Unpacking the Concept of ‘Gender Identity’: Not Fit for Purpose?

Gender identity

The term ‘gender identity’ is a key element to any discussion about trans-related issues. There are six reasons why it is not in any way an accurate or meaningful concept for use in therapeutic practice. The reasons relate to:

• Major ethical concerns about the origins of the concept;
• The contested status of the concept as being ideological rather than scientific in nature;
• The absence of set criteria and related problems of accurate and consistent definition;
• The problem of legally defining gender identity in order to actively police therapeutic practice;
• The emergence of alternative and more compelling explanations for people identifying as trans;
• The adverse clinical and therapeutic effects arising from its use in practice.

Major ethical concerns about the origins of the concept

The concept of gender identity was originally devised by John Money and further developed by Robert Stoller (1964).

“The New Zealand psychologist and paediatrician John Money is perhaps most well known for his involvement in an ethically dubious clinical case: the involuntary medical ‘sex reassignment’ of male child David Reimer after a severely botched circumcision, whose tragic story ended in his suicide as an adult” (Stock, 2021: 16). (See also Ayad and O’Malley, 2023).

The parents were persuaded to bring David up as a girl, as a case study monitored by Money, in evaluating the relative influence of biology versus environment. This unethical experiment ultimately had tragic consequences for the subject, David Reimer. This was a failed attempt to impose an internalised, psychologically dominant sense of sex via an external process of social and behavioural reinforcement. However, the experiment tragically ended in a catastrophic failure to achieve this intended goal.

Undeterred, Money went on to define his key concept in the following terms: “Gender identity is the private experience of gender role, and gender role is the public manifestation of gender identity” (1994: 164-5). The concept of gender identity is, therefore, not a neutral construction, born of earnest academic discussion, held in ivory towers. Gender identity as a concept is mired from its very beginnings in deceit, abuse and a disregard for the emotional and physical harm caused to patients, particularly children. This continues to be the case today.

The status of the concept as ideological rather than scientific in nature

The existence of a pre-social, innate and immutable gender identity, originating from birth, or even from gestation, is a central part of gender ideology as a complex belief system. It is also, by definition, an untestable and therefore an unfalsifiable hypothesis. Gender identity is a pre-scientific, ideological concept, which has more in common with religious or cultural belief systems than with well-established scientific or legal concepts. It resides in a pantheon of unproven concepts such as phlogiston, auras and Aryan physics, and pre-scientific practices, such as mesmerism, phrenology and now, gender identity affirmative therapy (Gordin, 2021).

Absence of set criteria and related problems of accurate and consistent definition

Gender identity is described as an internal sense of orientation towards one’s biological sex, or the absence of such orientation. As it depends entirely on individual subjective experiencing, it is impossible to define objectively for legal purposes. Gender identity is presented as being distinct from gender, i.e. the social construction of sex-based roles and behaviour. According to trans ideology, biological sex is not binary, but exists on a spectrum, e.g. male, female, non-binary, etc. On this basis, there are now reported to be more than one hundred distinct genders, although it appears that there are no set agreed objective criteria for their definition.

The World Professional Association for Transgender Health (WPATH) recently announced its recognition of eunuch as yet another gender identity. No criteria for recognising its new status as a gender identity were made public, or deemed to be necessary. WPATH provided a link to a website  specialising in fantasies of the abuse and mutilation of children and young people, apparently as a bizarre form of evidence of the substantive nature of this new gender identity. This gender identity had formerly been defined as ‘Scoptic syndrome’ in the psychiatric manual, DSM-4. In the absence of any agreed criteria for identifying or recognising emerging gender identities (with all the implications this holds for therapeutic practice), this process clearly has more in common with the nature of a revealed truth, rather than as the outcome of considered deliberation by experts in the field (Jenkins, 2022).

It is a key element of post- (i.e. anti-) modernism that all definitions require ongoing critique and continuous reformulation. It follows from this that the boundaries between the concepts of gender and gender identity are also not fixed. In practice, concepts of gender are increasingly bleeding into those of gender identity, so that the reputed hundred-plus genders could quite possibly also be taken to refer to a hundred-plus gender identities. When the 112 genders/gender identities are combined with a further 71 suggested prefixes or suffixes (e.g. pan-, or omni-), then the current potential total of gender identities could rise to just less than 8,000 (Stucky, 2021). Clearly, seeking to ban or even to police conversion therapy on the unstable foundation of this growing plethora of gender identities may well prove to be something of a challenge for any reasonable legislator.

