity and willing to talk to anyone without endorsing any particular viewpoint, it might not be immediately apparent how tweeting about a video like this is going to play out once your ideological opponents seize upon it.

Three of the people featured in this film are or were members of The American College of Paediatricians (ACPeds), which - despite its important-seeming name - is essentially a small conservative and homophobic organisation who split from the much larger American Academy of Paediatrics, specifically over its endorsement of gay adoption in 2002. ACPeds undeniably endorses the sort of “reparative” (conversion) therapy that Spiliadis’ 2019 paper disavows. Indeed, in 2010 it wrote to schools saying that same-sex attraction “can respond well to therapy”, suggesting how to avoid adolescents engaging in “harmful homosexual behaviors”. For anyone following the debate over gender, this 2010 letter contains language that is eerily familiar with regards sexual orientation:

It is not the school’s role to diagnose and attempt to treat any student’s medical condition, and certainly not a school’s role to “affirm” a student’s perceived personal sexual orientation.

Everything that follows has to be seen in this light. Conservative organisations in the US have a long history of advocating outright conversion therapy under reasonable-seeming language. They have treated same-sex attraction and gender nonconformity as the same thing, both deviations from a heterosexual norm, and both to be prevented if possible. Activists are rightly wary of attempts by such organisations to conceal their true motives with sanitised language and front groups.

However there is a difference between being alert to the covert actions of bad faith actors, and baselessly smearing ideological opponents.

Two days after the Genspect webinar, the term “gender exploratory therapy” was picked up on by Mallory Moore of activist group Trans Safety Network, claiming it was simply a new term for conversion therapy:

This tweet was shared by Ky Schevers, of activist group Health Liberation Now:

In August 2021, Schevers went on to tweet about “gender exploratory therapy” as a conversion practice.

In August 2021, Trans Safety Network also went on to publish posts attacking SEGM and Genspect and anyone associated with them, playing up purported affiliations between them and ACPeds.

In September 2021 Schever’s Health Liberation Now co-founder Lee Leveille published an article titled “When Ex-Trans Worlds Collide” citing Moore’s tweets and the Trans Safety Network piece on SEGM, mostly attacking detransitioners, but also outright claiming that “exploratory psychotherapy” is conversion therapy. Leveille warns:

Groups or programs like Inspired Teen Therapy and GDSN, operated by SEGM members, promote what they call “compassionate exploration-based counseling” for teens and young adults built on ROGD frameworks. Florence Ashley cautioned that this was likely to occur, in part because of how politics has merged with trans health in the midst of increased medical support for trans youth. “The new, unsupported theory rapid-onset gender dysphoria is being used to oppose affirmative care for adolescents, and newspapers in the United Kingdom are attacking the national gender clinics for allowing youth to transition, despite their approach falling on the conservative side of trans health. After a steady decline over the past decades, trans reparative therapy may be heading toward a dangerous revival.”

Leveille cites Florence Ashley here to attack the hypothesis of “rapid onset gender dysphoria” (ROGD) originally advanced by Lisa Littman in 2018, and tie it to what Ashley at the time called “reparative therapy”. Both Leveille and Ashley are convinced that ROGD is part of a ploy to attack trans healthcare, and usher in conversion therapy by stealth. Since ROGD posits the idea of peer influence on gender identity it cannot be accepted by advocates of medicalised affirmation, since evidence for social contagion is something that would fatally undermine the straightforwardly affirmative model and mandate a more cautious, exploratory approach. The evidence must be a lie, and the true agenda must be conversion.

This is essentially ground zero for an ensuing web of citations and insular groupthink spreading the claim that bog standard, curious, undirected, exploratory therapy is actually conversion, much of which revolves around the academic musings of Florence Ashley in particular.

By the middle of 2021, this group of activists had already spent well over a year attacking Stella O’Malley as a conversion therapist, targeting the entirely made-up term “gender-critical therapy”, over one repeatedly misrepresented tweet in February 2020. After the Wider Lens podcast, the launch of Genspect and the Gender Exploratory Therapy Association (GETA), all of those prior accusations simply transferred to all possible variations of exploratory therapy, most notably “gender exploratory therapy”.

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2022 - A New Era

On June 1st 2022, Lee Leveille published another article on Health Liberation Now titled “A New Era: Key Actors Behind Anti-Trans Conversion Therapy”. This article included a definition of “gender exploratory therapy” which stated that term, and all of its synonyms, are in reality conversion therapy:

“Gender exploratory therapy”: New label for forms of conversion psychotherapy advertised to trans and gender diverse adolescents and young adults, as well as detransitioned individuals. Additional terms interchangeably used by GICE actors are “exploratory therapy,” “exploratory psychotherapy,” or “exploratory talk therapy”, which can be differentiated from affirming models of exploratory therapy via the context of a group or clinician’s beliefs surrounding gender identity and affiliations they hold.

