Reasons for treatment

Early models for treating gender-variant children involved attempts to change their gender identity and behavior to conform to social expectations for their assigned gender at birth (AGAB).^[11] The most significant works on this approach were formulated by Richard Green, Susan Bradley, and Kenneth Zucker.^[12] The approach became best known through the work of Susan Bradley and Kenneth Zucker, and through their colleagues at CAMH in Toronto, where it became known as the "living in your own skin" approach.^[11]

Zucker has stated that children with gender dysphoria should be treated to eliminate peer ostracism, treating underlying psychopathology, and preventing the child from becoming transgender.^[13][14][15] Zucker saw preventing children from becoming trans adults as justifiable in part due to the perceived difficulties posed by gender transition.^[13][16][17]

Kenneth Zucker and Susan Coates described the mothers of gender-variant children who are assigned male at birth (AMAB), as being overbearing, and contributing to gender dysphoria by transferring unresolved trauma to their children.^[18] This idea echoed early theories on homosexuality that blamed mothers for the gender non-conformity of their children.^[18] Zucker believed these children wished to become closer with their mothers by becoming girls.^[19] For children assigned female at birth (AFAB), Zucker believed they wished to become boys after they saw their mothers as disenfranchised.^[19]

In 2011, Jemma Tosh stated that Zucker considers the prevention of homosexuality a rationale for treatment.^[20] In 2003, Zucker and Susan Bradley wrote “In none of our publications have we ever endorsed prevention of homosexuality as a therapeutic goal in the treatment of children with GID, although we note that this might have been a goal of some therapists and also of some parents”.^[21] In 2020, Zucker stated “there is little evidence that treatment of children with GD alters their eventual sexual orientation“, citing the work of Richard Green.^[22]

Methods

Since the mid-1970s, Zucker has treated about 500 preadolescent gender-variant children to have them conform to the gender identity they were assigned at birth until they are at an age he believes they may determine their own gender identity.^[23] Zucker has stated he has tried to encourage children to accept their birth sex and supports them in transitioning if they still experience gender dysphoria into adolescence.^[24]

For children assigned male at birth (AMAB), Zucker has parents take away toys associated with girls, and instruct their child not to play alongside girls, or draw pictures of girls.^[25][19] Children are also prohibited from engaging in cross-dressing.^[26][19] Friendships with the same gender are encouraged, while friendships with the opposite gender are halted.^[19] Zucker and Bradley believed that conversion treatments could reduce peer rejection by enabling gender non-conforming children to mix with children of the same sex, reducing the possibility of adult gender dysphoria.^{[27][page needed]}

In 1994, Zucker's follow-up of 50 treated children found that, "about 10 percent are still very unhappy about their gender, still cross-dressing, and thinking about having sex reassignment surgery" as young adults.^[26]

In 2004, Zucker expressed the belief that socialization played a major role in transition, citing lower number of female-to-male transitions at the time.^[28]

In 2008, Zucker stated that "the therapist must rely on the 'clinical wisdom' that has accumulated and to utilize largely untested case formulation conceptual models to inform treatment approaches and decisions."^[29]

In 2015, an external review of Zucker's clinic found that the clinic considered being cisgender and heterosexual to be the preferred treatment outcome.^[17] The external review recommended that the clinic's methodology should be changed to be more in line with current clinical practices, and recommended a patient-centered, affirmative approach.^[17]

Criticism

Critics have compared Zucker's approaches with conversion therapy. The Gay and Lesbian Medical Association believes "'reparative' therapy that seeks to reverse sexual orientation or gender identification"^[30] is an "extreme example" of bias that "may lead to increased self hatred and mental health problems."^[31] Psychiatrist Simon Pickstone-Taylor has cited similarities between Zucker's therapeutic intervention and conversion therapy for homosexuals.^[32] Zucker responded that prevention of homosexuality was never a goal in their treatments and cites a lack of empirical evidence for the most effective approach.^[21] Journalist Marc Lostracco described Zucker's therapy as "well-meaning" but "problematic and harsh."^[33]

In February 2017, Zucker was slated to speak at a panel in Los Angeles for USPATH, the United States branch of WPATH.^[34] However, there was a protest by trans women who requested that Zucker be removed from the list of speakers, and who said that WPATH was grounded in cisnormativity and trans-exclusion.^[34] As a result, Zucker was removed from the list of speakers.^[34]

Ontario conversion therapy ban

In January 2015, Zucker was the psychologist-in-chief at Toronto's Centre for Addiction and Mental Health (CAMH) and head of its Gender Identity Service.^[1] That month, members of Rainbow Health Ontario, a provincial health promotion and navigation organization, approached CAMH expressing their concerns regarding Zucker's clinic.^[35] Rainbow Health Ontario submitted a review of academic literature and clinical practices for transgender youth, and expressed concern that the gender identity clinic was not following accepted practices.^[17] Others linked the Gender Identity Clinic's practices to suicide of transgender youth caused by conversion therapy, and referenced the high-profile case of Leelah Alcorn, a transgender teen from Ohio.^[35]

In February 2015, CAMH ordered an external review of its gender identity clinic for children and teens.^[36] A report from March 2015 stated that the review was the result of growing online scrutiny of CAMH for alleged conversion therapy practices.^[7] The same report stated that the clinic would not be accepting new patients until the review was finished.^[7]

In March 2015, the Ontario Provincial Parliament introduced the Affirming Sexual Orientation and Gender Identity Act, aimed at banning conversion therapy practices.^[7] In June 2015, the legislation was passed unanimously into law by the provincial parliament.^[37][36] The law made LGBT conversion therapy illegal to provide to minors, and removed it from public health insurance coverage for adults.^[36] After the bill was passed into law, CAMH stated that they welcomed the unanimous support for the bill.^[38]

External review

The external reviewers for the gender identity clinic were child and adolescent psychiatrists Suzanne Zinck of Halifax, and Antonio Pignatiello of Toronto. They invited stakeholders to comment on their experiences in the clinic.

In November 2015, the external review was published.^[39] The review noted numerous strengths of the clinic, but also described it as an insular entity with an approach dissimilar from other clinics and described it as being out of step with current best practices, including WPATH SOC Version 7.^[39] They also raised concerns about clinicians asking age inappropriate questions.^[39]

Closure

In December 2015, CAMH announced that it was "winding down" the clinic and that Zucker was no longer employed there. Kwame McKenzie, medical director of CAMH's child, youth, and family services, said "We want to apologize for the fact that not all of the practices in our childhood gender identity clinic are in step with the latest thinking".^[40] CAMH announced a process of consultation with community leaders to examine how best to offer care.^[41]

McKenzie said that Zucker's treatments were against the centre's guidelines. Prior to the review, he stated that there existed two schools of thought on such therapy for children under 11 among professionals.^[7][42][43]

Settlement

The client who accused Zucker of calling him a "vermin" withdrew his accusation, which was reported as false.^[44][45]

CAMH removed the report from its website and apologized, and replaced it with a summary of the report which has not survived a move to its new website.^[45]

Zucker sought legal justification with McKenzie and CAMH, for which CAMH again apologized to, and settled with Zucker,^[46] paying $586,000 in damages, legal fees, and interest.^[8]

When the settlement was announced, CAMH stated that it "stands by its decision to close the child and youth gender identity clinic following an external review which concluded the clinic was not meeting the needs of gender-expansive and trans children and their families",^[47] adding that "We believe our modernized approach to delivering services to youth better supports diverse patients through best practice and timely care."^[48]