The problem of legally defining gender identity in law in order to actively police therapeutic practice

There are major difficulties in defining gender identity in law fairly and effectively. Gender identity is:

• supposedly internal, and unknowable to others (unless revealed by the individual);
• an ideological concept with no agreed criteria;
• part of a belief system held by a small minority;
• conflated with gender expression, i.e. external signs and behaviours;
• subject to definitions which are circular and tautologous;
• held to be at the same time innate and immutable, but also subject to rapid change;
• unlikely to meet established standards of causation in cases of alleged conversion therapy.

There has been a wave of legislation across the world to impose a criminal law ban on conversion therapy or conversion practices which are aimed at changing an individual’s sexual orientation or gender identity (Jenkins and Esses, 2021). Given the systematic failure to identify compelling evidence of conversion therapy currently taking place, it can be argued that the main purpose of this legislation is not so much to prohibit conversion therapy, as to ensure that the concept of gender identity is enshrined in law. Once established in law, however weakly defined, the concept of gender identity can then be used to radically redefine the wider nature and purpose of therapy and healthcare more generally, with as yet poorly understood longer-term results.

States with current gender identity legislation include Canada, Australia (Victoria State) and Malta, see below.

Canada: “Gender identity is each person’s internal and individual experience of gender. It is their sense of being a woman, a man, both, neither, or anywhere along the gender spectrum.”

Australia (Victoria State): Change or Suppression (Conversion) Practices Prohibition Act 2021.

Gender identity is defined in the Equal Opportunity Act 2010 thus: “… a person’s gender-related identity, which may or may not correspond with their designated sex at birth, and includes the personal sense of the body (whether this involves medical intervention or not) and other expressions of gender, including dress, speech, mannerisms, names and personal references.

Malta defines gender identity in the following curiously similar terms: “…each person’s internal and individual experience of gender, which may or may not correspond with the sex assigned at birth, including the personal sense of the body (which may involve, if freely chosen, modification of bodily appearance and, or functions by medical, surgical or other means) and other expressions of gender, including name, dress, speech and mannerisms; “ The Act requires that: “The gender identity of the individual shall be respected at all times.” (Gender Identity, Gender Expression and Sex Characteristics Act 2015)

The legal definitions of gender identity are therefore either circular and tautologous (Victoria: ‘gender-related identity’), or entirely subjective (Canada and Malta: ‘internal and individual experience of gender’). Gender identity is further conflated here with gender expression, i.e. ‘dress, speech, mannerisms, names, and personal references’. For legal purposes, an individual alleging discrimination on the grounds of gender identity is in practice more likely to claim adverse treatment on the basis of their socially preferred gender expression. Allegations of conversion practices on grounds of gender identity will rest totally on the personal statement of the complainant. The concept of gender identity derives from an unfalsifiable belief system, similar to cultural beliefs about the need for compliance with concepts such as shame and honor. Apart from the complainant’s own statement, no other evidence will be needed in order to bring a prosecution of the therapist alleged to be responsible for the attempted gender identity conversion.

Gender identity might be assumed in the above legal definitions to be distinct from gender, particularly for the purposes of legislating against conversion therapy intended to change a person’s gender identity. However, while gender is held to exist on a spectrum, gender identity is also held to be extremely fluid. Gender identity, it is claimed, can change more or less rapidly, say from agender to neutrois, or from demifluid to genderqueer. Gender identity is supposedly therefore not a stable, consistent or fixed entity existing over time. This ethereal quality should present a substantial barrier to establishing the legal test of causation, should it be alleged that a person’s gender identity has been changed by therapy. If gender identity is regarded as being fluid and subject to unpredictable degrees of internal change over time, then this would still apply, regardless of whether or not an individual had participated in any kind of therapy at all. Prosecutors will find it hard to prove beyond reasonable doubt that a therapist had changed, or sought to change, a client’s gender identity, when the latter’s claimed gender identity was already in a constant state of flux.

The emergence of alternative and more compelling explanations for people identifying as trans

If allowance is made for exploring the potentially social roots of gender identity recognition and expression, then there are a number of productive avenues for research, which could usefully offer alternative and more compelling explanation of the rising number of persons claiming to be affected by gender identity issues.

• Exploratory research suggests that peer influence and exposure to activist social media may partly explain the recent rapid growth of gender dysphoria amongst some female adolescents (Littman, 2018).
• One survey indicates that referral rates by UK health authorities to gender identity services fluctuate widely across the UK. This suggests that differing professional cultures and priorities may serve as an important mediating social factor, boosting the rapid growth in demand for national gender identity services (Da Costa, 2022).
• Desistance rates, i.e. of young people presenting with gender dysphoria and then reverting to a previous path of sexual development, consistently hover at around 80%. This suggests that adolescent gender identity is neither fixed, nor the single determining factor at play here (Singh et al, 2021).
• The discrepant fact of the growing number of detransitioners would tend to challenge any assertion of gender identity self-recognition as an innate and certainly as an immutable process, with one survey of adult gender identity services suggesting a detransition rate of 8-10% (Hall et al, 2021).