This is, as far as I can make out, the first online resource explicitly making this allegation about the phrase “gender exploratory therapy”, outside of the earlier social media posts by Schevers and Moore, and builds on Leveille’s earlier claim about “exploratory psychotherapy” being conversion therapy.

Leveille claims not only that any therapeutic language which uses “exploratory” in any combination is suspect on its face, but also a key to unlocking whether someone is a conversion therapist is group affiliations. The rest of the article is then devoted to charting such “affiliations” using the loosest possible interpretations, building on the earlier work by both Health Liberation Now and Trans Safety Network.

Much space is devoted to explaining why actual hard-right conversion therapy advocates such as Heritage, ADF and the aforementioned ACPeds are not to be trusted, but when it comes to the actual criticism of organisations like SEGM, the occasional valid points here and there are buried under a mountain of overstatement making it very hard to take in good faith and get to the truth.

For example, it is legitimate to point out that Will Malone of SEGM once co-authored a letter with members of ACPeds, but far more disingenuous to state in “key findings”:

Citations of the work of Kenneth Zucker, Susan Bradley, and Lisa Littman serve as a bridge between “gender exploratory therapy” worlds and established SOGICE actors or advocates.

The logic is that if your work is capable of being cited by someone who is “anti-trans”, to advance an “anti-trans” point, then it must have been created to support that agenda, and therefore whoever produced it - and anyone they associated with - is suspect. Smearing individuals and organisations for such sins as being “cited” by bad actors is an absurd and unreasonable standard.

Really this is an exercise in collating sub-prime evidence for a reputational attack on an entire organisation to tarnish everyone associated with it for all time.

If the aim is to raise awareness of bad actors and nefarious intent, this sort of bad faith accumulation of evidence is wholly counterproductive, as absolutely no-one has time to sift through sorting the wheat from the chaff, and what results is just intense polarisation, where any legitimate claims are brushed off by one side, while baseless claims are taken as gospel by the other.

This is all just throwing everything at the wall and hoping as much sticks as possible, and if there are any legitimate criticisms to be made they are near-impossible to tease out. The point is that the worse SEGM and Genspect can be portrayed, the more anyone who connects to them or anyone connected to them, or cites them, or so much as breathes in their vicinity can be portrayed as spreading “conversion therapy”, no matter what form of words they actually employ.

Posts like “A New Era” are not about teasing apart true claims from false in an effort to genuinely raise the alarm about the very real threat posed by some bad actors on the US right-wing. Rather, this is amassing an arsenal to perform total reputational annihilation against absolutely anyone even remotely, tangentially, six-degrees-of-separation connected to ideological opponent.

Notably, this also makes the completely made-up claim that it is their opponents responsible for a shift in language from a previous focus “gender-critical therapy”:

“gender exploratory therapy,” previously known as “gender critical therapy”,

This conspiracist logic enables Leveille to pretend all previous sources attacking that confected term simply apply to this one too, creating a mountain of “evidence” from nothing whatsoever, and any confusion over changing terminology is just more evidence of how shifty those conversion/gender-critical/exploratory/gender exploratory therapists are.

Importantly, the basis of key claims are several publications authored or co-authored by Florence Ashley. These works are invariably academic opinion essays, cited as authoritative here, and themselves forming a tight network of self-citing publications covering such topics as:

• The Clinical Irrelevance of “Desistance” Research

• Puberty Blockers Are Necessary, but They Don't Prevent Homelessness

• In Favor of Covering Ethically Important Cosmetic Surgeries

• Gatekeeping hormone replacement therapy for transgender patients is dehumanising

• Banning Transgender Conversion Practices: A Legal and Policy Analysis

• A critical commentary on ‘rapid-onset gender dysphoria’

• There is no evidence ROGD Exists

• Why ROGD is bad science

These are all expansions of Ashley’s general view that access to medical transition should be available on a demedicalised, informed consent model. Notions of peer-contagion are myths, detransition and desistance don’t matter, gatekeeping is bad. Fundamentally the perspective is that trans people seeking therapy know they are trans and should be affirmed as such. Puberty blockers must be given to “trans kids” and denial or delay for any reason is “conversion therapy”, and Ashley has built up a few dozen papers on these subjects, which all support the same essential view.

