From the time she could talk, Maggie* has told her parents that she is a boy. She doesn't say, "I want to be a boy." She doesn't say, "I feel like a boy." She says, "I am a boy." She tells her classmates, too. Lately-she's in elementary school now-they've been having debates about it. "Maggie's a boy," one kid said recently, in a not-unfriendly, matter-of-fact sort of way.
"No, you idiot," countered another. "She's a girl. She's wearing pink shoes."
On a recent Tuesday morning, psychologist Kenneth Zucker tells this story at a weekly group supervision meeting, where he reviews cases with his dozen graduate students and postdocs. "As if, 'duh'-it's so obvious," he says, and the room chuckles along with him.
Head of the child and adolescent gender-identity clinic at Toronto's Centre for Addiction and Mental Health, Zucker is one of North America's most widely published experts in the field of transgender and gender-variant11. Gender-variant: (adj) acting in a manner that varies from the stereotypical behavior associated with one’s gender. Because “vari- ant” may connote deviance, the term is being replaced by “gender nonconforming.” children. Since it was established in the mid-1970s, his clinic has assessed more than 600 kids with gender-variant behavior and gender dysphoria-the distress that results from feeling that one's body does not match one's sense of self. He has treated more than 100 of those children.
Given how early dysphoria can emerge in kids like Maggie and how deeply it cuts to the core of who they are, a growing number of therapists, doctors, and parents are advocating an early gender transition: If Maggie says she's a boy, then it's our duty to believe him and treat him as such. Given the very real risks to transgender people who remain in the closet-at one prominent clinic for transgender adolescents and young adults, 20 percent of patients have engaged in cutting or other self-mutilation, and almost 10 percent have attempted suicide-those in this camp say that to deny that Maggie is a boy is to set the child up for a lifetime of repression and pain.
Zucker, on the other hand, believes that girls who say they are boys are not expressing their true identity. Rather, they are confused. Their mismatched gender identity is likely the result of a childhood experience or trauma, or a manifestation of some underlying psychiatric or family problem. The situation will only be made worse, he argues, if parents and teachers encourage it. Zucker's aim, if a family comes in with a kid like Maggie, is to make her more comfortable in her own body: to make her understand that she is a girl.
"We don't know why Maggie mislabeled herself as a boy when she was younger," Zucker says. "Was it because she was in some home day-care thing where she was around a lot of boys?"
One of Zucker's doctoral students has been working with Maggie in play therapy. The student, Julia Vinik, pulls out a drawing that she and Maggie made together. Four stick figures represent a girl who likes to play sports, a girl who likes to play with dolls, a boy who likes to play sports, and a boy who likes to play with dolls. Vinik had asked Maggie which one she was. "She first went to circle the boy," Vinik recounts at the supervision meeting. "And then stopped herself and said, 'Wait a minute. Can you make another one here called tomboy?'
"I asked her, 'What's a tomboy?'
"'It's a girl who likes to do boy things.'
"I said, 'Do you think there's one already here like that?'"
Maggie pointed to the girl who likes sports. "She said, 'Oh yeah, that's a tomboy,'" Vinik tells her colleagues. "And she decided this one over here"-Vinik points to the boy who likes dolls-"would be called a tomgirl." Everyone chuckles. Vinik recounts how Maggie then pointed again to the tomboy. "'OK,' she said, 'This is me.'"
"That was very encouraging," Vinik says. "She didn't see herself as a boy anymore."
This kind of therapy is precisely what worries Zucker's critics. "That looks like psychodynamic free play, but it's really coercive," says Herb Schreier, a San Francisco Bay Area psychiatrist who has worked with children as young as kindergarteners to help facilitate gender transition. Schreier is part of a consortium of some 30 Bay Area psychiatrists, psychologists, and therapists who work with gender-variant children and their families. He's one in a large and growing chorus of voices that accuse Zucker of relying on regressive gender stereotypes and practicing a thinly veiled version of 1950s-style reparative therapy22. Reparative therapy: (noun) any clinical practice that aims to change a gay person's sexual orientation to heterosexual. Also known as conversion therapy, it was widespread in the years homosexuality was considered a mental illness; it is now regarded as unethical since it is both ineffective-not a single peer-reviewed scientific study has demonstrated that orientation can be changed at will-and harmful, since it fosters shame and self-aversion. Still, according to the Southern Poverty Law Center, nearly 70 therapists in 20 states and D.C. currently advertise that they practice conversion therapy. Many are affiliated with fundamentalist Christian groups., which was used to "cure" homosexuality.
