gender dysphoria

You Should Watch the BBC’s Controversial Documentary on the Gender-Dysphoria Researcher Kenneth Zucker (Updated)

A lot of people don’t realize that there is a genuine scientific debate over how to best help out children with gender dysphoria, or those who feel discomfort — sometimes extremely intense discomfort — with the body they were born into, and who insist they really are, or should be, a member of the other sex. That’s partly because most mainstream journalistic treatments of the subject tell stories that, while inspiring and important, are somewhat straightforward: The child knows from a very young age they were born in the wrong body, the parents (perhaps after a brief period of reflection or resistance) agree, and the kid transitions, blossoming into their true self as a result.

This definitely happens. But a lot of cases of childhood gender dysphoria are far more complicated, and that’s where the debate comes in. Last night the BBC aired an hour-long documentary called Transgender Kids: Who Knows Best? Produced by the filmmaker John Conroy, it is one of the best journalistic accounts yet to fully dive into this subject and all of its messy nuance. The film zeroes in on the controversy surrounding the late-2015 firing of Kenneth Zucker, a leading childhood gender-dysphoria researcher and clinician, and the shutdown of his gender-identity clinic — but it’s really about the broader controversy that has raged over this subject, mostly a bit beyond the attention of mainstream audiences.

Many people are upset the BBC aired the documentary at all — to them, Zucker is a monster who practiced a brutal form of “conversion therapy” in which he tried to turn transgender kids cisgender. These and other accusations peppered the negative coverage the documentary received prior to its airing, on sites like PinkNews (“BBC documentary features doctor who tried to ‘cure’ trans kids”), Gay Star News (“There are fears a BBC documentary on trans children will be ‘blatant transphobic propaganda’”), and the Guardian. More than 11,000 people even signed a petition arguing the BBC program “should not be broadcast until reviewed by experts” — experts, it’s safe to say given the content of the petition, who aren’t fans of Zucker.

As Science of Us explained in a series of investigative articles I wrote early last year, the truth about Zucker and his clinic is a lot more complicated. Many of the claims activists have made about him are false or seriously overblown, and the “external review” that led to his firing commissioned by the hospital which oversaw his clinic, Toronto’s Centre for Addiction and Mental Health, was absolutely riddled with errors and falsehoods. CAMH itself quickly decided it couldn’t stand by the review it had commissioned; after we reported that the single most damning allegation in the review was completely false, CAMH yanked the document off its website entirely, replacing it with a toned down “summary.” Zucker has since sued CAMH for releasing what he and his lawyer claim was a defamatory report, and that suit is ongoing.

So it’s a good thing BBC didn’t listen to those claiming this documentary shouldn’t have run. As it turns out, it’s an informative, sophisticated, and generally fair treatment of an incredibly complex and fraught subject. People should watch it (it’s unavailable to stream in the U.S., but apparently there are browser-extension workarounds), and here are the key reasons why:

The viewer hears a lot from Kenneth Zucker himself. During much of this controversy, Zucker has been more of a character in a movie than a real-life human being, in part because he has been generally silent (sometimes for legal reasons). To those who were happy his clinic was shuttered, he was a villain — a reminder of a darker, less enlightened time in which trans people were pathologized and brutalized. To those who were unhappy the clinic was closed, he was a martyr — the victim of an activist campaign to unfairly discredit him.

What’s nice about Who Knows Best? is that Zucker gets a lot of screen time simply explaining his belief that gender dysphoria can have a lot of causes, and that it’s an oversimplification to assume transition is the best approach when someone is suffering from its effects. Obviously people are going to arrive at this documentary with preconceptions, and obviously they are going to interpret his words differently — but given that many of the key claims against him were false, it’s useful to see a journalistic treatment of this episode that covers his actual beliefs about gender dysphoria and trans kids rather than a caricatured version of them.

The documentary nicely covers the debate over the question of what gender dysphoria ‘is.’ Some clinicians and activists hold that gender dysphoria is an important signal or clue about someone’s innermost, stable identity — namely, that there is mismatch between their gender identity and their natal biological sex. This means that until the person transitions to an extent they are comfortable with (which can be anything from a social transition to hormones to surgery), they will never feel okay with who they are. From this point of view, asking a gender-dysphoric patient questions geared at better understanding the roots of their gender dysphoria is, from a clinical standpoint, about as productive as trying to figure out “why” a patient is gay — and just as offensive. “Transgender activists are now campaigning to stop gender dysphori[c] children being considered a medical or psychiatric problem,” notes Conroy at one point. Then he quotes Hershel Russell, one of the activists I interviewed in my piece who helped get Zucker’s clinic shut down: “It’s not about mental health, so why does it belong in a mental-health institution?” says Russell. “This is one of the things we’re hearing more and more emphatically from families who have gender-diverse kids — ‘We don’t want mental-health assistance … We don’t want to see the psychologist, we don’t want to see the psychiatrist.’”