“Trans kids” need to be medicalised, anything in the way of that is conversion, any evidence to the contrary is a lie.

Below is an illustration of Ashley’s self-citations and how they feed into the citations in “A New Era”, as cited by Leveille, along with some of Leveille’s earlier work, combined with the 2021 Trans Safety Network piece on SEGM:

Obviously there are many more citations than these - but these are the ones that, at root, are employed to support the notion that “exploratory therapy” is conversion therapy. And again, there is nothing wrong with self-citation per se, but this does reveal the interconnectedness of all of these beliefs, and how evidence which challenges these views (desistance, regret and detransition, peer contagion) must be attacked and questioned, and anyone who calls attention to them maligned. The claim that ROGD cannot be in any sense a real phenomenon, and the claim that exploration is conversion are inextricably intertwined.

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2022 - Interrogating Gender Exploratory Therapy

In September 2022, Florence Ashley published a paper titled “Interrogating Gender Exploratory Therapy”. This is an academic work that explicitly posits that the term “exploratory” is a euphemistic ruse akin to rebadging gay conversion therapy:

Descriptions of reintegrative therapy by people who offer it are reminiscent of how gender-exploratory therapy is described by its proponents.

This paper is - like much of Ashley’s other work - little more than an opinionated essay. As Ashley states:

In this article, I offer questions for clinicians and then offer my personal reflections on gender-exploratory therapy.

However, this work has been cited over and over again by subsequent sources as proof that gender exploratory therapy is conversion therapy. There are no prior academic works that make this explicit claim that I have found, and all subsequent citations can be traced back here, or to one of the precursor works.

What this paper achieves is to take Ashley’s previous focus on reparative therapy and ROGD, combine them with the ideas and language presented by Health Liberation Now, and re-present them with an air of academic authority, refocusing on the new term, “gender exploratory therapy” and all its possible variations.

Ashley’s central point is:

Proponents of gender-exploratory therapy situate their approach as neutral, agenda-free, and more in line with foundational principles of psychotherapy. Yet approaching trans identities and gender dysphoria from a position of suspicion—suspicion that, regardless of indication, they may be attributable to pathological causes and should be explored as such—is incompatible with therapeutic neutrality.

The core of the argument is: that positing a reason why someone might come to think of themselves as “trans” is impermissible. The distinction between “affirmation” and “exploration” rests on the affirmative model exploring only the options for how to express that “transness”, rather than exploring any underlying reasons why they might have come to think of themselves as trans. Positing causal factors - such as autism, peer contagion, or internalised homophobia (as in the case of Spiliadis’ original paper) is forbidden, and to do so erases trans identities, because it implies (or indeed reveals) that they are not some definitive self-truth, but a likely transient stage of confusion and distress.

This is why in a paper supposedly about conversion therapy, Ashley attacks those who have studied ROGD, as well as detransitioners, as “hostile” to the affirmative model, since the existence of individuals for whom social influence was a factor in opting for medical procedures they went on to regret does not sit well with a zero-gatekeeping, informed consent model of transition.

The similarity to the focus of Health Liberation Now’s piece is no accident - the paper cites Health liberation now three times, and gives special thanks to Lee Leveille for reviewing an early draft.

It is perhaps worth pointing out that Florence Ashley is not some marginal figure writing academic texts nobody reads. Until bowing out due to alleged “scheduling conflicts”, Ashley was due to be a key part of the WHO’s working group to set global policy on trans healthcare. Having someone as deeply enmeshed in this sort of partisan, conspiracist activism anywhere near global health policy in this area ought to be a huge concern.

Another person thanked for reviewing this paper is clinician AJ Eckert, who, a month after the publication of Ashley’s paper online, co-authored a post on Science Based Medicine with Quinnehtukqut McLamore titled “Cutting through the Lies and Misinterpretations about the Updated Standards of Care for the Health of Transgender and Gender Diverse People”.

Here, Eckert states that exploratory therapy is conversion because it considers that:

first-line “treatment” for trans youth with gender dysphoria is psychological and seeks to “avoid the risks of social and medical transition“.

Below is an illustration of some of the sourcing for this, removing many of the internal self-citations of Ashley’s work for simplicity (really). The claim about conversion therapy rests on Ashley’s then-freshly-published “Interrogating Gender-Exploratory Therapy”, which cites Leveille, and was reviewed by both Leveille and Eckert, and then published on Science-Based Medicine by Eckert and McLamore.