"The therapy session starts with an incredible assumption: that these kids have a problem. 'We're trying to figure out what problem you're dealing with that gives you this particular way of being.' It's not a neutral therapy if it starts with that premise," Schreier says. "Any therapy that starts with that assumption is bound to be problematic. In essence, he's asking parents to deny who the kids say they are."
Schreier characterizes Zucker's approach as, "I think we should change them, and this would be for their betterment." To Schreier and his colleagues, this sounds ominously paternalistic. "We would strongly raise the point: Isn't there a downside to be had by denying a child's identity?"
Zucker's peers have written detailed, impassioned critiques of his work and his theories in professional journals-to which he writes detailed rebuttals-and his lectures and panels at professional meetings are often peppered with hostile questions and comments. A quick Google search turns up scathing, profanity-laced takedowns of Zucker and his clinic, including one calling Toronto the "global epicenter for oppression of sex and gender minorities."
"The reason there is such dislike of and distrust for Dr. Zucker in the community is because he holds a position of immense power," says Madeline Deutsch, a Bay Area emergency-room physician specializing in transgender health care. Since he publishes so widely, and edits an influential journal in the field, Zucker's opinions matter. His opinions, she says, "fail to incorporate the very real empiric findings and experiences of other experts in the field, experienced clinicians, and activists … and instead remain focused on attempting to prove his own theories."
Zucker does have a tone-deaf tendency to operate from the lofty perch of academia rather than engaging with communities on the ground. Despite a palpable empathy for his patients when he's with them, in conversation with his colleagues he slots patients into scientific categories and describes their lives in psych-speak. Zucker doesn't use the language or terminology that members of the trans community use to talk about themselves; instead, he refers to "homosexual persisters" and "homosexual desisters," by which he means boys who grow up to be trans women and boys who grow up to be men. In meetings with his staff, he insists on referring to his patients-even those who have already begun to transition-by the pronouns of their birth sex. In an e-mail to me, he referred to a young patient by using that patient's preferred gender pronouns in scare quotes: "… help us understand 'his' insistence/belief that 'he' 'is' a boy."
The criticism of Zucker only became fiercer in 2008 when the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual, or DSM-psychiatrists' bible of mental disorders-announced that for the manual's upcoming fifth edition, Zucker would chair the committee to revise the section on Sexual and Gender Identity Disorders. The National Gay and Lesbian Task Force issued a statement calling the appointment "extremely disappointing and disturbing." In The Nation, Peter Rothberg called Zucker "retrograde" and encouraged readers to sign a petition opposing him. More than 9,000 people did. Circulated by the transgender community, the petition asked for Zucker's resignation or removal, declaring that "in order to have any credibility in the field of gender identity, the DSM must not include discounted theories or junk science."
The DSM is the primary tool by which psychiatrists and other mental-health professionals standardize, diagnose-and, crucially, bill insurance companies for-the mental-health problems their patients suffer. As the authoritative psychiatric guide for the National Institute of Mental Health, pharmaceutical companies, and other national and international organizations, the book's practical and cultural significance is hard to overstate.
It's also a historically loaded book for the LGBT community. Until 1973, homosexuality was listed as a mental disorder, and it was under the guise of treating it as an illness that many psychiatrists offered reparative therapy. (The diagnosis also meant that gay psychiatrists, psychologists, and psychoanalysts were forced to remain closeted in order to practice.) It wasn't until a huge push by the gay community-and with fierce resistance by many association members-that the diagnosis was removed.
Transgender advocates and activists say that in a generation we will see the diagnosis of gender identity disorder as equally ridiculous. "Being differently gendered is not a psychiatric problem," says Lisa Mottet, director of the Transgender Civil Rights Project at the National Gay and Lesbian Task Force. "It's a human variation." Or, as the University of California, San Francisco, child psychologist Diane Ehrensaft writes in a recent journal article, "As with left-handed children, who are also a small minority of the population, I believe these children who experience this discord [between their bodies and their sense of self] are not abnormal, they simply vary from the norm." Ehrensaft and Zucker have sparred publicly on this issue. Gender identity disorder in children, or GIDC, is "a diagnosis and implied treatment that pathologizes perfectly healthy children who are simply expressing their authentic gender identity," Ehrensaft writes. "The job of the clinician is not to ward off a transgender outcome, but to facilitate the child's authentic gender journey."