None of these four research-based examples are consistent with the assertion that gender identity recognition and expression constitute an innate and immutable physiological process, with its own unfolding natural history and dynamic.

The adverse clinical and therapeutic effects arising from the use of gender identity in practice

The adoption of the term gender identity is having a number of seriously damaging effects on clinical and therapeutic practice, on our professional associations and on research and publication in professional journals. These adverse ‘chilling’ effects have had a damaging impact, both on therapeutic practice and on clinician and therapist professional associations:

Adverse impacts on therapeutic practice

• displacement of standard exploratory therapy by gender identity affirmative therapy;
• uncritical promotion of  the themes of trans fragility and trans exceptionalism;
• undermining established professional neutrality and boundaries, in order to adopt allyship and advocacy roles;
• minimisation of clinical responsibility for assessment, risk management and safeguarding;
• marginalising the distinct contribution of therapy to alleviating gender distress, and instead colluding in the facilitation of social and medical transition for clients;

Adverse impacts on clinician and therapist professional associations and their influence:

• censorship of publications and denial of open professional debate to critics of gender identity ;
• politicisation of professional complaints against gender critical clinicians and therapists;
• promotion of anecdotal lived experience as the benchmark for research and continuing professional training;
• displacement of rigorous research methodology e.g. systematic reviews and randomised controlled trials, by easily misrepresented cohort studies;
• growing defensive practice by clinicians and therapists in working with gender identity, with evidence of increasing professional flight from the field.

Adverse impacts on therapeutic practice:

The growth of gender identity ideology has had a number of damaging impacts which directly affect the work of clinicians and therapists. These include the adoption of gender identity affirmative therapy, which incorporates key assumptions about trans fragility and trans exceptionalism, and which violates established principles such as therapeutic neutrality.

The assertion of the primacy of gender identity over biological sex has a number of significant adverse clinical consequences (CAN-SG, 2021). These include mandating the medical priority of changing the physical body in order to match an inner gender identity, through hormones and surgery. Given that there is no objective test for the existence of a gender identity, only the subjective one of patient self-declaration, then clinical expertise becomes irrelevant and must give way to the patient’s demands for treatment. If patient self-diagnosis is unchallengeable through the usual careful process of clinical review and negotiation, then the role of the clinician becomes one of simply affirming the patient’s self-perception. To do otherwise may be characterised as being abusive, persecutory, discriminatory, or tantamount to practising conversion therapy. The usual clinical response of exploring the patient’s inner feelings and wider social context must be replaced by that of simply affirming the correctness of the patient’s own firmly held belief system.

Using an exploratory approach is common to most forms of therapy. However, this is being challenged by the assertion of the primary need to provide therapy which specifically affirms the client’s gender identity. This can be done initially, for example, by the therapist declaring their own personal pronouns and by carefully negotiating the client’s own preferred use of pronouns. The therapist is then encouraged to accept the client’s self-concept, as overly forceful challenge may destabilise the therapeutic alliance. This cautious approach is based on an implicit model of trans fragility, whereby the client’s newly emerging sense of gender identity requires continuous validation by others, including by the therapist. The client is assumed to be at significantly heightened risk of suicide, on the grounds of minority stress caused by societal oppression. The overriding need to provide unqualified empathic support for clients exploring their gender identity in turn pulls the therapist into more of an ally and advocacy role.

This form of therapy also incorporates the theme of trans exceptionalism, whereby standard practice, such as careful assessment, risk management and safeguarding issues are often given short thrift for this client group, on the grounds of being potentially stigmatising. The status of therapy as a valuable intervention in its own right is subtly eroded within this overall process, as the ulterior primary purpose becomes to support the client in their progress towards social and medical transition. Therapy thus becomes little more than a portal leading to medication and surgery. Needless to say, this model of gender identity affirmative therapy has no substantive evidence base.

Damaging effects on clinician and therapist professional associations and their influence

The process of adopting gender identity ideology has also had a profoundly damaging effect on professional associations governing the work of clinicians and therapists. Unfavourable research findings have been redacted, and articles by gender critical therapists discouraged. Open debate, normally the staple of professional life, is reframed as being highly offensive to supporters of gender identity ideology, by threatening them with existential erasure. Therapists who are critical of gender identity affirmative therapy are at heightened risk of hostile complaint via the disciplinary procedures of their professional association, while simultaneously being denied a platform for their views. Research and continuing professional development promote the educative value of gender minority’s lived experience over and above the supposedly reductive thematic of evidence-based practice. In the face of a potentially litigious client group, an authoritarian, hostile professional membership body, and the corruption of research practice, clinicians and therapists are becoming increasingly reluctant to engage with clients seeking affirmative therapy, or are considering leaving the field entirely to the more vocal advocates of gender identity.

