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Debate: Different strokes for different folks

DOI:10.1111/camh.12330
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Kenneth J. Zucker at University of Toronto
Kenneth J. Zucker
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Abstract

A gender social transition in prepubertal children is a form of psychosocial treatment that aims to reduce gender dysphoria, but with the likely consequence of subsequent (lifelong) biomedical treatments as well (gender‐affirming hormonal treatment and surgery). Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence when compared to follow‐up studies of children with gender dysphoria who did not receive this type of psychosocial intervention and, oddly enough, might be characterized as iatrogenic. Parents who bring their children for clinical care hold different philosophical views on what is the best way to help reduce the gender dysphoria, which require both respect and understanding.
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Debate: Different strokes for different folks
Kenneth J. Zucker
Department of Psychiatry, University of Toronto, Toronto, ON, Canada
A gender social transition in prepubertal children is a form of psychosocial treatment that aims to reduce gen-
der dysphoria, but with the likely consequence of subsequent (lifelong) biomedical treatments as well (gen-
der-affirming hormonal treatment and surgery). Gender social transition of prepubertal children will increase
dramatically the rate of gender dysphoria persistence when compared to follow-up studies of children with
gender dysphoria who did not receive this type of psychosocial intervention and, oddly enough, might be char-
acterized as iatrogenic. Parents who bring their children for clinical care hold different philosophical views on
what is the best way to help reduce the gender dysphoria, which require both respect and understanding.
Keywords: Gender identity; gender dysphoria; psychosocial treatment
The proverbial saying ‘Different strokes for different
folks’(The Oxford Dictionary of Phrase and Fable, 2006)
reflects well the contemporary clinical debate on best-
practice therapeutics for children with gender dyspho-
ria. It reflects not only the variation in the philosophical
and theoretical perspectives of front-line clinicians, but
also variation in the philosophical belief systems of par-
ents who bring their children to mental health profes-
sionals for clinical advice and care.
For prepubertal children with gender dysphoria, I
would argue that there are three main approaches to
therapeutics, which I list here in chronological/histori-
cal order: (a) active psychosocial treatment to reduce
gender dysphoria so that the child’s eventual gender
identity is more congruent with her or his biological sex
(thus obviating the necessity for what some now call
‘gender-affirming’hormonal and surgical treatment); (b)
‘wait-and-see’or ‘watchful waiting’, which makes the
assumption that it is difficult to predict what the long-
term outcome will be and so, well, the clinician should
not recommend very much one way or the other; and (c)
gender social transition, in which the child’s‘social’
gender identity is shifted from the gender assigned at
birth to the putative desired gender (e.g., change in
name, change in pronoun usage, and change in other
phenotypic social attributes, such as hair-style and
clothing-style that mark one’s gender to significant
others). Dreger (2009) characterized the first approach
the ‘therapeutic’model and the third approach the
‘accommodation’model.
These rather marked variations in the type of psy-
chosocial treatment considered to be in the best interest
of the child reflect deep structure variations in theoreti-
cal perspectives on the nature and nurture of psychosex-
ual differentiation (see the edited volume by Drescher &
Byne, 2012). On the one hand, the first approach
assumes that, for young children with gender dysphoria,
gender identity is not fixed or ‘locked in’at an early age
and that there is a much greater degree of malleability
and plasticity than might be the case for both adoles-
cents and adults with gender dysphoria. On the other
hand, the third approach assumes that gender identity
is fixed and locked in at a very early age because of
underlying biological mechanisms. One of the most well-
known children with gender dysphoria, ‘Jazz Jennings’,
has promulgated this view in her book, written for chil-
dren, ‘I Am Jazz’(Herthel & Jennings, 2014) where Jazz
writes ‘I have a girl brain but a boy body....I was born
this way!’