At the heart of the debate between Zucker and his critics lie fundamental questions: Are transgender people "born this way," as people who support early gender transition argue? Or is gender a set of learned behaviors, a mix of "biological factors, psychosocial factors, social cognition," and other mechanisms, as Zucker argues?
For Zucker, these questions are partly matters of scientific and intellectual curiosity. But for gender-variant kids, the stakes are much higher: If being transgender is part of one's hard wiring, then to try to change kids like Maggie would be impossible at best, psychologically destructive at worst. Therapy that aims to change gay people's sexual orientation is condemned as harmful and unethical by a slew of major professional organizations, including the American Psychiatric Association. Gay people subjected to conversion therapy as children have higher rates than their counterparts of depression, anxiety, and self-harm, including suicide.
Critics say that Zucker's approach will have the same effect on trans kids: It will teach them from an early age that a fundamental part of their identity is wrong. What's more, if these kids aren't truly changed-if they simply learn to hide their identity until they are old enough to make autonomous decisions-then aside from the psychological harm caused by this hiding are issues of physical comfort and safety: Those who transition later in life have a harder time being perceived as the gender they identify with and require many more surgeries.
The argument about the origin of our gender identity has been simmering for decades, particularly among feminist theorists. On one side is the view called "social constructionism": the idea that everything we know about what it means to be a man and a woman is something we learn, through subtle cues and explicit lessons, from our parents, TV, the world around us. The flip side is "essentialism," a word radical feminists have used derisively, snubbing their noses at the idea that there might be something hardwired into women's brains to make them more inclined to like lipstick and less inclined to fix a leaky faucet.
It's not just the drag queens, social constructionists argue; we're all in drag, performing our gender as surely as RuPaul does. Gender is "a kind of persistent impersonation that passes as the real," writes social constructionist Judith Butler in her seminal 1990 work, Gender Trouble. Or, as Simone de Beauvoir famously said, "One is not born a woman, but, rather, becomes a woman."
To embrace social constructionism means that there is no "born this way," no born any way, except with a body around which the world begins spinning meaning and symbolism even before we are born. (See: blue nurseries, "it's a girl" balloons, and, the latest, "gender reveal parties.") So to hear the politically progressive, trans-positive community embrace essentialism, and then to hear Zucker, the man they accuse of being retrograde, embrace social constructionism is enough to make one's head spin. Until you remember the gay gene.
When, in the early 1990s, geneticists discovered a relationship between homosexuality and certain genetic markers, many members of the gay community embraced these findings, using them as the basis of a new push for acceptance. If we were born this way, the argument went, then you can't hold it against us; we can't help it. Indeed, the work of these geneticists was read from the floors of many a senate chamber, and the "gay gene" was part of what turned the tide of public opinion in favor of compassion and nondiscrimination.
But this emphasis on biological determinism is discomfiting. First of all, even if gay folks weren't born this way-even if they "learn" to be gay or develop the identity over time as a result of complex social processes-why would that make it any easier to change their identities? Second, there's something apologetic about the whole premise that the world should accept gay people because they can't help being gay. The unspoken part two of that argument is that if they could change, they surely would-or should.
It's now widely accepted that no amount of therapy can change a person's sexual orientation, and Zucker says he would not try to do so. But gender identity and sexual orientation are not the same thing. Sexual orientation is a matter of whom you are sexually attracted to. Gender identity is more elemental: It's who you feel in your bones that you are. Zucker's critics say that most transgender children know precisely who they are. "These kids come out very early and say, 'Mommy, I'm in the wrong body,'" Schreier says.
Sure, Zucker says, but that doesn't make it a fait accompli. Children's gender identity is plastic and malleable, he says, shaped and formed by the world around them, by the feedback they receive, by the emotional resonance of the things they do, by their personal relationships, even by the clothes they wear. If this is true, then it should be possible for these kids to change.
Zucker is quick to point out that his clinic has referred more than 60 kids for the medical interventions required to begin their transitions; a paper he wrote on the subject was, in fact, the first such study published in North America. By age 11 or 12, he concedes, trans kids are typically "locked in" to their gender identity, and for them, "I very much support that pathway, because I think that is going to help them have a better quality of life." But it's different, he says, for younger kids. "If a child can grow up and feel comfortable in his or her own skin that matches their birth sex," Zucker argues, "then you avoid the complexity of fairly serious surgical treatments. Penectomy and castration are not the same thing as having mild and minor cosmetic surgery. Lifelong hormonal therapy. It's serious."
