Amen to That - The War Against Trans Children is Over, Part 2

Finally, the event for which we had all been waiting, the presentation by Dr. Zucker. Having lost his job and clinic in December, and having filed three lawsuits since, he came in with his boots on, opening with:

This feels like a Bernie Sanders rally.

He went on to say that he doesn't like politics, having stayed away from it since 1968 when he held a Vietcong flag at a rally, and preferring to focus on the lack of the "evidence base" I've discussed above. He couldn't understand, even with the help of a $500/hour attorney, the operational meaning of "identity exploration" in the Ontario conversion therapy law and how it differed from his therapeutic treatments, but concluded by saying that these conversion therapy laws (and the repudiation of his therapeutic approach which they represent) were:

a political hegemonic maneuver [by activists] leading to complete control over what constitutes best practice clinical care [of trans and gender non-conforming children].

He came closest to the fundamental issue when he mentioned that people had "divergent ideas of optimal outcomes." Dr. Zucker's suggestion that the law was vague was challenged by Nicole Nussbaum, Past-President of the Canadian Professional Association for Transgender Health (CPATH), who had presented in favor of the Bill to the legislative committee. Nicole read more of the law to the crowd which showed there really isn't the ambiguity he fears. The Ontario law, sponsored by LGBTQ opposition critic, Cheri DiNovo, is seen by many as the primary factor leading to the closure of his practice by the Province of Ontario.

I would note that the bill received unanimous support in the legislature, and that each leader, as well as other members of the ruling Liberal party, New Democratic party, and Progressive Conservative party, spoke in resounding support of the bill.

Darlene Tando, a licensed clinical social worker who is a leader of the gender-affirming movement, responded pithily:

I do this work all the time with children and have never once been worried about my work being conflated with conversion therapy. It is my job, ethically, to explore the difference between gender expression and gender identity, and I do that all the time without worry that this is anything like reparative therapy. I would just suggest that anyone who was worried about that probably is inching their way to trying to change the child.

When he replied he didn't understand her point, amidst the laughter she concluded:

People who are scared of this are probably trying to do reparative therapy, and they can't, and that's a good thing.

Then Dr. Francoise Susset, a fellow Canadian psychologist in Montreal, confronted him gently, though directly:

I think, these activists as you call them - many are therapists and clinicians and front-line workers in Ontario who met many of the people who reported that they suffered from negative, iatrogenic effects after attending your program over the years. There has been a lack of communication, after many attempts made to communicate, probably for more than a decade, and I find it unfortunate that everything had to happen the way it did. But I do think we're not talking about activists, we're talking about therapists and community workers who met with clients like those Richard Green talked about, who internalized many negative messages about gender identity over time. It's not easy to measure those iatrogenic effects; we don't have many studies but clinicians who side with validating and affirming gender identity have come to this over time. After starting out twenty years ago cracking open your book and cracking open the literature and going, "OK, I'm going to try this," I realized the problems that emerged, creating a lot of distress in these families and children. So this polarization comes out of clinical experience for many of us.

To conclude, Dr. Mayer-Bahlburg added that he didn't like government and politicians involving themselves in this work, and reported one incident where he wrote to the commission in Ontario and described that if he counseled a gender non-conforming teen in New York, where he works, to tone done his gender expression when in a dangerous neighborhood, that he could be found guilty under this law.

The best discussion of this issue had come earlier from Dr. Diane Ehrensaft, author of Gender Born, Gender Made, and arguably the leader of the effort to treat children in a gender-affirming manner, who described the problem with a lovely group of metaphors. The problem has always been that the Greens and Zuckers of the world have conflated all the gender non-conforming children into one pile, greatly diluting the trans girls with those who could be considered proto-gay boys. Given that, the conclusion that social transition doesn't work (the 80% number is thrown around a lot) makes perfect sense.

Diane separates the categories into apples, oranges, and fruit salad. The apples (primarily biological) are the trans girls who basically say, "I am a girl." This is mirrored in their behavior, and they thrive with transition. The oranges (primarily social) are those who say, "I want to be a girl and do girl things," usually without any genital dysphoria, and with an exaggerated sense of femininity. These children might enjoy transition for a while but would desist and grow into puberty as gay boys. The fruit salad (primarily cultural) is the gender expansive group, who don't declare a gender, are fluid in their presentation, and might very well grow up to be genderqueer (though as it's a new phenomenon it's too early to tell).

So -- if one can distinguish these children by classification, one could comfortably transition the trans girls while not doing so with the other two groups. Diane and her colleagues believe they are doing this today, while Zucker and Green believe it simply can't be done.

Going one step deeper, however, we discover over years of experience that the problem is the definition of harm. The Zucker side believes gay is good and trans is bad. One could go so far as to say Dr. Zucker believes that "not one more trans person" is the preferable outcome, and he has practiced what can be considered reparative therapy to prevent that. The Ontario commission that closed down his practice stated, in a very convoluted manner, that it could not be determined that he did not practice conversion therapy. This aversion to the trans experience is evident in his deep resistance to possibly transitioning gay boys, believing that such a transition would do irreparable harm to those boys, while feeling nothing of the same about trans girls who we know are deeply harmed when refused transition. I have a very dear friend who believes the same, and I have tried to understand her fear, but I can't. I believe it's grounded in a profound misogyny, and ignores the fact that a gay boy who is very feminine in his behavior is very unlikely to suffer from "going all the way" for a few years before he reverts to living as a gay boy. Will he be teased by his peers? Maybe. These boys often call one another "girls" anyway, so how bad could it be? But closeted and denigrated trans girls become depressed and suicidal. We know this, and we have statistics to prove it, but some people simply don't care, or care enough.

If one follows the Hippocratic system and prioritizes doing no harm, the priority must be to transition the trans girls and not worry as much about the inadvertently transitioned gay boys. I believe not simply in a gender-affirming approach, but what a colleague called a "reality-affirming" approach. One clinician at the conference emphatically stated that "all that matters is Now," though he backed off some when questioned about the absolute tone of that statement. Every child and teen needs her particular circumstance to be fully considered. Some can transition with supportive families at age 5; others should wait until they leave home and go away to college. It does get better, but in some places in the U.S., and many places around the world, it's not getting better fast enough for these children to safely transition and lead fulfilling lives. With that caveat, I believe the gender-affirming approach is the proper one, and also that Gender Incongruence of Childhood (GIC) should not be a formal ICD-11 diagnosis for those younger than age 8-10 when puberty-blocking hormones can be considered.

Dr. Zucker was overheard telling Dr. Meyer-Bahlburg that "these are not the good old days." Amen to that.