Dr. Ken Zucker
© Jim Ross
Dr. Ken Zucker’s approach made him a polarizing figure in an emotional debate about how to best treat children and teenagers not so easily pushed back into one box or the other.
Gender dysphoric children who are treated using a "watchful waiting" approach largely desist, no longer identify as transgender as adults, and accept their bodies as they are. Those who are subjected to medical intervention do not.

Last month a new chapter was opened in the debate on childhood desistance with the publication of a new article in the International Journal of Transgenderism by a group of transgender-affirming activists and clinicians headed by Julia Temple Newhook. Desistance is when children who are diagnosed as gender dysphoric by medical practitioners go on to accept their bodies and do not end up identifying as transgender once they have passed through puberty. The article questions the exceedingly high rates of desistance reported by previous studies.

Kenneth Zucker's rebuttal, "The myth of persistence," is a brilliant riposte. Zucker, a psychologist and clinical lead from 1981 to 2015 at the Child Youth and Family Gender Identity Clinic (GIC), Center for Addiction and Mental Health (CAMH), is an internationally renowned specialist in the field of gender dysphoria and gender-identity development as well as the editor of the journal Archives of Sexual Behavior. The American Psychiatric Association named Zucker to be the head of the Sexual and Gender Identity Disorders group in 2008 for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM-5, and he is a member of the World Professional Association for Transgender Health (WPATH). In short, Zucker is a professionally trained psychologist with a profound expertise in gender dysphoria and the intricacies involved with childhood gender identity disorder (GID) diagnosis (which was reclassified as Gender Dysphoria under the DSM-5).

One of Zucker's specialties is childhood desistance. His moderate approach to treating gender dysphoric children-which I will describe in more detail below - eventually ended his time at CAMH in December 2015. Trans activists spearheaded a successful campaign to have Zucker terminated following what Jesse Singal refers to as a "show trial."

Zucker's Response

But Zucker is not staying silent. In his response to the new article, Zucker calls attention to Temple Newhook's obfuscation of the effects of socially transitioning of pre-pubescent children. He writes:
I would hypothesize that when more follow-up data of children who socially transition prior to puberty become available, the persistence rate will be extremely high. This is not a value judgment-it is simply an empirical prediction . . . parents who support, implement, or encourage a gender social transition (and clinicians who recommend one) are implementing a psychosocial treatment that will increase the odds of long-term persistence.
Taking the "desistance myth" and inverting it perfectly, Zucker shows how the Temple Newhook commentary speaks against desistance by pushing social transition:
Temple Newhook et al. (2018) go on to state that "It is important to acknowledge that discouraging social transition [with reference to the Dutch team's putative therapeutic approach] is itself an intervention with the potential to impact research findings . . ." Fair enough. But Temple Newhook et al. (2018) curiously suppress the inverse: encouraging social transition is itself an intervention with the potential to impact findings. I find this omission astonishing.
Zucker effectively debunks the article, which reads more like a policy paper, not any sort of objective "critical commentary." He even goes so far as to accuse the researchers of engaging in a tacit form of suppression of research on this subject.
Although I agree it should not be the only metric for understanding the needs of children with a diagnosis of gender dysphoria, the implicit message is something like this: Research on persistence and desistance should be suppressed: it should just disappear without a trace. This is empirical and intellectual "no platforming" at its worst. I find this ominous, but not surprising.
Such transparent no-platforming of scientific inquiry should be stopped immediately. Such actions create politically motivated propaganda instead of using science to understand the intricacies of childhood gender identity.

Building a False Narrative

Desistance has been at the center of the transgender advocates' fight to have transgender identity publicly accepted as an urgent medical condition. At the same time, these same advocates have pressured clinicians to remove the stigma of its psychiatric diagnosis in order to create a social acceptance of the idea that "gender" is truly biological and that "sex" is a social construct. Stunningly anti-scientific rhetoric like this is taking as its hostage the bodies and lives of children in order to prove the point that children are "born transgender." This assertion is a self-fulfilling prophecy involving a domino effect of parents and clinicians who are effectively engaging in Munchausen syndrome by proxy (MSbP).