It's not just the medical interventions, he says. "One could argue, like many things, that there's a strong value component to it. Holding everything else constant, at least at this point in time it's relatively easier to grow up with a gender identity that matches your birth sex."
That may be true. But for how much longer? Society is changing. The alphabet soup of LGB-lesbian, gay, bisexual-has, bit by bit, broadened, first to include "T" for transgender, and, more recently, to become the unwieldy LGBTQQIAA, which includes people who identify as queer, questioning, intersex,3
3. Intersex: (noun or adj) someone whose genitals, chromosomes, hormonal systems-or some combination of these-don't fit the standard parameters for male or female. "Intersex" replaced the outdated and derogative term "hermaphrodite"; the more culturally neutral term is "disorder of sex development," or DSD. As many as 1 in 100 people have a DSD like Turner Syndrome, androgen or estrogen insensitivity syndrome, and Klinefelter's (or XXY) Syndrome.
4. Genderqueer: (adj) used to describe someone whose gender identity or gender expression blurs the line between masculine and feminine or rejects the binary of male and female altogether.
5. Bi-gender: (adj) identifying or presenting as female at some times and male at other times.
6. Agender: (adj) identifying as having no gender, which is known as “neutrois.” Agender people often prefer the pronoun “they” to the singular “he” or “she.”
7. Two Spirit: (noun) a traditional American Indian term for people who occupy a third gender category. Also known as berdaches, Two Spirits were typically genetic/physical men who did women’s work, cross-dressed, and formed relationships with non-berdache men; some tribes had additional gender categories for women who hunted and acted as warriors.
asexual, and ally. "Transgender," usually used broadly to encompass a range of gender-variant people (including transsexuals, the word traditionally used to describe people who make a full medical change to the "opposite" sex), is bursting at the seams as 21st-century gender identities proliferate. There are people who identify as genderqueer,4 bi-gender,5 agender,6 Two Spirit.7 There are trans people who choose surgery but no hormones, hormones but no surgery, or no medical interventions at all.
To the extent that Zucker builds upon this gender diversity by encouraging kids to widen their sense of what their gender can be-by helping kids feel comfortable as "tomboys" or "tomgirls," or other gender inventions in between-he furthers the worthy cause of making the two traditional boxes bigger or helping to break them down, rather than stuffing kids inside them. At the same time, Zucker knows that the more society moves in this direction, the more his work becomes obsolete. "One could argue that with the emergence of gender-transition subculture, Western culture in some ways now has a third gender category," Zucker says.
"Gender-transition subculture" is Zucker's mildly dismissive go-to term for the approach of people like Schreier and Ehrensaft who advocate allowing gender transition for very young children in certain cases. "One could argue" is also a favorite formulation-it's an easy way to distance himself from potentially controversial statements. He's not necessarily arguing this, it seems to imply-just that one could. "It could be that in the next 10, 15 years, there will be more and more acceptance of extremely gender-variant kids, and the reaction will be, 'Oh, he's just a transgender.' And we'll see. If there is this greater acceptance, the argument that [not being transgender] is an easier pathway may be harder to make."
Alex exemplifies the growing acceptance of gender diversity. Born with a girl's body six years ago, Alex is "just a cool little kid, really," says his mom, Andie. At school, he is a boy: boy clothes, boy hair, boy pronouns. "And at home, we respectfully-somewhat faking it, because I'm not 100 percent there-we treat Alex as a boy."
Andie knew from the time Alex was a toddler that something was different. "I noticed that Alex gravitated towards playing with the boys," Andie recalls. "She* preferred to do the boy things." At three, Alex refused to put on a girl's bathing suit. She refused to wear dresses, then she refused to wear skirts, and then "it got down to, if there was a little pleat that you wouldn't even notice on the shoulder," Alex would refuse to put it on. Still, Andie was herself a tomboy as a kid, so she mostly let Alex dress how she wanted and didn't think much of it.
About halfway through Alex's kindergarten year, Andie's usually easygoing, happy kid seemed anxious and irritable. She discovered that Alex was polling kids at school: "Do you think I'm a boy or a girl?"
"And I go," Andie says, "'Why are you doing that? You're obviously a tomboy.'
