I am agnostic on the topic of “conversion,” though I suspect the subject is more diverse and complicated than political soundbites let on. But I’m not agnostic about the new JAMA Psychiatry study. There are at least four good reasons for being leery of the results appearing therein.

In a “study” that arrived to much media fanfare last week in the journal JAMA Psychiatry, researchers affiliated with Harvard University and Massachusetts General Hospital purported to offer convincing proof that “conversion therapy” predicts longstanding toxic outcomes among Americans who self-identify as transgender, including greater recent suicidality and more severe psychological distress in the past month. Its results, the authors state, “support the policy positions” of such medical professional organizations as the American Medical Association and American Academy of Pediatrics.

I am agnostic on the topic of “conversion,” though I suspect the subject is more diverse and complicated than political soundbites let on. But I’m not agnostic about the new JAMA Psychiatry study. There are at least four good reasons for being leery of the results appearing therein.

First, the study fails to define or better distinguish what it means by GICE—that is, gender identity conversion efforts—its key variable and a term the authors appear to have invented. It comes from a solitary question that respondents were asked:

“Did any professional (such as a psychologist, counselor, or religious advisor) try to make you identify only with your sex assigned at birth (in other words, try to stop you being trans)?”

That’s what the survey asked. Given the hundreds of questions and items the United States Transgender Survey, or USTS, posed to its respondents, that it lumps any scenario that does not involve unqualified affirmation (including “watchful waiting” for minors) into one imprecise, binary measure is, I hold, psychometrically irresponsible.

Psychiatrist and longtime gender identity expert Stephen Levine highlights the quandary facing professionals attempting to counsel transgender patients on the biological, social, and psychological risks posed by any treatment approach. Such risks are real and ought to be discussed. This is what ethical informed consent does. But in the USTS survey lingo, an ethical discussion of risk could be interpreted by the patient as “trying to stop you being trans.” In other words, obtaining informed consent may constitute GICE. It need not even stretch the imagination. Levine sees it. He notes that while the World Professional Association for Transgender Health endorses informed consent, this principle remains at odds with its recommendation of providing hormones on demand.

But the authors of the JAMA Psychiatry study, following the USTS’s survey measurement, aren’t interested in subtleties. The authors paint an entire class of cautious therapeutic approaches as intrinsically harmful, sending a clear message to psychiatrists and psychotherapists alike. Scientifically, we learn nothing of the respondent’s motivations for interacting with the “professional” in the first place. It’s not hard to understand how reality is far more complicated than the USTS data allow here. Their question can’t distinguish between truly harmful approaches and potentially beneficial considerations.

Second, the data come from a nonrandom, opt-in survey—the USTS—that only targeted networked, self-identified transgender or nonbinary persons by advertising their survey among “active transgender, LGBTQ, and allied organizations.” There’s nothing wrong with collecting data using a nonrandom approach like this—I’ve done it myself and will do it again. The problem is when such data are delivered to the reader, as these were, in a way that suggests the conclusions would be consonant with everyone who has identified as transgender or experienced gender identity disorder or dysphoria. The survey’s “United States” label further creates the impression that the data collection effort was a population-based random sample, sort of like the US Census. It is not. And you can’t extrapolate the results of a non-random sample to the general population as a whole. (But you can hope that the media and readers will.)

When compared with a 2017 study of the demographic characteristics of transgender adults from the CDC’s Behavioral Risk Factor Surveillance System—a genuinely population-based sample—the USTS respondents appear decidedly dissimilar. How different are they?

1. Unemployment: 15% in the USTS vs. 8% in the BRFSS
2. Sexual orientation: 47% of male-to-female identify as LGB in the USTS vs. 15% in the BRFSS; 24% of female-to-male identify as LGB in the USTS vs. 10% in the BRFSS
3. Currently married: 18% in the USTS vs. 50% in the BRFSS
4. Child in the household under 18: 14% in the USTS vs. 32% in the BRFSS
5. General health rated as fair or poor: 22% in the USTS vs. 26% in the BRFSS

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