Garrard Conley’s memoir, Boy Erased, which was turned into a popular film in 2018 starring Nicole Kidman and Russell Crowe, chronicles his experience growing up in a conservative Arkansas Baptist family and being forced into conversion therapy at age 19. After he’s outed to his parents, Conley is given two options: He can either join a program called “Love in Action” or lose his family, his friends, and his faith. Conley chooses conversion, and the story details the trauma this choice inflicts on his sense of self, how he survives, and his journey to eventual self-acceptance.
It’s a familiar story for many living in the United States. Well over a half a million adults in the U.S. have received some form of conversion therapy, according to a 2019 study by the Williams Institute at the UCLA School of Law—around half of them as adolescents. The practice took off in the 1970s and ’80s, particularly in Evangelical Christian communities. But by the late 1990s, medical organizations began to recommend against it. A growing body of research showed that it wasn’t only unsuccessful but could be traumatizing and even dangerous—increasing rates of depression, anxiety, and suicide risk in adults who experienced it as kids. By the 2010s, states across the U.S. began to ban the practice, and today, more than 20 states have such laws in place.
Now these bans are at risk. At the end of March, the Supreme Court ruled 8 to 1 that conversion therapy may be “protected speech” under the First Amendment in a case that pit Kaley Chiles, a Christian mental health counselor, against the state of Colorado, which banned conversion therapy in 2019. The Supreme Court justices sent the case back to a lower court to weigh in on whether the law is constitutional.
I caught up with Jack Turban, a pediatric psychiatrist known for his research on the mental health of transgender youth, who authored the 2024 book, Free to Be: Understanding Kids and Gender Identity. We talked about the difference between talk therapy and conversion therapy, how the media spin on the Supreme Court case has been misleading, and what the ruling means for trans kids.
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In the Supreme Court case, the Christian counselor Kaley Chiles distances herself from older conversion therapy practices, saying that she’s just offering to talk. I wondered what you make of that distinction.
There was a lot of confusion in the case about what exactly Chiles does. There was a lot of back and forth between the two sides. The standard of care, particularly for gender therapy, is what a lot of people would call exploratory therapy, where you’re absolutely allowed to talk to people in a non-directive way to help them understand themselves and explore their gender. That’s what Chiles was saying that she does, and she was describing something that’s quite similar to what the standard treatment is. But exploratory therapy isn’t conversion therapy. Conversion therapy is when you enter the treatment with a predefined goal to change the person. So your predefined goal is to make the person straight or to make the person cisgender. Every major organization has said that that’s dangerous: the American Psychiatric Association, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry. So that’s a major factual confusion in the case that muddied the waters.
So was Chiles in some way misrepresenting what she actually does?
I’m not sure anyone quite knows what she does, but that was a major critique of the case. She was never targeted for disciplinary action by the state of Colorado under this law. She didn’t describe any practices that seemed to actually fall under what the law bans. She never came out and said that she does practice therapy with the goal of forcing people to be straight or cisgender. The court glossed over that nuance, but I do think it’s important in terms of deciding whether her practices diverge from what the state was banning or not.
In your experience, what does conversion therapy generally look like today where it’s still practiced?
It’s not practiced very much, certainly not in mainstream mental health treatment, because all major professional organizations have labeled it dangerous and unethical. So you’re not going to find a mainstream psychiatrist or psychologist practicing it. It’s illegal in half the states, so most of it appears to be kind of underground and difficult to track. It’s mostly probably unlicensed people, maybe coaches or religious practitioners.
The harms of conversion therapy are so well documented, but for people who don’t know the research, why is this kind of therapy so dangerous?
There’s a lot of research at this point, and I think of it falling into two categories. One is that research into sexual orientation conversion efforts—attempts to force gay or bisexual people to be heterosexual—has consistently found that those exposed to this practice are more likely to have depression, anxiety, trauma-related symptoms, and suicidality. Then there’s another body of research that looks at gender identity conversion efforts—attempts to force trans people to be cisgender. The findings here are very similar: Those exposed to the practice are more likely to have a range of mental health problems, including suicide attempts.
What is gender dysphoria exactly, and what do we know about what is happening in the brains and bodies of kids who have it?
Gender dysphoria is a diagnosis from the American Psychiatric Association’s diagnostic and statistical manual of mental disorders. It refers to having a gender identity that’s different from your sex—so let’s say your birth certificate is male, but you identify as female—and also having clinically significant impairment from that. If I were a trans woman who was so distressed by my body not aligning with my identity that I couldn’t go to school or couldn’t work or had other impairments in my functioning, these might qualify as criteria for that diagnosis.
In terms of what’s going on in the brain, that’s a big question. It’s very hard to study the innate biological bases of trans-ness, but we do have a lot of signals indicating that there is something innate in the brain. I talk about all the different studies in my book—as a shameless plug, ha ha—but one of the most interesting types of studies are twin studies. They compare identical twins where one is trans with non-identical twins, where one is trans. And the question is: Are identical twins much more likely to both be trans than non-identical twins, given that identical twins share the same DNA? Those studies have estimated that 70 percent of transness appears to be genetically determined. You are much more likely to find a twin pair to both be trans if they’re identical twins than fraternal twins.
Historically, there were a lot of theories that different brain-based conditions were from the environment. Mothers have gotten blamed for child psychopathology a lot. People thought autism was from how your parents treat you. And specifically, there was this “refrigerator mother” theory, that cold mothers made kids that have autism. Much later, people did these twin studies and found that there was this biological basis, and that it wasn’t environmentally determined. The same thing happened with schizophrenia. There was this theory of the schizophrenogenic mother. It wasn’t until much later that we understood that it was also genetic.