"'Well, I want to be a boy.'
"I'm like, 'Well, you're not a boy.' I had no idea, really, about issues like that."
She went to talk to Alex's teacher, who had noticed a similar change in Alex's behavior. "It's almost like she doesn't know who to play with or what to do," the teacher said. "Have you heard of gender dysphoria?"
Andie took a few weeks to think it over, do some research, and talk to her family. Then she called the principal. "Listen," she said. "Alex thinks she's a boy. So we need to somehow make Alex comfortable at school." The principal said, "OK. I'll make some calls."
It was that easy. But it won't necessarily stay easy.
In five or six years, as boys his age find their voices deepening and their upper lips darkening, Alex will begin to develop breasts and hips. He will get his period. Unless, that is, he begins the long journey of medical interventions that will allow him to stay a boy.
First there are hormone blockers, medications that are used to suppress puberty in one's birth sex. These are fully reversible-an adolescent who stops taking them will begin puberty in their birth sex-and are meant to buy the child some time to mature enough before he or she makes irreversible choices.
For adolescents who continue their transition, hormone blockers also help to prevent later surgeries; a boy like Alex who never grows breasts in the first place need not have them removed. By around age 16, Alex could start on cross-sex hormones, which would deepen his voice, cause hair to grow on his face and his chest, and prompt the other hormonal changes of a typical teenage boy. Genital surgery-a much less common choice in transgender men since the surgical techniques are less advanced than they are for transgender women-can happen as early as age 18.
Andie admits that she would prefer Alex not go down this path. Not because she has a problem with him being transgender but because she hates giving her kids medication. "I don't care what drug it is," she says. "I don't like the thought of kids putting drugs in their body. But I also want a kid that's alive," rather than at high risk for suicide. "My other little guy has epilepsy. So he has to take high levels of meds to keep his body safe. I'm going to try to look at this the same way. If that's what Alex needs to feel secure, that's what Alex will have."
Andie brought Alex to Zucker's clinic after Alex had already made his gender transition at school. She Googled Zucker only once her family had gotten to know him and was shocked by the criticism she read; she says he has been supportive of her approach and has never encouraged her to treat Alex like a girl.
"One starts, more or less, with where a family is at," Zucker says. "I offered for us to see Alex in individual therapy to get a further and more in-depth understanding of Alex's internal, subjective world. I think that both Andie and I are watching to see if Alex will develop any alternative ways of how Alex currently experiences 'his' gender." Zucker stops short of saying that fostering these alternative ways is his aim. "It would have to be their aim," he says of Alex's family. "It's not my job to impose it."
With encouragement from Zucker, Andie reminds Alex that he could grow up to be anything-a girl, a boy, or anything in between-and tries to encourage him in any case to love his body. "My goal is for Alex," she says, "to feel good about herself, and to have the tools she needs to be able to say, 'Hey, this is who I am.' I have no right to tell somebody that they're something that they're not."
Alex plays on a local boys' hockey team; his dad volunteered to coach so Alex would feel more comfortable playing. He goes snowboarding and dirt biking with his mom. In advance of Thanksgiving, Andie called her own mom-who is slowly coming around-to lay out the ground rules for their family dinner: "'Refer to Alex as he, or I'm not OK with it.'" Andie's family complied.
Andie doesn't want Alex to talk to reporters, so I didn't get to meet him. But as Andie was gathering him to leave after his therapy session, I couldn't help but see his little snowboarder jacket and his mop of dark hair out of the corner of my eye. Zucker was bending down, hands on his knees, to look at the newly loose tooth Alex was excited to show off. "Now what," Zucker said, with grandfatherly excitement, "do we have here?"
The industrial sign marking the bathroom in Zucker's clinic is all-inclusive, with a hybrid male-female symbol indicating a myriad of gender possibilities. Zucker's office door is papered with colorful marker drawings of smiling cartoon figures, trees, flowers, and houses. "Thank you!" several of them read, in rainbow letters. "I enjoyed being with you!" reads one. "Thanks for helping me," reads another.
While countless individual therapists work with transgender kids on an individual basis, there are only about a dozen clinics for transgender kids and adolescents at major medical centers in the Western world. Most clinics take a "watchful waiting" approach. They advise against an early gender transition, instead counseling parents to find "a sensible middle-of-the-road approach," as one clinic describes it-neither encouraging nor actively discouraging. A few, like Herb Schreier's Bay Area group, will-in extreme cases-help children make an early gender transition. But none attempt to actively prevent transsexuality as Zucker does.