This belief that gender dysphoria shouldn’t be seen as a psychological issue helped motivate the shuttering of Zucker’s clinic. One of the most striking passages from the rescinded external review, in fact, contained an argument against psychologists and psychiatrists doing therapy at all when it came to gender-dysphoric patients: “The GIC’s therapeutic focus on ‘understanding why’ someone is the way they are, is described by former patients, current therapists of former clients and parents as ‘disturbing’ and ‘harmful,’” the authors of the review noted. “One participant described that being told by a clinician that there is a need for ongoing treatment or assessment to ‘understand why you are the way you are’ is problematic in and of itself.” If it’s problematic to ask why, then it’s impossible to do therapy.

In other words, Zucker got in trouble for believing that gender dysphoria isn’t necessarily a signal of a stable internal identity; rather, he approached it the way he would a psychological symptom like anxiety or depression, by trying to understand whether there might be other causes which are causing it and can be addressed. As Conroy puts it, Zucker “believes that a whole range of psychological issues can manifest themselves in a child’s obsession with changing their gender.” “Taking any behavior in isolation when thinking about gender dysphoria is not the way that I think about it,” Zucker explains. Rather, it’s key to understand a child’s family, life history, and other factors. Gender dysphoria is more complicated than being a signal of a stable underlying identity, in Zucker’s view, especially in light of developmental psychology research which suggests it takes a long time before a child’s gender identity really solidifies in the first place. That said, Zucker did believe that in some cases transition was the best bet, and according to my reporting his clinic never tried to “switch back” a child who had already transitioned (none of the in-depth reporting that has been done on his clinic has found any evidence that he has, despite the frequency of allegations to the contrary). He seems to view transition clinically — as a treatment, in a sense, that offers better outcomes for intensely and persistently dysphoric people than anything else we have.

Who Knows Best? violates the emerging taboo against acknowledging the importance of two groups we don’t hear much from. This is good. The research we have, which isn’t perfect but which is rather convincing, suggests that a solid percentage of kids who experience gender dysphoria “desist” in these feelings, meaning they eventually grow up to be comfortable in the bodies they were born in — they’re more likely to be end up gay or bi than trans. People often criticize the commonly cited “80 percent” figure, and it may well be the true percentage is lower, but experts who follow the literature closely don’t actually find the general idea controversial: There’s a reason the American Psychological Association and SAMHSA and WPATH, the leading professional body for clinicians who work with trans and gender-nonconforming people, all acknowledge in their treatment guidelines that a significant percentage of children with gender dysphoria end up growing out of their gender dysphoria.

Desistance matters hugely to this debate, because it complicates the theory that gender dysphoria is always a mark of a stable, deep-seated identity. So too do the stories of detransitioners, or people who transition, sometimes getting serious hormonal or surgical interventions, and who subsequently transition back after realizing they weren’t really trans — while only a small minority of people who transition transition back, detransitioners often tell troubling stories about how they were told transition was the only option for them, and how other mental-health issues they were dealing with at the time of their transition were simply ignored or attributed to the fact that they hadn’t transitioned yet. Unfortunately, many progressive media outlets have done a poor job covering desistance and detransition. Vice and Vox and ThinkProgress have all written misleading articles falsely claiming that desistance is a “myth” (or close to it), that detransitioners are nothing more than pawns for transphobic bigots to make it harder for people to transition, or both.

Luckily, Who Knows Best? does not fall into this trap. Rather, it offers a balanced approach: Yes, the documentary is full of people who have transitioned, some of them quite young, and who insist that doing so changed — if not saved — their lives. It is vital to acknowledge that for many, many people, transition “works.” They need access to transition services. Conroy’s documentary makes this clear.

