Affirming Therapy

She stripped the names off the results and handed them to three of the most respected readers in the country, including the man who had taught America how to score the Rorschach.

They could not tell which profiles belonged to which men. Their guesses were no better than chance, and they rated the two groups as equally well adjusted.

Hooker presented the findings at the American Psychological Association convention in Chicago in 1956 and published them the following year. Homosexuality was in the Diagnostic and Statistical Manual of Mental Disorders, the book American psychiatry uses to define what counts as an illness. It stayed there another seventeen years.

What moved it was pressure. From 1970, activists including Frank Kameny and Barbara Gittings began interrupting psychiatric conventions and demanding the floor. In 1972 a psychiatrist named John Fryer took the floor wearing a rubber mask, a wig several sizes too big and a microphone that distorted his voice. He introduced himself as Dr. Henry Anonymous and told the room he was a homosexual and a psychiatrist, and that there were more than two hundred of them in the association who could not say so.

The following February a psychologist named Charles Silverstein asked the committee that decides what goes in the manual to take homosexuality out of it. The same year he opened a clinic in New York built on accepting his clients rather than curing them.

In December 1973 the board of the American Psychiatric Association voted homosexuality out of the diagnostic manual. The membership forced a referendum the next year and upheld the decision, with 58 percent in favor.

It didn't leave entirely. What replaced it was a diagnosis for people distressed about their orientation, renamed ego-dystonic homosexuality in 1980 and deleted in 1987. Even then a line stayed in the manual allowing a clinician to diagnose persistent distress about sexual orientation. It was cut in 2013, forty years after the initial vote.

Attempts to cure it were older than the diagnosis. In 1899 a German psychiatrist claimed a success after forty-five hypnosis sessions and some trips to a brothel. In the 1920s an Austrian endocrinologist tried transplanting testicles. By mid-century the method was electric shock paired with images, or drugs that induced nausea, used on trans and gender-nonconforming people as well as on gay people. The churches had their own version all along, and neither stopped when the diagnosis did. The name conversion therapy came afterward, applied to all of it looking back. 

But some therapists, many of them gay themselves, had been working the other way for years without a word for it. In 1982 a psychologist named Alan Malyon put a name to it, gay affirmative therapy, and was careful about what he meant. It was not a new system or a set of techniques. It was a body of knowledge and a starting position, brought to whatever therapy a person already practiced.

What the work lacked was not practitioners but standing. In 2000 the American Psychological Association published guidelines for working with lesbian, gay and bisexual clients, which turned a stance into an expectation. In 2009 a task force reviewed 83 studies published between 1960 and 2007 and concluded that efforts to change orientation were unlikely to work and carried a risk of harm. It told practitioners to offer acceptance, support and identity exploration with no predetermined outcome instead.

For trans people the story ran on its own track. Harry Benjamin published The Transsexual Phenomenon in 1966 and sorted patients into true transsexuals and everyone else. The gender clinics that followed made access conditional on assessment and on a real-life test, which meant living in your gender for months or years before anyone would prescribe anything.

Until 1979 each clinic set its own rules. That year an association named for Benjamin published the Standards of Care, a single list of what a clinician should require before treating someone. The assessments and the real-life test were on it, and the gatekeeping requirements were narrow. Patients were expected to hold a gender-normative job, to be in a heterosexual relationship and to conceal that they were trans at all. People learned which answers opened the door and which closed it, and they gave the answers that worked.

From the late 1990s an alternative to the Standards grew, built on informed consent, where an adult who understands the effects of a treatment can decide to have it without proving themselves to a panel first. In 2018 the American Academy of Pediatrics published a policy statement on gender affirmative care, written for children and the adults around them, which holds that gender diversity is not a disorder and that a child's own account of themselves is where the work starts.

The diagnosis changed too. In 2013 the diagnostic manual dropped gender identity disorder and put gender dysphoria in its place, moving the condition from who a person is to the distress they feel. In 2019 the World Health Organization approved a bigger change, taking it out of the mental disorders chapter altogether and into conditions related to sexual health. A diagnosis is still required, and that is the part that has not moved. Without one, hormones and surgery can be called cosmetic and refused coverage, so the label that pathologizes is also the label that pays.

Affirming therapy did not stay where it started. Therapists now advertise sexuality-affirming, gender-affirming, neurodiversity-affirming, disability-affirming and culturally affirming practice, all of it from a stance worked out by people who had been treated as ill for being themselves. Each of those has a history of its own, and the neurodiversity one came from autistic people organizing for themselves.

The word spread but the harm did not stop.

Canada only made conversion therapy a crime in January 2022, for adults as well as children. The offences cover providing it, advertising it, profiting from it and taking a child out of the country for it.

The gatekeeping also left its own mark. A generation learned that being taken seriously depended on telling the story correctly, without hesitation and without complication. Certainty became the price of being believed, and doubt became the one thing you could not afford to say out loud. That habit does not switch off when you finally sit down with someone who is not assessing you. 

The early affirmative writing was also built largely around white gay men. Bisexual people were treated as undecided, trans people were handled by a separate system built on permission, and Two-Spirit people were working against a much older erasure, since colonization and the residential schools set out to destroy Indigenous traditions that had held gender and sexuality differently all along.

Access is still governed from outside the room. In Alberta, what care a person can get, and at what age, is currently shaped by law and policy rather than by them and their clinician, and it is contested and changing.

And affirming is a word any therapist can type on their profile. No regulator checks it, no training is required to claim it, and everyone has different values and beliefs.  

Trauma-sensitive affirming therapy works inside those gaps. It treats affirming as something a therapist demonstrates rather than announces. It centers whoever is in the room and honors their experience and history. It makes room for uncertainty. And it holds that the thing needing attention might be what you have been put through, not who you are.

Trauma-sensitive therapy starts by not asking you to prove anything.