There are also some genetic studies that have looked at the innate bases of transness, including neuroimaging studies and animal studies, where they’ve altered the full hormonal milieu in utero and found that it can impact gender-based behaviors. So we don’t have one gene or one brain region that we can point to that is the signature of transness in your brain, but lots of science suggests there is something innate.
Read more: “Gender Is What You Make of It”
Is there a continuum between trans kids and kids who like things that aren’t culturally typically assigned to their gender?
It’s important to know that those are two different things. There are kids who are trans—who see themselves as a gender that’s different from their sex. There are other kids who just defy gender stereotypes, but still identify with their birth sex. This becomes really important in this body of research that was called “the desistance literature,” where they have these studies of young pre-pubertal kids who were referred to gender clinics for some reason, and researchers followed them over time and found that 80 percent of them weren’t trans at follow-up in adolescence. A lot of people were like, “Oh, all of these kids who are trans are gonna stop being trans later.”
What people missed in those studies is that most of those kids weren’t trans to begin with. Up to 90 percent of these kids still identified with their birth sex. They were just boys who liked dolls, or boys who liked playing with dresses, or cisgender girls who were tomboys. That’s a very different thing from actually identifying as trans, which is a kid who says, “I am a boy,” when their sex is female, or “I am a girl,” when their sex is male. Kristina Olson at Princeton did a study where she followed those kids for five years, and around 94 percent of them still identified as trans five years later.
At what age do kids generally recognize that they’re trans?
There appears to be some variability. We published a paper a few years ago now in the Journal of Adolescent Health where we asked trans adults when they first realized that they were trans. We broke it into two groups: Those who knew before age 10 represented 60 percent of people. The other 40 percent didn’t realize until after the onset of puberty. But these are all people who identified as trans in adulthood.
Is endocrine therapy the standard of care for kids who do identify as trans?
Kids aren’t candidates for any medical interventions until after the onset of puberty. But it’s really an individualized assessment. And like with everything in medicine there are risks, benefits, and side effects. Generally what happens is if a young person is expressing interest in, say, puberty blockers or hormones, the standard of care is to do what’s called a comprehensive bio-psychosocial mental health evaluation, where you spend time with a young person and their parents really getting to understand their biological factors, the social factors in their life, what their psychological processes are, going into detail about the risks, benefits, and side effects of an intervention. And then with the young person and their parents, trying to come to a consensus about what’s most likely to be helpful, and if it seems like the benefits outweigh the potential risks and side effects, then maybe a family will go forward with treatment.
I wouldn’t say it’s ever a small decision or an easy decision. We often are spending a lot of time with families weighing all those factors to decide if it makes sense.
What kind of alternative therapies exist for someone who decides not to go forward with endocrine therapy?
There aren’t any evidence-based treatments for gender dysphoria itself—the distress that’s related to one’s body not aligning with one’s gender identity. But we can offer treatments to help with comorbidities. A lot of patients may separately have major depressive disorder or generalized anxiety disorder, and so we will offer the same common treatments that cisgender kids get for those, like SSRI treatment or cognitive behavioral therapy.
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If conversion therapy bans are undone around the country, what can psychiatrists, pediatricians, and school therapists do to protect kids?
One important thing to know about the Supreme Court case is that it didn’t strike down Colorado’s law. What they did was to say that the law is subject to a level of judicial review called strict scrutiny, and they sent it back to the lower courts to decide whether or not the law will be upheld under that standard. So we really need an answer from the lower courts about whether the law stands. Most laws that are subject to strict scrutiny get struck down, but we’ll need more information from the courts to see what happens with the laws.
Even if they do get struck down, states are already working on other ways to prevent conversion therapy. California is considering a bill that would extend the statute of limitations so that somebody who’s a victim of conversion therapy would have much more time to sue and collect damages from the therapist who harms them. That might be a deterrent. There are a handful of other strategies that might be at play also. It’s hard for me to imagine any mainstream therapists practicing conversion therapy, given all the evidence we have and all the guidance from medical organizations. It would more be fringe practitioners, which is what it was to begin with.
But Supreme Court decisions like this have really dramatic indirect impacts. Even if kids aren’t exposed to conversion therapy, the way this is covered in headlines was that the Supreme Court says conversion therapy is okay. That’s not accurate, but the Alliance Defending Freedom, which sponsored the case, has been doing a massive media campaign to try and make it out like that’s the case, which is false. But it sends a message to these young people that who they are is wrong or it can be changed, or that being trans or gay is a psychopathology that therapists can fix.
What are you working on now, research wise?
We just finished a study that we’re submitting for peer review that looks at the impact of conversion therapy bans on suicide attempts, and we found that conversion therapy bans caused a drop in suicide attempts among gay kids specifically in a pretty substantial way. Our lab also looks a lot at the interface of transgender youth law and mental health, so we’re also doing some studies looking at the impact of anti-trans sports bills—do bans on trans girls participating on sports teams actually cause a drop in concussion rates among athletes? Because one of the theories about why these bans are needed is this theory that trans girls participating in girls’ sports causes more injuries among cis girls. We’re also gonna look at the mental health impact of these laws on people.
There’s been so much movement in the policy space that there’s a lot to analyze. Far too often these policy debates are made without any scientific evidence, so our lab really focuses on trying to generate that evidence to help lawmakers in the courts. 
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