Eckert takes Ashley’s reworking of Health Liberation Now’s claims and presents them as definitive, and in the process makes it harder to see their origins with Health Liberation Now and Trans Safety Network, as well as Eckert’s involvement in that process. Between them, they have agreed that “gender exploratory therapy” is conversion, and cite each other in turn to support that claim.

To be clear, this relationship between sources is not so much a conspiracy, as a highly motivated interconnected group of activists all sharing the same world view, all saying the same things and reinforcing each others statements - it is just that at each level of citation, the origin is further obscured, and the certainty of the claims increases.

By the time it appears in Science Based Medicine, the fact that this is purely the ideological opinion of a few activists, rather than something that has been empirically found to be true, is hidden behind multiple levels of back and forth citation. This obfuscation is helped along by a writing style that employs a dense accumulation of citations, hyperlinking practically every word - presumably in an attempt to overwhelm any reader with the sheer apparent weight of evidence - little of which stands up to scrutiny.

This is also the point where the Cass Review enters the picture, years before its final publication, in two connected ways.

Firstly, this piece cites an earlier one by Eckert which explicitly attacks the National Institute of Health and Care Excellence (NICE) review of puberty blockers commissioned at the outset of the Cass Review in 2020. Eckert’s earlier article makes multiple false or misleading claims about evidence that was excluded, as well as arguing that randomised controlled trials are unethical, all attack lines that came to be used against the final Cass Review upon publication. Despite being supposedly about the NICE review, the piece devotes half its length to attacking SEGM, who “favorably commented” on the review. Notably, citations for this piece again include the earlier “SEGM Uncovered” article by Trans Safety Network. Again, it is all a dense mess of conspiracist dot joining and tenuous misrepresentation of evidence, and exemplifies how far Science Based Medicine has fallen in recent years, with its total blind spot on trans issues.

Secondly, this also cites another earlier piece by Eckert (“Gender-affirming care is not experimental”) which in turn cites Cal Horton, who also cites Eckert’s earlier work on the NICE review. Horton went on to write the 2024 “academic” critique of the Cass Review, which recycles many of the same points in that article, but more on this later.

Again, trying to take these articles point by point is a task in itself, but to demonstrate the process of exaggerating strengths of claims through extra levels of citation, one example is Eckert’s claim about the reversibility of puberty blockers:

It should be emphasized that the effects of blockers are both temporary and reversible.

This is a strong claim presented with no caveats, and the citation for “reversible” is Cal Horton, who says:

Puberty blockers have a temporary and reversible impact on pausing secondary sex characteristics, with the development of secondary sex characteristics recommencing once puberty blockers are discontinued (Hembree et al., 2017). Puberty blockers also have a temporary and reversible impact on fertility – when puberty blockers are discontinued, endogenous puberty recommences, including the maturation of gametes (Hembree et al., 2017).

This is a slightly more caveated claim (specific to sex characteristics and fertility) than Eckert’s - but the citation for both claims is Hembree et al., 2017, which says something even less definitive:

For those designated male at birth with GD/gender incongruence and who are in early puberty, sperm production and the development of the reproductive tract are insufficient for the cryopreservation of sperm. However, prolonged pubertal suppression using GnRH analogs is reversible and clinicians should inform these individuals that sperm production can be initiated following prolonged gonadotropin suppression. [..] Note that there are no data in this population concerning the time required for sufficient spermatogenesis to collect enough sperm for later fertility. In males treated for precocious puberty, spermarche was reported 0.7 to 3 years after cessation of GnRH analogs. In adult men with gonadotropin deficiency, sperm are noted in seminal fluid by 6 to 12 months of gonadotropin treatment. However, sperm numbers when partners of these patients conceive are far below the “normal range”.

So this is talking about:

• Sperm production in males

• Using those treated for precocious puberty or in adulthood as comparators

• And even then the claims are not without caveats about lack of data

And for girls?

In girls, no studies have reported long-term, adverse effects of pubertal suppression on ovarian function after treatment cessation. Clinicians should inform adolescents that no data are available regarding either time to spontaneous ovulation after cessation of GnRH analogs or the response to ovulation induction following prolonged gonadotropin suppression.

This is very carefully worded, but is questionably using the absence of evidence to imply evidence of absence, and at the same time pushing the lack of data onto the child to make an informed choice about.

So this dubious guidance specifically about fertility based on virtually no data and supposition from other clinical populations becomes cold, hard certainty, through 2 levels of citation. Eckert’s bold claim about complete “reversibility” has nothing to back that up except this chain of obfuscated sources, and citation stacking.

