Summary

Florence Ashley, a legal scholar and ethicist who works on conversion therapy, wrote this essay to challenge "gender-exploratory therapy". This is talking therapy that looks into possible causes of a young person's trans identity, such as trauma, autism or shame about being gay, before any social or medical transition. The essay asks 16 leading questions for therapists. It compares how exploratory therapists talk with how past "ex-gay" conversion programmes talked. It argues that starting from suspicion goes against the therapist's duty to stay neutral and put the patient first. It contains no data. Its claims that affirming care works better and that detransition is rare (about 3% at most) rest on evidence that later reviews, including those for the 2024 Cass Review, rated as low quality. It is best read as one side's position paper, not as evidence about results.

Key findings

• This is an argument about ideas and ethics. It reports no new data, cases or measured results.
• Ashley describes gender-exploratory therapy as talking therapy that treats a young person's trans identity or dysphoria with suspicion, and delays social and medical transition until possible underlying 'causes' have been explored.
• The essay asks exploratory therapists 16 questions, which the author openly calls leading, about how long exploration lasts, how causes are identified and whether there is evidence it helps.
• Ashley argues that exploratory therapy closely matches the ideas and stories of gay conversion therapy, including its use of detransitioner stories in the way 'ex-gay' stories were once used.
• Based on the therapist's duty to stay neutral, put the patient first and build a trusting relationship, the author concludes the approach 'may be unethical'.
• The essay cites a high estimate of about 3% of people detransitioning, and argues that even allowing for unreported cases, about 88% of people do not detransition.
• Ashley mainly targets writing by D'Angelo et al. (2021), Edwards-Leeper & Anderson (2021), Spiliadis (2019) and the Gender Exploratory Therapy Association. Their own accounts describe exploration as open-ended and not aimed at changing a person's identity.

Abstract

Opposition to gender-affirmative approaches to care for transgender youths by some clinicians has recently begun to consolidate around "gender exploratory therapy" as a proposed alternative. Whereas gender-affirmative approaches follow the client's lead when it comes to gender, gender-exploratory therapy discourages gender affirmation in favor of exploring through talk therapy the potential pathological roots of youths' trans identities or gender dysphoria. Few detailed descriptions of the approach's parameters have been offered. In this article, I invite clinicians to reflect on gender-exploratory therapy through a series of questions. The questions are followed by an exploration of the strong conceptual and narrative similarities between gender-exploratory therapy and conversion practices. Finally, the ethical dimensions of gender-exploratory therapy are discussed from the lenses of therapeutic neutrality, patient-centered care, loving attention, and therapeutic alliance, suggesting that the approach may be unethical.

Conclusion

Ashley concludes that gender-exploratory therapy is an emergent and underdefined paradigm whose proponents leave many critical questions unanswered, and that its conceptual and normative stance seems incompatible with evolving understandings of clinical ethics and trans identities; being trans is not undesirable and should not be approached as if it were. Proponents resent the conversion-practice label while opposing conversion-practice bans because those bans would cover their approach, yet a close comparison shows many conceptual and narrative similarities, and the way proponents describe the therapy is nearly identical to how providers of sexual-orientation conversion practices framed their work. Starting from the premise that trans identities are suspect and often rooted in pathology, Ashley argues, makes the therapeutic approach indistinguishable from conversion practices.