With short silver hair and beard, mismatched belt and shoes, and a perpetual pen stain on his shirt pocket, Zucker looks, and has the demeanor of, the workaholic grandfather that he is. The first thing you notice, talking to him, is his voice: Its deep basso timbre rumbles in a blend of Canadian and Midwestern accents. He has a dry sense of humor and a penchant for deadpan teasing that at times catches even friends off guard. "One of the things I told everybody that they really needed to think about today," Zucker said at the opening of his Tuesday-morning clinic-supervision meeting, "was what to wear." He never even broke a smile, but he was (mostly) joking that everyone should try to impress the visiting journalist. "I wore my best shirt and got here early and then"-he pointed to that day's pen stain-"put my blue pen in upside down."
Zucker grew up in suburban Skokie, Illinois, the older of two kids (his sister Barbara, he points out with an ironic smile, is nicknamed Barbie). His "intellectual, left--winger" Jewish parents were victims of McCarthy-era witch hunting-his dad lost several jobs, Zucker says, because he refused to "rat on his Commie friends." In Zucker's telling, they ultimately decided that "for the sake of their children, they needed to become conformist," and they moved to the suburbs to "disappear from the scene-trapped in middle-class consumer subculture for the good of the cause."
Born in 1950, Zucker came of age at the dawn of a different kind of scene. During our time together, Zucker happened to mention, in passing, a cow that stuck its head into his VW van at Woodstock and a summer he spent in Cambridge, Massachusetts, driving "the People's Bus," but when I pressed for more details, he would say only, "We'll leave it at that." What he will say is that he emerged from those times with a distaste for dogmatism and a sense that "maybe hiding in science is safer than fighting political, dogmatic battles."
He regards his detractors as dogmatists. "I would say one thing that does bug me about some of the debates in this area is people's supreme confidence that gender is a complete social construction, or that gender is completely biologically determined, or that this can all be explained by specific psychodynamic mechanisms." Zucker calls himself a "gender agnostic." He thinks that gender emerges as a mix of these elements, but he feels that the mechanisms are still far from clear.
His fascination with gender identities began while Zucker was a psychology graduate student and he read a book by UCLA psychiatrist Richard Green, whose pioneering work in the emerging field of sexology laid the groundwork for Zucker's practice today. Green's 1974 book Sexual Identity Conflict in Children and Adults was the first longitudinal, scientific description of a cohort of "feminine boys" and included transcripts of Green's sessions with these boys and their families. Zucker was intrigued. "Identity is such a core part of what it means to be human," he says, "and gender identity is such a core aspect of the self that it's inherently interesting."
When Green began his "Feminine Boy Project," the research study on which his book (and The Sissy Boy Syndrome, a subsequent book) is based, his aim was to describe the "natural history" of transsexuals. He thought that by studying these boys early in life, he could watch their cross-gender identities unfold, like caterpillars in chrysalises. That's not what happened. Green's most striking finding was that only one of his 44 "sissy boys" turned out to be transsexual. Most of them-75 percent-grew up to be gay men. Subsequent studies led to similar findings: Gender-bending kids who grow up to be transsexual adults are the exception, not the rule.
This may be changing. Given increasing visibility and acceptance (think Chaz Bono, Transamerica, RuPaul), more and more people who challenge traditional gender stereotypes (from butch women to "sissy boys" to those whose gender identity is more fluid) feel empowered to take on the mantle of genderqueer or transgender-and, in some cases, to seek medical attention. Recent studies indicate that the number of people seeking treatment at gender clinics in the United Kingdom and Canada has risen sharply in the last five years.
Does this mean that Green's numbers are an under-estimate-that with greater parental and societal acceptance more of his "sissy boys" would have grown up to be transgender? New data might help to answer this question. During the time I was in Toronto, Zucker talked a lot about a scholarly paper currently under review by a group of well-respected Dutch clinicians and researchers. In their group, kids like Alex who underwent an early gender transition were more likely than other gender-variant kids to be "persisters"-that is, to continue to identify as the opposite sex into adolescence and early adulthood.
Because the Dutch data seem to support Zucker's theory-that the way parents respond to a child's early gender dysphoria has an impact on whether it persists-the paper feels, to him, like something of a vindication. Herb Schreier sees the same data and reaches the opposite conclusion: The kids who transition early, he says, are the ones who identified themselves vocally and from an early age-the ones who were clearly going to persist anyway.