This paucity of evidence of safety and reversibility is exactly why the Cass Review found insufficient basis for those claims - but activists like Eckert and Horton could never accept that is true from the outset, and have to attack those looking for evidence as “anti-trans”. To them, it is clear and obvious and robust, and anyone looking closer and coming to a different conclusion can only be doing so out of hate and bigotry.

Time and again, claims like this become ever more definitive at each layer of citation, none more so than the assertion that exploratory therapy is conversion therapy, which by this point has reached the level of received wisdom.

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2023 - SEGM Exposed: Reloaded

In February 2023 Lee Leveille and Quinnehtukqut McLamore co-authored a piece on the Health Liberation Now site that is, frankly, the conspiracist motherlode. It takes everything in “A New Era” and dials it up to eleven - recycling many of the same sources as before and simply adding more certainty and hyperbole along the way.

“SEGM Exposed: Reloaded” hits all the major themes that have arisen so far: exploratory therapy is conversion therapy, anyone even tangentially attached to Genspect or SEGM is a conversion therapist in cahoots with the Christian right-wing, ROGD is debunked pseudoscience, randomised controlled trials are unethical, detransition and regret aren’t problems, and so on.

It attacks Tavistock whistleblowers Sue and Marcus Evans for the standard of care provided by the Tavistock while Marcus Evans was governer:

Incidentally, the types of intrusive psychoanalytic therapies that the NHS actually practiced during Marcus Evans’s governorship have been described by patients and their families as fundamentally degrading, unhelpful, destabilizing, and pathologizing.

The three citations given to support this claim are all opinionated essays and parental reports by Cal Horton again, none of which specifically cover Evans’ tenure, all of which cite Florence Ashley’s claims about ROGD and conversion practices, and all laying out the ideologically-led push for affirmative approaches and total removal of psychotherapeutic gatekeeping which the Cass Review overturned.

It attacks Sue and Marcus Evans as conversion therapists:

the Evanses instead worked to advocate for psychoanalytic conversion therapy in Gender Dysphoria: A Therapeutic Model for Working with Children, Adolescents and Young Adults. […] this book been roundly criticized by transgender activists, including the Polish transgender knowledge base Tranzycja

This links to a report titled “Exploring Till They Bleed” by a Polish transactivist group. That report cites some of the same sources as this piece and many of the precursor works by Florence Ashley, while also thanking Quinnehtukqut McLamore for consulting on the report.

Once more, interdependent sources are cited with every indication that they are separate, when they all rely on the same sources, and the same activists, producing work that is steeped in that same perspective in service of the same political ends. Leaving aside that the vast majority of space is devoted to amassing an orgy of evidence to damn SEGM, the driving force of this whole article is ideological opposition to any psychotherapeutic intervention on gender-questioning children that might lead to them simply growing up to be gay, because the authors and the sources they rely on believe it is conversion therapy.

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2023 - CAPTAIN

In December 2023, Southern Poverty Law Centre released its CAPTAIN report, a huge, multi-part series focused on an “anti-LGBTQ+ pseudoscience and disinformation network”.

The core allegation is that a tight-knight group of conservative ideologues are citing each other’s fabricated and tenuous claims to give the appearance of a stronger evidence base than really exists, in order to pass anti-trans legislation in the US.

Ironically, the report was co-authored by Lee Leveille and Quinnehtukqut McLamore, and essentially retreads all of the ground in “A New Era” and “SEGM Exposed: Reloaded”, repeating all of the same tenuous claims, citing themselves as authorities, compiling a vast dossier of fabricated and tenuous claims to give the appearance of a stronger evidence base than really exists.

To illustrate the back and forth laundering:

• Trans Safety Network makes claims about conversion therapy in “SEGM Exposed”, after Moore claims “gender exploratory therapy” is “conversion therapy” on Twitter.

• Which are cited as a definitive claim about “exploratory psychotherapy” by Leveille in “When Ex-Trans World Collide”, combined with Florence Ashley’s opinions on reparative therapy.

• Leveille then expands on these and adds “gender exploratory therapy” in “A New Era”.

• Leveille then has input to Florence Ashley’s “Interrogating Gender-Exploratory Therapy”, which also cites Leveille and Schevers.

• Which is then cited by Trans Safety Network again.

• Both of which are cited in the Tranzycja report McLamore consulted on

• All three of which are in turn cited by both Leveille and McLamore in “SEGM Exposed: Reloaded”

• Which is then ultimately cited again in Leveille and McLamore’s co-authored “CAPTAIN” report, as are many of the intermediary steps.