This new article isn't the first one to question high rates of desistance. In 2016, transgender advocate Brynn Tannehill wrote in the Huffington Post about the "desistance myth," attempting to discredit a dozen studies that demonstrate that a majority of children identifying as transgender cease do to so as they enter adulthood. Tannehill believes that desistance is a fiction "built upon bad statistics, bad science, homophobia and transphobia." Yet Tannehill never defines these terms, nor does she validate these accusations with any proof. Even so, this false narrative - that desistance is a myth - has become part of the transgender lobby's push to medicalize gender non-conforming children.

Transgender discourse advances the notion of the "true transgender" by accepting all the signs of gender non-conformity as unmistakable signs of being transgender - at least until they cease. Then, suddenly, people like Tannehill dismiss the child's gender non-conformity, claiming that these trans-identifying children were never really transgender in the first place. Why do they care so much? Well, if the child desists and is allowed to accept his or her sexed body, this poses a threat to the trans narrative, especially since no single human ever conforms to all the gender stereotypes of either sex. In short, everyone is gender non-binary and potentially a candidate for a transgender diagnosis.

Tannehill's claims about desistance are steeped in cherry-picked studies that constantly shift the goalposts of diagnostic measurement. The first assertion is that previous research did not differentiate between children with persistent gender dysphoria who socially transitioned and, as Tannehill states, those "kids who just acted more masculine or feminine than their birth sex and culture allowed for." While Tannehill is correct in making this observation, the problem is that, as I later demonstrate, one of the diagnostic factors in gender dysphoria is acting more masculine or feminine than the subject's birth sex.

This critique refers to a qualitative 2011 study by Thomas Steensma which concludes that 84 percent of children desist. Tannehill then goes on to cite Steensma's quantitative follow-up study published in 2013, claiming that it contradicts this finding. It doesn't. Steensma's later study merely shows that the "intensity of early [gender dysphoria] appears to be an important predictor of persistence of [gender dysphoria]."

Then, Tannehill tries to undermine Steensma's study due to the inclusion of twenty-eight non-responders in the desistance group for follow-up interviews. In fact, the study assumed that this group were all desisters for clear and cogent reasons and states so quite clearly. Nothing was hidden. Tannehill is also incorrect in asserting that the number of gender dysphoric children was never known in the Dutch study. This was not only a known quantity, but it was well documented using the then-current diagnostic criteria.

Other critics of Steensma's study have since rescinded their claims. New York Magazine writer Jesse Singal, for example, wrote a correction to his 2016 piece on desistance in Medium earlier this spring, rectifying his earlier misinterpretation of the Steensma's study.

Watchful Waiting

When it comes to the diagnoses and treatment of children with gender dysphoria, there are two fundamentally different approaches: transgender-affirmation and non-intervention.

Diane Ehrensaft, Director of Mental Health at San Francisco's Child and Adolescent Gender Center, advocates the transgender-affirmative approach, all the while downplaying the effects of puberty suppression, even the cost of sterilizing children. She contends that children as young as one year of age are capable of announcing they are transgender, even before they can speak. Ehrensaft gives the following examples of transgender identification in small children: a toddler ripping out her barrettes, a one-year-old girl saying "I boy," or a one-year-old unsnapping his onesies. Even without any specialist training, the ludicrous nature of such interpretations is immediately apparent. Yet Ehrensaft is uncritically praised in liberal media.

Non-intervention or "watchful waiting" is the more moderate - yet somehow controversial - approach that Kenneth Zucker upholds. His view is that most cases of childhood gender dysphoria will resolve themselves over time. His approach aims at helping children feel comfortable in their own bodies. However, many transgender activists view Zucker's "watch and wait" approach as a form of gatekeeping the true transgender child.