In the vast majority of these kids, however, gender dysphoria resolves on its own. In light of that, I asked Zucker, how do you know your interventions are working? He was honest: "I don't think we know."
As a child, Karl Bryant, now a sociologist at the State University of New York, New Paltz, "desperately wanted to be a girl, and I expressed it often," he recalls. But this was the early 1960s-there was no early gender transition subculture-and Bryant was growing up in a small farming town about an hour from Los Angeles. So he became one of the earliest subjects of Richard Green's Feminine Boy Project. He was enrolled in the "treatment" arm and had sessions with Green every other week.
Bryant liked Green and remembers trying hard to please him. "I knew at a certain point what the expectation was," he recalls. Bryant wrote his Ph.D. dissertation on the politics of gender identity disorder, and he recounts the story in the introduction. "I remember occasionally trying to muster the kinds of masculine behaviors that I knew I was supposed to naturally express," he writes. "Ultimately I learned to hide as best I could my feminine behaviors and identifications."
Bryant grew up to be a happy, successful gay man, and he refuses to speculate how, or whether, things would have been different if his parents had allowed him to follow his fervent childhood wish to be a girl. But his "happy outcome," he says, is despite, not because of, Green's interventions. The study, he says, gave him the lasting impression that "the people closest to me, and that I trusted the most, disapproved of me in some profound way." He says it's hard to overstate the harm that such knowledge can inflict: "The study and the therapy that I received made me feel that I was wrong, that something about me at my core was bad, and instilled in me a sense of shame that stayed with me for a long time afterward."
Zucker acknowledges "more similarities than differences" between his treatment and Green's. "The UCLA group, Richard's group, certainly had a big impact on me," Zucker says. That said, developmental and cognitive psychology are much more sophisticated now than they were then, and Zucker says that the theoretical underpinnings of his work rely on much of this new research. For example, he bases his approach in part on the concept of "gender identity self-labeling." Zucker explains: "You somehow, by the age of two or three, have recognized that gender is a social category. The world consists of males and females: mommies, daddies, men, women, boys." Children figure out how to label themselves as a boy or a girl (how they do this is the big question, and one that has not been satisfactorily answered) and then "search out information in their environment: If I'm a girl, how is a girl supposed to behave? You look to the social environment."
Take something as seemingly arbitrary as color preferences. In general, girls like pink and boys like blue. This is not just anecdotal, Zucker says; studies have confirmed "sex-dimorphic88.Sex-dimorphic: (adj) used to describe a trait or characteristic that varies along gender lines-height, for instance, or the presence of facial hair. color preferences." This isn't because girls are "born" to like pink, Zucker says, but rather because they say to themselves, "'I'm a girl. OK, so what do girls do?' You have your own self-label and then you actively try to behave in a way that matches the label." Zucker's aim, then, is to broaden the kids' sense of what someone of their birth sex can be. "Let's say a little boy with a strong desire to be a girl, in part, has come to this because temperamentally he has a lot of trouble with rough-and-tumble play," Zucker says. "And so recognizing that some kids might think in binary terms-'I'm not like that, therefore, the only alternative is to be a girl.' But if one can help kids realize there are different ways one can be a boy, maybe that lessens the wish to be a girl. Because one realizes, 'Oh, I don't have to be running around on a soccer field as the only way one can be a boy. I can do something else.'"
Zucker also relies on more traditional behavior--modification therapy, in which you reinforce or reward certain behaviors and ignore or discourage others. He encourages "limit setting," like allowing your boy to wear a dress at home but not out of the house, for example, or only for a certain number of hours a day. But he stresses that each child's treatment plan is individualized: For a kid like Alex, encouraging him to be flexible in the way he thinks about gender is as far as he'll push. For a kid like Olivia, he felt comfortable going further. This is largely because Olivia's parents felt comfortable going further.
Olivia is nine now. But from the time she was two, "She wouldn't wear things if there were a pleat or a bow or a sparkle," her mom, Erin, says. Olivia wouldn't drink from a pink cup or eat off a pink plate. She refused to go to school on her birthday, because the teacher gave girls a princess crown to wear on that day. "And if there was a special day where I would tell her that a dress was required, there would quickly be juice dumped down the front of it." Erin laughs recalling it. "Smart kid."
