Gender Mad

19 Dec 2015

A group of transgender activists has achieved a major victory—the shutting down of the Child Youth and Family Gender Identity Clinic at Toronto’s Centre for Addiction and Mental Health (CAMH). Even better from their point of view, they got the head of it, psychologist Ken Zucker, fired.

The activists didn’t like Zucker because he never did subscribe to the “true transgender” model of identity, wherein you simply accept what any child (no matter how young) says about his or her gender. The transgender activists who called for his ouster insisted that Zucker was doing “reparative therapy,” trying to talk children out of being transgender when they “really” were.

I don’t doubt that these particular transgender adults look back and see that, from very early on, they had been assigned a gender that didn’t make sense for them. The mistake they make is then to assume that every child who expresses doubt about his or her birth gender assignment should simply be “affirmed” by parents and clinicians in their “new” gender.

This is an unbelievably simplistic understanding of what’s going on with these children. Yes, some of them will grow up to be transgender; Zucker and others have documented that, over and over again. But if history is a guide, the majority will not. Trying to make sure they all get the best care they need is the goal of clinics like Zucker’s, as well as the clinics run by other good folks at the children’s hospitals of UCLA, Northwestern, Seattle, and on and on.

Why not transition everybody who says she or he is the other sex? All other things being equal, it’s a lot easier on your body if you don’t try to change your sex hormones, genitals, etc. The interventions involved in sex reassignment are non-trivial.

Make no mistake: If you start hormonal sex change before your inborn-sex-directed puberty is well on its way, then you’ll end up much better off in terms of your adult sexed appearance and in terms of avoiding other interventions, and so you’ll also benefit psychologically, if it was the right choice. So, for example, if a birth female starts sex change early in puberty, that person will avoid growing breasts that he would later want surgically removed. A birth male who starts sex change early in puberty will avoid having the voice and body hair patterns become male-like, features that are very difficult to undo once set in the body.

That’s why starting transition earlier is good for young people who will benefit from changing their sexed bodies. But as I said, these interventions are not trivial, and many are not easily reversible. This is particularly true for females who undergo male hormonal puberties by taking testosterone. So you want to make sure you get right your calculation of who will benefit.

For many years, there was pretty heavy medical gatekeeping around sex reassignment. This had some to do with homophobia, heterosexism, and so on, and some to do with defensive medicine (fear of being sued if a patient later regretted transitioning). Today, the pendulum has swung really hard in the other direction. It is now much, much easier for children, adolescents, and adults who signal that they are transgender to gain access to social gender changes, hormone therapies, and sex changing surgeries. This has a lot to do with political rejection of homophobia, heterosexism, transphobia and so on, and some to do with defensive medicine (fear of being attacked as anti-transgender).

In other words, it’s still pretty damned political. Whereas before, some people who would have benefitted from transition were denied it, today some people who might benefit from alternative clinical help (alternative to transition) are effectively denied that help and are instead being “treated” with transition.

To read some narratives of people who started transition and stopped, you could look here, and for some who transitioned and later re-transitioned back to their originally-assigned genders, you could look here and here. There are more and more of these, and they are typically not written by people who are anti-transgender by any means. They are written by people who realize transition isn’t what they needed after all. They are written by people who urge caution.

Many people today are afraid to urge caution, because when you do, you get labeled anti-trans, and sometimes coopted by genuinely anti-trans people. But some people are willing to talk in private or to speak pseudonymously. So, earlier this year for WIRED magazine, I interviewed a thirty-something woman I called Jess. She had been a gender nonconforming female child and was skeptical about sending children too quickly down the road of transition.

Today, in the clinics presumably the transgender activists want, a gender nonconforming, gender-questioning child like Jess would simply be transitioned over and sent out into the world. But Jess told me that, today, “I’m very happy having the body I have, with just some changes in how I express it.” She identifies as a genderqueer gay person with a female body (the body type she was born with), and works on LGBT rights issues professionally. She’s not anti-trans.

By Jess’s own account, her life might have turned out okay if she had transitioned to become male. But that approach would have failed to address her core psychological needs. When I interviewed her, Jess told me that, looking back, she wished that “someone had worked with me on my body image and my relationship to my body, on how my body displays gender and how I can convey gender in a way that makes sense for me.” She told me that if that had happened, “she might have avoided the social withdrawal and eating disorder that ensued from her identity struggles.”

Jess also told me—and I agree—that the clinical goal of working with gender nonconforming children “should not be to solidify labels of L, G, B, and/or T . . . but to ‘avoid the harmful impacts of stigma towards this population and promote a healthy sense of self.’”