Conclusion

Gender identity can be defined as an internal sense of an individual’s orientation towards their sexed body. The concept lacks any agreed criteria, and the number of identifiable gender identities appears to be growing exponentially. The origins of the concept lie in a failed and unethical live experiment on a child, based on deceit, abuse and disregard for the emotional damage thus caused. The concept of gender identity is a crucial underpinning element of a wider ideology or belief system. As a concept, it is unfalsifiable, and depends simply on personal declaration, rather than on any objective test or independent evidence of its existence. Gender identity is held to possess a mercurial quality, in being at the same time innate and immutable but also liable to undergo rapid fluctuation. Current legal definitions of gender identity tend to be circular, tautologous, or subjective in nature. There are competing and more compelling sociological models for the recent rapid growth in the adoption of gender identity, rather than as simply the emergence of an innate personal characteristic.

The adoption of gender identity as a concept and the necessary acceptance of its wider ideology has had seriously damaging consequences for clinicians and therapists. Exploratory therapy is being displaced by gender identity affirmative therapy, despite the latter lacking a substantive evidence base. Therapists are encouraged to abandon established principles, such as therapeutic neutrality, in favour of taking on the role of ally and advocate. Professional associations are largely captured and in thrall to the concept of gender identity, reflected in their partisan policies and bleak internal regimes. Research has been seduced into the promotion of anecdotal lived experience at the expense of identifying evidence-based practice. A generation of clinicians and therapists is faced with the choice of ceding the field to the highly vocal advocates of gender identity, or fighting to reclaim the very soul of therapy.

References

Ayad, S. and O’Malley, S. (2023) “Transitioning Children: The Clinician’s Assumptions and Client Suggestibility” in Thomas, V. (ed.) Cynical Therapies: Perspectives on the Antitherapeutic Nature of Critical Social Justice, Brisbane, Aus, Ocean Reeve

Clinical Advisory Network: Sex and Gender (CAN-SG) (2021) “FAQ:  Are people born with a gender identity?” https://can-sg.org/frequently-asked-questions/are-people-born-with-a-gender-identity/

Da Costa, N. (2022) “NHS Clinical Commissioning Group referral rates for young people with gender dysphoria.” Transgender Trend. https://www.transgendertrend.com/nhs-ccg-referral-rates-young-people-gender-dysphoria/

Gordin, M. (2021) On the fringe: Where science meets pseudoscience. Oxford; Oxford University Press.

Hall, R., Mitchell, L. and Sachdeva, J. (2021) “Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: Retrospective case note review”, BJPsych Open, 7(6), e184, 1-8 doi: 10.1192/bjo.2021.1022. https://pubmed.ncbi.nlm.nih.gov/34593070/

Jenkins, P. (2022) “Suing for medical transition: The case against considering WPATH as a competent reasonable body of expert opinion.” Genspect. https://genspect.org/suing-over-medical-transition-the-case-against-considering-wpath-as-a-competent-reasonable-body-of-expert-opinion/

Jenkins, P. and Esses, J. (2021) Thoughtful Therapists: Scoping Survey for Government Equalities Office Consultation on Conversion Therapy. https://thoughtfultherapists.org

Littman, L. (2018) “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.” PlosOne, 13(8), e 0202330 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330

Money, J. (1994) “The concept of gender identity disorder in childhood and adolescence after 39 years”, Journal of Sex and Marital Therapy, 20(3), 164-5.

Singh, D., Bradley, S. and Zucker, K. “A follow-up study of boys with gender identity disorder”, Frontiers in Psychiatry.  doi: 10.3389/fpsyt.2021.632784

Stock, K. (2021) Material Girls: Why Reality Matters for Feminism. London: Fleet.

Stoller, R. (1964) “The hermaphroditic identity of hermaphrodites”, Journal of Mental and Nervous Disease. 139: 453-457. doi: 10.1097/00005053

Stucky. (2021) “All 112 genders, plus the 71 suffixes.” https://www.theburningplatform.com/2021/03/06/all-112-genders-plus-the-71-suffixes/embed/#?secret=NZFmBq611s

Legal references

Australia (Victoria State): Change or Suppression (Conversion) Practices Prohibition Act. 2021 https://content.legislation.vic.gov.au/sites/default/files/2023-02/21-3aa002-authorised.pdf

Canada: Act to amend the Canadian Human Rights Act and the Criminal Code – C-16. 2017. https://www.justice.gc.ca/eng/csj-sjc/pl/identity-identite/about-apropos.html

Malta: Gender Identity, Gender Expression and Sex Characteristics Act. 2015: https://legislation.mt/eli/cap/540/eng/pdf