Zucker's approach is the prevailing standard of care in countries like the United Kingdom and Australia. It allows the child to avoid a lifetime of medicalizing the body (accompanied by sterilization and other health complications). However, the American Psychological Association (APA) and the World Professional Association for Transgender Health (WPATH) have turned the tables here. The non-interventionist approach is now framed by these two organizations as an intervention that pushes the child toward suicide and stigmatization. The 2011 WPATH Standards of Care states that:
Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization. As the level of gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al., 2010), withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents.
Just as Zucker has been attacked for allegedly engaging in conversion therapy and abuse of children by allowing them the time and space to desist, the APA and WPATH have framed "watchful waiting" and desistance as "withholding treatment." Both organizations maintain that there is no preferred outcome and that prolonging the medicalization of the body is to behave unethically. Yet these two professional associations still push gender dysphoric children toward persistence by framing anything but trans-affirmation as "harm."

Zucker is not alone in questioning the medical transition of children before or during puberty. In the UK, Dr Bernadette Wren, consultant clinical psychologist at the Gender Identity Development Service (GIDS) at the Tavistock Centre in London, urges caution in rushing a child through medical transition at younger ages than ever before:
There is increasing concern about puberty suppression and the risks and uncertain outcomes. They may affect gender identity development by increasing the likelihood of persistence. We don't know the long-term effects on cognitive development, sex organ development and so on.
And Polly Carmichael, Director of the Gender Identity Development Service Director, states that parents should be engaged in "affirming without confirming" which translates to the "watchful waiting" approach that the GIDS recommends.

The Effect of Childhood "Transgender-Affirmation"

The pressure put on doctors by the transgender lobby to pursue the transgender-affirmative approach is having serious, harmful effects on children. As one UK-based parents organization, TransgenderTrend, explains:
Daily affirmation by trusted adults that a boy is really a girl (or vice versa) is likely to have a self-fulfilling effect and create persistence of a child's belief, as children believe what adults tell them. The created fear of a puberty the child now believes to be the "wrong" one creates the need for puberty blockers.
Medical professionals such as Sahar Sadjadi, a physician and anthropologist, have expressed concerns regarding the growing use of puberty suppression treatments in children diagnosed with gender dysphoria. These children are offered Gonadotropin Releasing Hormone (GnRH) agonists (puberty blockers) at the pre-pubertal stage (ages nine to thirteen) to suppress puberty as the first step in transitioning to the desired sex. Many children are also receiving cross-sex steroid hormones at ages fourteen to sixteen as well. Some practitioners such as Johanna Olson-Kennedy start cross-sex hormones on children as young as twelve years of age. Yet there has been no long-term testing to determine the potential dangers of both hormone blockers and cross-sex hormones on young bodies.

The caution over medical transitioning of children is justified. There is demonstrable evidence that children who are put on puberty blockers do not desist. London's GIDS clinic reports that persistence is
correlated with the commencement of physical interventions such as the hypothalamic blocker (t=.395, p=.007) and no patient within the sample desisted after having started on the hypothalamic blocker. 90.3% of young people who did not commence the blocker desisted.
Another 2010 Dutch study showed that 100% of the children put on puberty blockers went on to receive cross-sex hormone treatment. And while the numbers vary, there is a general consensus among the various studies that anywhere between 60 and 90 percent of children with gender dysphoria who receive no medical interventions desist when they reach adulthood.

In short, children who are treated using a "watchful waiting" approach largely desist, no longer identify as transgender, and accept their bodies. Those who are subjected to medical intervention do not.

It's No Myth

The evidence is clear: the "desistance myth" is no myth. The consistent findings about gender-dysphoria desistance are real, to the chagrin of the more militant transgender advocates. When the evidence is studied, it is clear that the dissemination of the "desistance myth" is an attempt to render scientific truths fictional. It also works to de-emphasize the dangers of social transition that pushes the use of puberty blockers and cross-sex hormones.

The larger question is this: will we continue to make children pay for the identity experiments of adults while vilifying researchers like Kenneth Zucker?

There comes a point when we must accept scientific facts-or face the consequences.
Julian Vigo is a scholar, film-maker, and human rights consultant. Her latest book is Earthquake in Haiti: The Pornography of Poverty and the Politics of Development (2015). She can be reached at: julian.vigo@gmail.com