The basis of the claim that “gender exploratory therapy” is conversion - a claim which runs through the CAPTAIN report - is a chain of back and forth citations between the same four or five people, absolutely none of which is clear in SPLC’s document, and I doubt even clear to the authors themselves by this point - it has just become received wisdom in this tiny echo chamber.

Based on Leveille’s assertion that ordinary therapy can be identified as “conversion” by the network associations of the people espousing it, link after spurious link are thrown at the reader to imply crossover and overlap on the most tenuous of grounds. Science that casts doubt on the certainty of their position is “pseudoscience”, not because it has actually been established to be fake, but because this sort of strong denunciation - repeated dozens and dozens of times across the whole report - is politically useful. Exploratory therapy which was in its origins about avoiding medically harming children who would most likely simply grow up to be gay otherwise, becomes “anti-LGBTQ+”, through the power of demanding that TQ+ and LGB always go together. Actions specifically in service of protecting LGB youth are rhetorically inverted out of political calculus into something anti-LGB because it goes against the demands of a section of TQ+ activism.

Once again, the CAPTAIN report is huge, and trying to go point by point through it is a sisyphean task, and a good portion of it is devoted to discussion of the legal activities of the hard right in the US, where the gender debate seems to be far, far more polarised between two equally deranged extremes than in the UK.

It should be enough to simply warn of the machinations of dubious bad actors pursuing a genuinely regressive agenda, but - in order to advance the cause of unfettered access to transition - this aspect of the report is secondary to the aim of smearing absolutely everyone that a small core of activists dislike, for political ends. Everyone cautioning about regret and detransition and peer contagion and diagnostic overshadowing, or advocating exploratory therapy, must be denounced as a purveyor of pseudoscientific bigotry. If bad actors use your evidence in court, then your evidence is bad, QED.

The indiscriminately conspiracist nature of work like this is, I think, dangerous and self-defeating because there is a core of this report that is highlighting a very real tendency on the right of US politics - ADF, Heritage Foundation, Project 2025 - to exploit the “trans issue” as a wedge. Hammering on “family values” messages, “protecting children” from “LGBTQ+” degeneracy.

As a clear illustration of the polarisation at play, and how SPLC’s framing is counterproductive, one of the responses to the CAPTAIN report came from the The Heritage Foundation’s media outlet, The Daily Signal. This hits most of the main points that to many casual readers would seem reasonable - drawing attention to the unwarranted demonisation of doctors who question the gender-affirming model, and the legitimate concerns about the way that blindly affirming cross-sex identification - especially in children - can mask other issues.

But then about halfway through, you find paragraphs like this:

As ex-gay rights leader Christopher Doyle explains in his book “The War on Psychotherapy,” “One of the strategies that far-left advocacy and gay activist organizations use to smear professional psychotherapists assisting clients distressed by sexual and gender identity conflicts is to intentionally conflate professional therapy with religious practice and/or unlicensed, unregulated counseling. They do this by labeling all efforts—therapeutic, religious, or otherwise—to help clients distressed by sexual and gender identity conflicts [as] ‘conversion therapy.’”

What this paragraph is really referencing is actual sexual-orientation conversion therapy, and promotion of “ex-gay” advocacy, portraying criticism of that as exactly the same disingenuous smear campaign, and blaming the “far-left” and “gay advocates”.

The author of this piece has previously tweeted opinions such as this, praising men who “embraced their masculinity and left the gay lifestyle”:

If you have legitimate concerns about affirmation of cross-sex identity in children being harmful to gay youth, then people who espouse views like this are not your friends. They are not on your side. They are using your reasonableness, your stories, your moderate words as a shield. These are the people who do not want to stop at “trans” and want to carry on getting all mention of “LGB” out of schools, who consider gay men not to be “masculine” enough, and a problem to be fixed.

When SPLC say that some on the US right-wing are using concerns about the affirmative model as cover for conversion therapy they are absolutely right. It is not enough to dismiss SPLC as a bunch of conspiracist loons trying to smear reasonable, decent people with lies when some of it is not lies at all, and it has to be possible to be critical of SPLC’s shoddy work without leaping to the defence of organisations like Heritage. Ultimately, these indiscriminate attacks on reasonable people serves only to polarise and provide cover for bad faith actors. There is a version of this report that could have teased apart the reality of the situation, that could have found the nuance and recognised the political hatchet jobs being perpetrated against some people who are truly acting in good faith.