As noted in several guideline reviews on clinical prac-
tice for the treatment of children with gender dysphoria
(AACAP Practice Parameter on Gay, Lesbian, or Bisexual
Sexual Orientation, Gender Nonconformity, and Gender
Discordance in Children and Adolescents, 2012; Ameri-
can Psychological Association, 2015; Byne et al., 2012),
the field suffers from a vexing problem: There are no ran-
domized controlled trials (RCT) of different treatment
approaches, so the front-line clinician has to rely on
lower-order levels of evidence in deciding on what the
optimal approach to treatment might be. One quote is
sufficient to document this point: ‘Different clinical
approaches have been advocated for childhood gender
discordance.... There have been no randomized con-
trolled trials of any treatment....the proposed benefits of
treatment to eliminate gender discordance...must be
carefully weighed against... possible deleterious effects’
(AACAP Practice Parameter on Gay, Lesbian, or Bisexual
Sexual Orientation, Gender Nonconformity, and Gender
Discordance in Children and Adolescents, 2012, pp.
968–969). Given the cautious conclusions that these
types of reviews have reached, it is of interest how, in
recent years, so many clinicians have embraced the
treatment approach that recommends an early gender
social transition. Chen, Edwards-Leeper, Stancin, and
Tishelman (2018) observed that ‘Over the last decade, we
have seen a sea change in approach to pediatric trans-
gender care, with the gender affirmative model now
widely adopted as preferred practice’(p. 74).
In my view, there are reasons to be skeptical about the
merit in recommending an early gender social transition
as a first-line treatment. One should recognize that if
one peruses carefully the follow-up studies of young chil-
dren with gender dysphoria (or traits of gender dyspho-
ria), the majority of such children do not have gender
©2019 Association for Child and Adolescent Mental Health
Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
Child and Adolescent Mental Health Volume **, No. *, 2019, pp. **–** doi:10.1111/camh.12330
dysphoria when followed up in adolescence or adulthood
(Zucker, 2018). In these studies, one can say with rea-
sonable confidence that when these children had treat-
ment (and not all did), the one type of treatment they
did not receive was in the form of a prepubertal gender
social transition. As I argued elsewhere (Zucker, 2018),
if one conceptualizes gender social transition as a type
of psychosocial treatment, it should come as no sur-
prise that the rate of gender dysphoria persistence will
be much higher as these children are followed into their
adolescence and young adulthood (see Rae et al.,
2019). If this is, in fact, the case, one might ask why
would one recommend a first-line treatment that is, in
effect, iatrogenic.
Even if there was a team of researchers motivated to
design an RCT, the implementation of such a study
would be formidable. For example, some parents would
decline to place their child into a psychosocial treatment
arm that would attempt to reduce the child’s gender dys-
phoria so as to be more congruent with the gender
assigned at birth; other parents would decline to place
their child into a psychosocial treatment arm that would
attempt to reduce the child’s gender dysphoria by ‘af-
firming’their felt gender vis-a-vis a social transition. Per-
haps parents who prefer one of these two approaches
would agree to ‘wait-and-see’at least for a while, before
deciding on a more intensive therapeutic approach. This
variation in parental preferences reflects, as noted ear-
lier, differences in underlying theoretical and philosophi-
cal perspectives which need to be respected. As the field
moves forward and more follow-up data become avail-
able, we will learn more about the developmental course
of gender dysphoria in particular and well-being and
mental health in general.
Acknowledgements
The author has declared that he has no competing or potential
conflict of interest.
Ethical information
No ethical approval was required for this article.
Correspondence
Kenneth J. Zucker, Department of Psychiatry, Univer-
sity of Toronto, Toronto, ON M5T 1R8, Canada; Email:
ken.zucker@utoronto.ca
References
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Accepted for publication: 18 March 2019
©2019 Association for Child and Adolescent Mental Health
2Kenneth J. Zucker Child Adolesc Ment Health 2019; *(*): **–**
... A related theme concerns what critics of the gender-affirming medical pathway refer to as the self-fulfilling prophecy of initiating medical treatment with puberty blockers (p. 5) [74,75]-what Zucker has referred to as "treatment that is, in effect, iatrogenic" (p. 37) [76]. Additionally, Nahata and Quinn (2019) have suggested that young people on puberty suppression "may not have full developmental capacity due to lack of brain development (p. ...
... First, the study was a naturalistic followup study. It did not include a control group-sometimes known as 'wait-and-see' or 'watchful waiting' [76]-and it did not use a blinded, randomised approach. Notwithstanding this, the results raise many important questions for future research and for future reflection. ...