The transgender activists who demanded and ultimately achieved the shut-down of Zucker’s CAMH clinic said that Zucker’s approach was full of stigma. That’s because he didn’t simply “gender affirm” every child that came by. He worked with them to figure out what they needed psychologically. For some, that was transition. For others, it was coming to see that you could be gender nonconforming without changing your sex, or dealing with depression or bi-polar disorder, or dealing with the mental health needs of parents who were not well enough to really care for their children as their children deserved. It was a pretty idiosyncratic approach, designed to help each individual child be the most healthy in the long run, no matter which label she or he came to inhabit. Again, for some children, that meant transition (becoming “T”), and for those children, Zucker arranged puberty-blocking hormones and then hormonal and surgical transition.

Here’s a recent paper from Zucker’s clinic. (Disclosure: one co-author, Ray Blanchard, is a close friend of mine.) What’s it about? Trying to ascertain which children will benefit from being put on puberty-blocking hormones and then provided help transitioning hormonally and surgically. The same kinds of approaches and studies are being done at clinics around the world, because many clinicians are trying to figure out who will benefit from the risks and harms of early physical interventions, and who will benefit from the risks and harms of delaying physical interventions. They’re using the same basic approaches as Zucker in the clinic, although some see lower and higher rates of transition in their clinics, as the paper notes.

Is what’s described in this paper really so awful? So radical? I just don’t think so. If it is, then clinics all over the world "need" to be shut down.

If the CAMH administrators who closed the clinic and fired Zucker had actually wanted to provide care to these families in some better way, they would have used the review they ordered (which actually contains much praise of Zucker) to tell Zucker how they wanted to see his practices adjusted; indeed, the review made suggestions in that regard. They would have systematically surveyed all of the families he had treated to find out what worked and didn’t work for them. They would have provided enough staff to deal with the gigantic waiting list that had accumulated for the clinic. They would have at least kept the clinic open and put someone they liked in charge.

Instead, they shut the whole thing down, thus rescuing themselves from the constant pressure of transgender activists. This, I fear, will be what happens to clinics all over, if clinicians refuse to tow the party line about gender identity being something so simple, any two-year-old can tell you who they “really” are—especially if clinics’ top administrators are cowardly, as CAMH’s are.

The biggest irony to me comes on page 21 of the review’s findings, wherein the reviewers state:

Dr. Zucker states that he feels in many cases parents, schools, and community advocacy groups may advise too early a transition. There is a greater need than ever for the natural course of gender variance and dysphoria to be understood. The clinic focus is on intensive assessment and treatment and has not included participation in community education on this topic. This is a significant missed opportunity. While most advocacy groups clearly understand the natural course of very early gender variance and dysphoria, adding the voice of clinicians who advocate watchful waiting and where needed, an eclectic, child-centered approach would further improve the care of gender variant and gender dysphoric or questioning children and teens.

If I understand this correctly, what the reviewers are saying is that the “advocacy” community and society at large would benefit if clinicians like Zucker would do more outreach to explain that gender identity development ain’t so simple, and to explain why their clinics take that reality into account. In other words, we'd be better off if the advocates, not the clinics, changed their understanding.

So, what happens now? Presumably somebody will open up a clinic in the Toronto area that will satisfy the transgender activists who think they can spot children like the ones they were. Presumably, more children will be transitioned. I hope they will be well. I hope their real mental health needs, and the mental health needs of their parents, are met.

As for me, I so wish Zucker had done the “community education” that this review called for. Now it is too late. For years, I and others advised Zucker to be far more proactive in terms of the politics in which he was caught—to reach out to the public to directly engage them in conversation about the methods and reasoning of his clinic’s approach, the same approach used in many top clinics around the world. As late as this summer, I gave him a lot of the advice I also recently gave to the International Society for Intelligence Research about how to work to protect yourself in politically difficult fields (see video).

But Ken seemed to believe that he didn’t need to deal with the activists coming after him. He disregarded my repeated advice. As a consequence, what has happened to him reminds me very much of what happened to Napoleon Chagnon, as recounted in chapters five and six of Galileo’s Middle Finger. It’s the Galilean personality, stuck on the belief that truth will save you. Wrong. The Church of True Gender doesn’t give a crap what science shows.

So let me quote from the near the end of Galileo’s Middle Finger:

…if this project has taught me anything, it’s this: People don’t want to listen to us historians and our warnings. People don’t believe us when we come in at the start or the middle. They believe us only way after the end, if then. I’m learning to accept the fact that we are almost always too late. We can bear witness afterwards, of course. And witnessing matters. But so many days, I find myself selfishly wishing that witnessing felt like enough.

Today is one of those days.


If you want to read the story of a sex researcher who was a gender nonconforming girl and who is glad she did not transition, click here. (She’s not anti-trans.) If you want to read an op-ed by two scientists, both friends of mine, who think Zucker’s approach made sense, click here. (They’re not anti-trans.) And if you want to read about a mother of a “pink boy” who says the right approach is just to chill the hell out, click here. (She’s not anti-trans, either).