But SPLC have no interest in writing such a report because it is not in their interest to acknowledge anyone that disagrees with their deranged worldview might have a legitimate point. There is more political mileage to be gained from casting absolutely everyone as in league with the worst, most homophobic elements of the conservative right - and to that end, this report acts to launder of Health Liberation Now’s conspiracism into a higher profile, more “respectable” format, and hide the chain of reasoning behind their “exploratory therapy is conversion therapy” claims. The end result is that this report is now heavily referenced and influential, in a way that Leveille and McLamore’s self-published work could never hope to be, laundered into mainstream acceptability with the “SPLC” branding and stamp of authority.

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2024 - Cis-supremacy

Which at last brings us to Cal Horton’s “The Cass Review: Cis-supremacy in the UK’s approach to healthcare for trans children”.

It is worth noting up front that Quinnehtukqut McLamore is thanked for “helpful feedback”. Additionally:

• An article by Fran Amery is cited (“Protecting children in ‘gender critical’ rhetoric and strategy: Regulating childhood for cisgender outcomes”), which in turn cites Health Liberation Now’s “A New Era” as a source of the claim that “gender exploratory therapy” is conversion therapy. This article is tagged with the keywords “TERF” and “moral panic”, and appeared in a special issue of the Journal of Diversity and Gender Studies titled “Varieties of TERFness”, so clearly no bias on display there (!).

• Eckert’s Science Based Medicine post about the NICE Review is again cited by Horton to cast doubt on the strength of the evidence.

• Horton cites nine pieces of her prior work, all of which have similar levels of dependence on the same sources and hyperbole.

Obviously there are many more citations than these, but crucially, some of the key assertions come down to one of these sources.

Eg. on the specific matter of conversion therapy:

non-affirmative practices are rarely openly labeled as conversion therapy (Ashley, 2022b). Instead conversive practices, or approaches grounded upon the rejection, pathologization or problematisation of gender diversity are commonly veiled under language of “exploratory” therapy (Ashley, 2022c).

The foundation of this claim rests, once again, on Ashley, which means it can all be traced back to an evidence-free tweet about a podcast in 2021 about a paper published in 2019, and everything else is exaggeration, opinion and assertion. This claim that it is “commonly veiled” by this language has no evidence whatsoever to back it up, but chasing the citations to the bottom to discover that is clearly not something any reviewer for The International Journal of Transgender Health has any interest in doing. The entire point is to get into a supposedly peer-reviewed journal article strong claims that the Cass Review advocates conversion therapy and/or is connected to people who do, and thus any language they use to protest this is suspect.

This paper is not a novel contribution, nor is it specifically an attack on the final Cass Review, which was not published until several weeks afterwards. What it is is a synthesis of all of the preceding conspiracist and ideological claims into one academic-seeming text, tying together the multiple strands of argument, and condemning Cass ahead of publication, fashioning something that could be cited time and again to dismiss the Cass Review, whatever its findings turned out to be.

• Exploratory therapy is conversion therapy because it is a cis-supremacist view of the world that treats trans identities as suspect or lesser or undesirable, denying personal autonomy to children who truly know themselves.

• Peer contagion is a cis-supremacist view of the world, that considers trans identities as lesser, a mere fad, a mental health condition, rather than important and honest and true and integral.

• Concern for regret and detransition is a cis-supremacist view of the world, that sacrifices the well-being of the many for the supposed safety of a tiny minority who are really tools of anti-trans forces, and even words like “detransition” are wrong when its all part of a journey of self-discovery.

• Calling for better research and randomised-controlled-trials is a cis-supremacist view of the world, believing that this is “treatment of a disorder” rather than affirming bodily autonomy, placing new, impossible evidentiary bars to life-saving treatment the authors already know works definitely, absolutely, no more evidence needed.

• Anyone advocating any of these points is cis-supremacist, and connected to anti-trans groups, and thus connected to the US Christian right, and look at this mountain of evidence that proves these are all bad people because they use similar words and cite the same research.

The claim that “exploratory therapy” is “conversion therapy” fundamentally is a reflection of a perspective - and if you don’t share that perspective, you must be anti-trans. You can’t talk about one without taking on all the other points because they are all deeply interconnected and self-reinforcing - and these points all arise quite naturally and logically from the same echo chamber of activists, all sharing that worldview.

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Coda

There are many more notable branches along this tree of source laundering.

For instance, in May 2023, AJ Eckert and Quinnehtukqut McLamore co-authored another piece for Science Based Medicine, which is little more than a platform for Health Liberation Now’s views on ROGD, detransitioners, and fears of the Christian right. Or the October 2023 article published by the British Psychological Society authored by a group of private gender clinicians arguing that exploratory therapy is conversion, all based on citations of Ashley, Horton and Moore.