... Together, these processes gave young people with gender-related distress a clear message: "This is the best way to proceed," and "The medical affirmation pathway will take away your gender dysphoria." For many young people and their families, however, these messages favouring medical interventions, coupled with professionals' affirmation of this pathway, potentially displaced their consideration of other options or other pathways [76]. ...
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... Less is known about desistance in the novel cohort of young people presenting today. Unlike in the past when clinicians actively worked with children and their parents to lessen gender dysphoria or adopted a neutral strategy of "watchful waiting" (Cohen-Kettenis & Pfäfflin, 2003;Zucker, 2008aZucker, , 2008b, many of today's youth undergo some form of gender social transition (e.g., change in clothes, haircut, name, and pronouns; breast binding; use of opposite sex facilities, etc.) before contemplating medical interventions (Morandini et al., 2023;Olson et al., 2022;Zucker, 2020). Although social transition is often described as a neutral intervention with little, if any, longterm consequences, several studies support the hypothesis that it can concretize gender dysphoria Turban et al., 2021a;Zucker, 2020). ...
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... It should be noted that high resolution of childhood-onset gender dysphoria had been recorded before the practice of social transition of young children was endorsed by the American Academy of Pediatrics (Rafferty et al., 2018). It is possible that social transition will predispose a young person to persistence of transgender identity long-term (Zucker, 2020). ...
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... Little is known, however, about whether the developmental pathways of socially transitioned transgender children differ from those of cisgender children (Stynes et al., 2021). Many experts working with gender diverse youth have noted that data assessing gender identity and gender-typed preferences of socially transitioned transgender children over time are lacking (Byne et al., 2012;Coleman et al., 2012;Drescher & Pula, 2014;Singh et al., 2021;Steensma & Cohen-Kettenis, 2018;Stynes et al., 2021;Turban & Keuroghlian, 2018;Zucker, 2020). In the present research, we sought to examine the continuity (and/or change) of gender identity and gender-typed preferences for both cisgender and transgender prepubertal children across a period of 2.6 years (SD = 1.0). ...
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Growing numbers of transgender and gender-nonconforming (TGNC) youth are presenting for medical and mental health care, and increasingly, pediatric psychologists are being called upon to serve as critical members of interdisciplinary care teams. In this commentary, we present information on TGNC youth in three distinct developmental cohorts: prepubescent TGNC children, peripubertal TGNC youth, and pubertal TGNC adolescents. First, we describe the social, medical, and/or surgical treatments available to each cohort of youth. Next, we address the state of the science related to these treatments. Then, we highlight some of the ongoing controversies related to social, medical and/or surgical interventions that are most relevant to pediatric psychologists and the role they play in gender-affirming care. Finally, we conclude with a call for papers for an upcoming special issue of Clinical Practice in Pediatric Psychology focused on advancing the practice of pediatric psychology in transgender health care.
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Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orientation, Gender Nonconformity, and Gender Discordance in Children and Adolescents
Article
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  • Sep 2012
Children and adolescents who are growing up gay, lesbian, bisexual, gender nonconforming, or gender discordant experience unique developmental challenges. They are at risk for certain mental health problems, many of which are significantly correlated with stigma and prejudice. Mental health professionals have an important role to play in fostering healthy development in this population. Influences on sexual orientation, gender nonconformity, and gender discordance, and their developmental relationships to each other, are reviewed. Practice principles and related issues of cultural competence, research needs, and ethics are discussed.
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Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder
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Full-text available
Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.
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Predicting Early-Childhood Gender Transitions
Article
  • Mar 2019
Increasing numbers of gender-nonconforming children are socially transitioning—changing pronouns to live as their identified genders. We studied a cohort of gender-nonconforming children (n = 85) and contacted them again approximately 2 years later. When recontacted, 36 of the children had socially transitioned. We found that stronger cross-sex identification and preferences expressed by gender-nonconforming children at initial testing predicted whether they later socially transitioned. We then compared the gender-nonconforming children with groups of transitioned transgender children (n = 84) and gender-conforming controls (n = 85). Children from our longitudinal cohort who would later transition were highly similar to transgender children (children who had already socially transitioned) and to control children of the gender to which they would eventually transition. Gender-nonconforming children who would not go on to transition were different from these groups. These results suggest that (a) social transitions may be predictable from gender identification and preferences and (b) gender identification and preferences may not meaningfully differ before and after social transitions.