But it also presents this controversy in the full complexity it deserves, by including the voices of a desister and a detransitioner as well. Both stories are affecting. The desister was convinced, for years of her childhood, that she was really a boy. Around puberty, that feeling lifted all of a sudden — she said it helped when she found a community of other girls to play baseball with — and now, as an adolescent, she happily identifies as a girl. The detransitioner’s story is darker. At the time her gender dysphoria was at its worst, she explained, “I was struggling with self-harm and had attempted suicide on a number of occasions, and was very much told by the community that if you don’t transition, you will self-harm and you will kill yourself. I became convinced that my options were transition or die.” (The handful of detransitioners I’ve interviewed have told me the same thing, that this is a common message for young gender-questioning people: If you don’t transition you will likely kill yourself.) Eventually she had a double mastectomy, only realizing after the identity that felt truest to her was as a cis lesbian. Today, she regrets having lost her breasts.

Undoubtedly Conroy will receive flak for having included these stories. But they’re important, because they show that while trans people, of course, have a lot at stake in the debate over gender-dysphoric kids, other groups do, too. That’s why this needs to be an informed, intelligent conversation — the kind of conversation “Who Knows Best?” provides.

Update: As if to prove it’s impossible to sustain a reality-based public conversation about the Zucker clinic for any length of time, the morning after Who Knows Best? was broadcast, the BBC Breakfast morning show broadcast a sensationally misleading segment on the subject — one which wrongly implied that Zucker engaged in a variety of abusive practices that he has never even been publicly accused of.

“Now shortly we’ll speak to someone who has received therapy at the same clinic that Kenneth Zucker practiced at,” says co-host Steph McGovern at the top of the segment in question. “But first, here’s a clip from the documentary.” After the clip, the other co-host, Charlie Stayt, introduces the guests, all of whom are opposed to Zucker’s clinic. One of them is Victoria Richardson, a trans activist. “Victoria, if we can start with you first,” says Stayt. “So you went through similar therapy — this is also in Canada. Just explain a little bit about what it was.”

It’s easy to miss the switch, reading it as text, and even easier when watching the program: At the top of the segment, Richardson was a patient “at the same clinic that Kenneth Zucker practiced at.” Just a couple minutes later, she “went through similar therapy,” meaning she wasn’t a patient at Zucker’s clinic. This is, of course, a vitally important distinction. (The segment appears to no longer be available on the BBC’s website, but a Twitter follower uploaded a copy to Google Drive for me.)

“In Ontario, yeah,” replies Richardson to Stayt. “I was in that era. So I had ended up at A&E [an emergency department] when I was 5 years old for trying my own SRS [sexual reassignment surgery], gender confirmation surgery, at which point I was put into reparative therapy.” Richardson goes on to explain that the staff at the reparative clinic demanded that she accept that she was a boy, and that they brutalized her with horrific practices in their attempts to coerce her into renouncing what she felt was her true identity. Among other things, the clinicians threatened her with electroshock therapy if she didn’t comply, and they watched her when she went to the bathroom to make sure she didn’t pee sitting down (which is a common thing for gender-dysphoric natal boys to do). Richardson goes on to explain the long-term effects this treatment had on her and how she overcame them. “So it’s not just a question with right or wrong with a Zucker approach,” she explains, “it’s actually the effect not only on a child, but on society as a whole.”

“It sounds deeply traumatic,” says Stayt at one point. And he’s right, of course: Richardson went through a horrific and unfair experience. But that experience had nothing to do with Zucker. The fact that she was subjected to reparative therapy in Ontario, the same province where Zucker practiced, doesn’t mean Zucker practiced reparative therapy. No one has publicly accused Zucker’s clinic of anything like the treatment Richardson describes in the segment, of threatening patients with electroshock therapy, or of monitoring how they go to the bathroom — such claims weren’t even in the external review that got yanked off the CAMH website due to the fact that it contained at least one major false allegation about Zucker. Rather, Zucker’s clinic doesn’t appear to have engaged in any form of reparative therapy — when children showed up there having already transitioned, he and his staff never tried to “change them back.” Richardson is describing an entirely different universe of practices and then lumping them in, falsely, with the “Zucker approach.”

Of course, to the casual BBC viewer, who has first been told Richardson was a patient at Zucker’s clinic and then that she went through a “similar therapy,” it must be baffling that any of this is the subject of “debate” at all. Who would defend threatening a helpless little kid with electroshock therapy? If that were what Zucker’s clinic had done, there would be no debate, which is what the critics who got him fired based on false and misleading allegations want. The truth, again, is much more complicated. It’s frustrating that the BBC ran such a misleading and potentially defamatory segment — it fell into every trap Who Knows Best? deftly avoided.

The BBC Broadcast a Controversial Documentary on Trans Kids