Or in December 2023, the paper titled “Recognizing and responding to misleading trans health research”, which seems to exist solely to attack a followup study on adolescent transitioners for daring to mention ROGD. This article, strangely, is written by 9 Australian healthcare professionals - and, once again, Quinnehtukqut McLamore.

And just last week, Scientific American published a favourable interview with Florence Ashley about fighting “anti-trans misinformation”. In it, Ashley cites yet another new paper making the same claims:

Some clinicians have historically sought to minimize the likelihood of someone continuing to identify as trans and/or accessing gender-affirming interventions because of a belief that being trans is inherently undesirable (Ashley, 2022b). However, these approaches are tantamount to conversion practices and are no longer considered ethical (Ashley, 2022b; Coleman et al., 2012; Madrigal-Borloz, 2020).

Of the three citations, one is the 2012 WPATH SOC, which doesn’t support this claim, one is a report by Victor Madrigal-Borloz which doesn’t support this claim, and - once again - the only citation to support this claim is Ashley’s own “Interrogating Gender-Exploratory Therapy”.

This latest paper, once again, cites 12 other publications by Ashley, and despite the lofty title of “narrative review” is in reality a review of Ashley’s own narrative.

More interestingly, in the citations there is news of another forthcoming paper from Ashley, this time co-authored with Leveille and Schevers:

Ashley, F., Parsa, N., kus, t., Leveille, L., Schevers, K., & Rider, G. N. (2023). Gatekeeping gender-affirming care is detrimental to detransitioners [Manuscript submitted for publication].

Over and over the same names seem to crop up making the same attacks and repeating the same talking points. Claims and critiques that seem independent in reality have the same source, and simply repeat and amplify earlier falsehoods with more certainty, obfuscating where it all started and why.

Every single claim that “gender exploratory therapy” is “conversion therapy” ultimately traces back to these small, highly partisan groups of activists, who - as with earlier claims about “gender-critical therapy” - simply made it up. These claims are deeply intertwined with attacks on supposed “anti-trans” clinicians - which allows whole swathes of evidence and recommendations to be condemned - in turn connected to the supposed unethicality of certain kinds of evidence, the irrelevance of detransition and desistance, the “pseudoscience” of ROGD, and the unacceptability of any gatekeeping whatsoever. The claim that exploration is conversion is not an isolated fact that can be disproved, but an inherent component of a self-reinforcing worldview that rejects contrary evidence, since all evidence that does not accord with this worldview is deemed a priori morally suspect.

Academic publishing is now a powerful political tool for taking “grey literature” claims from deeply unreliable and highly partisan activists and lending them the patina of truthiness, a faux-sciencey gloss which allows people in positions of power and authority who would rather not think too deeply about a subject to simply assume that someone else has. Citations don’t say what they are claimed to say, but the exaggerated strength of each claim compounds with every extra cycle through the academic laundromat. This is now being employed to exploit the loaded language of conversion therapy to push for legislation that would mandate a modern form of conversion upon LGB youth under the euphemism of “affirmation”.

Focusing on the terminology of “exploratory therapy” was originally an attempt by those operating in good faith to chart a path through a political minefield, but one that has ultimately failed. Those regressives who genuinely advocate gay conversion therapy have seized on it as cover, and those who are deeply, ideologically invested in paediatric transition have thoroughly poisoned the well, convincing themselves that absolutely any position other than their own reckless demands for unfettered consumer choice is “conversion therapy”. I personally believe that people sounding the alarm in good faith on the harm gender affirmation has done to LGB youth must also endeavour not to be naive to the homophobic agenda of those like ACPeds, but this seems near impossible in a febrile political climate where such distinctions cannot be permitted to be drawn.

The biggest issue though is that the deep conflation of transgender identity with sexual orientation - as evinced by the unthinking propagation of the LGBT(etc) acronym - makes it impossible to tease apart these two subjects and treat them differently. In this environment, any moves to ban “conversion therapy” will inevitably criminalise any approach other than the affirmative model, while any moves to oppose the ban ends up endorsing gay conversion therapy by default.

While the Cass Review was right to draw attention to the danger of conflating exploratory approaches with conversion therapy, such straightforward attempts to respond to this as if it were an isolated claim are ineffective. I believe a far more serious effort is needed to unpick the insular echo chambers that have overtaken this area. We are at the point where political representatives credulously repeat talking points from activist groups that are based on nothing but a hyperbolic series of self-citations, so dense as to be immune to any proper examination. Regardless of what language is used to describe it, anything other than the affirmative model will always be condemned. Cass’ mild attempt to find neutral language is doomed from the outset, because no language is permissible.