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Guidelines for psychological practice with transgender and gender nonconforming people
Article
  • Dec 2015
In 2015, the American Psychological Association adopted Guidelines for Psychological Practice with Transgender and Gender Nonconforming Clients in order to describe affirmative psychological practice with transgender and gender nonconforming (TGNC) clients. There are 16 guidelines in this document that guide TGNC-affirmative psychological practice across the lifespan, from TGNC children to older adults. The Guidelines are organized into five clusters: (a) foundational knowledge and awareness; (b) stigma, discrimination, and barriers to care; (c) lifespan development; (d) assessment, therapy, and intervention; and (e) research, education, and training. In addition, the guidelines provide attention to TGNC people across a range of gender and racial/ethnic identities. The psychological practice guidelines also attend to issues of research and how psychologists may address the many social inequities TGNC people experience.
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Gender Identity Disorder in Childhood: Inconclusive Advice to Parents
Article
  • Jan 2009
For purposes of this essay, let's invent a contemporary American child named William Lee. William is five years old and, as far as anyone can tell, his body is that of a typical male. But William has long acted in a fashion more typical of girls: he likes to play with "girl" toys like Barbie dolls and My Little Pony; he strongly prefers playing with girls to playing with boys; and he likes to dress up like a conventionally pretty woman, in pumps and dresses, with jewelry and make-up. He increasingly insists he is really a girl and indicates a belief—or a desperate hope—that he will grow up to be a woman. He wants to be called "Julie" and to go to school as Julie. He exhibits what psychologists call gender dysphoria. This stresses out his parents; it is not easy to have a child who challenges social norms, especially norms about gender. If William's parents are not living in a media-free universe, they will know that there are two basic models of thought about what they should do. One, which I'll call the therapeutic model, maintains that William is showing all the signs of gender identity disorder (GID) and that he should be treated by a mental health professional. Or rather, his family should be treated by mental health professionals because, according to the typical contemporary therapeutic perspective, William needs—and lacks—a family that is functioning well psychologically and emotionally. If his mother is depressed or clingy, if his father is physically or emotionally absent, if his parents' marriage is a stressful mess, William is going to keep suffering from gender role confusion, and secondarily from the anger, shame, disappointment, anxiety, and guilt that his parents may exhibit in response. Although the therapeutic model does not point to a single cause of GID, it does see familial dysfunction as an aggravating factor in virtually all cases. Under the therapeutic model, mental health professionals will attend to the relevant family members—particularly William and his parents—and will try to help move William toward a less stressful, more sustainable family environment and gender identity. William will be given gender-neutral toys to replace his Barbie and My Little Pony and will, ideally, be led to develop friendships with other boys—not boys of the rough-and-tumble, army-toy-obsessed type, since William will never relate well to those boys, but boys of the calmer, gentler variety. William will implicitly learn that he can be a boy without having to be aggressive and competitive. As part of the new family discipline, William's mother and father will learn to act like a loving mother and father should, and William will not be allowed to go to school as a girl or to otherwise pretend he is a girl. Thus, the therapeutic approach assumes that William's desire to grow up as a woman represents a kind of problematic fantasy and that, with the right interventions, it can be made to dissipate.1 Evidence that this approach makes GID dissipate is lacking. The second model of thought, which I'll call the accommodation model, presumes that there is nothing wrong with William—or rather, Julie—and nothing wrong with the Lee family, either, except perhaps the largely unnecessary suffering they experience from failing to understand that William really is Julie. According to this model—but not according to any strong scientific evidence—Julie was born with a female brain in a male body. The problem is not the child, nor the family, but the culture, and so the culture must learn to accommodate Julie as she grows to become a woman. The role of medicine, according to the accommodation model, is not to "resolve" Julie's "gender identity disorder," but to provide her, when the time comes, with the hormones and surgeries she will need to make her body into what it should have always been and with the psychological support to help cope with a hostile world.2 Now, if the Lees were to ask me, "What should we do?" I honestly would not know what approach to suggest. But I do...
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