Erin also noticed that Olivia couldn't tolerate social situations. She got teased a lot at school, and at home, if Erin's friends came over with their kids, Olivia would either go up to her room and shut the door or sit and rock in the corner-"almost like she was autistic," Erin says.
By the time Olivia was four or five, they would argue about her gender constantly. "I would clarify-not understanding what the heck," Erin recalls. "I would say, 'Olivia, you're a girl. You're a bit of a tomboy. You're a girl that likes boys' things.' Then it started into the whole dialogue of, 'When am I going to become one?' That's when I realized that she needed help."
Erin was referred to Zucker by a therapist she was seeing, but having read some of the criticisms of him online, she was wary. "My values are that you take people for who they are, and people can be whoever they want to be in life," Erin says. "So if my daughter chooses to be a boy or chooses to be gay or whatever, so be it, and I'll love them and support them and do whatever I can to make them happy in their world."
But then Zucker asked her a question that stuck with her: "If your daughter said to you that she wanted to stay up until two in the morning, would you let her?" No, Erin told him. "Well," Zucker continued, "she's telling you that she's a boy and is going to change into one. And she's young enough that we think in this clinic that she's confused, and you can clarify that for her. What do you think about that?"
Erin thought, "OK, let's try this."
The first thing Zucker encouraged them to do was to go shopping for clothes. "You'll have to try to make her clothes gender-neutral," Erin recalls Zucker saying to her. "We're not telling you she'll ever wear a dress. But you need to try to get her to grow her hair, get it so she's not looking so much like a boy." He also told her to be clear with Olivia why they were coming to the center for ongoing therapy sessions and why they were going shopping. Erin was nervous about it, because she knew it would upset her daughter, but she recalls, "I said, 'You're not going to be able to wear boys' clothes anymore. So we're going to go to the store, and you're going to wear girls' clothes because you're a girl.'"
Zucker is mindful that clothes and hair length-not to mention toys and games, indeed, just about every outward sign of gender that he targets-are superficial. "Yet, if you look at normative studies of gender development, kids often use cues pertaining to hairstyle and clothing style to not only mark their own gender but to mark the gender of other kids," Zucker says. "So those cues, or markers, are surface representations of a child's underlying gender identity. And I think, in young childhood, there can be a feedback effect."
If a young boy feels he is a girl, Zucker argues, then playing with Barbies is not as simple or as neutral as playing with blocks or puzzles. Part of the thrill of the Barbies for that boy is that they make him feel like a girl. Because he feels like a girl, he will continue to want to play with Barbies. And so on. "There is a back-and-forth between gender identity and surface behavior," Zucker argues. "I've been trying little questions out lately, like: 'If you like to eat leaves off tall trees, would that make you a giraffe?' Some little kids fit that kind of thinking. Kids conflate identity with appearance."
This was certainly true for Olivia. Finding gender--neutral girls' clothes was a challenge, but she and her mom finally agreed on some collared shirts and cargo pants cut in a girl's style. "What happened over time was, she stopped getting bullied at school because she stopped looking like a boy," Erin says. "It would get her confidence going."
On days that Olivia came home from school and complained that "so-and-so called me a boy," Erin would steel herself and reply, "Well, you kinda look like one today, Liv. Your choice. I don't know what you're expecting." Ultimately, Olivia "got to a point where she would get upset when people would get confused, calling her a boy. Even though originally that was what she wanted."
The final recommendation her parents followed was to help Olivia make more female friends. She'd always had more boy friends than girl friends, but her parents enrolled her in girls' soccer and hockey and were amazed at the difference it made. "The girls are like her," Erin says. "They're still more girly than her, but they're rough, and when they go to a tournament, they're just tearing around playing Hunger Games. They relate to her."
Social interactions still don't come easily for Olivia, but Erin feels the changes they made have helped give Olivia the confidence she needs to move through the world more peacefully. "I think that if I hadn't gotten the help, I would have allowed her to continue to dress the way she was, and life would have been really tough," says Erin. "I think she would have been very withdrawn and disturbed and had difficulty making friends, and been bullied." Erin knows the future is still uncertain: "Who knows what she's going to decide? Is she going to be gay? Is she going to be transgender? I don't know. But I do know that she's going to be a confident person and be her own person and feel like she can make her own choices, and recognize how to fit in and how society works. I think this place has saved her."
There's a chance, of course, that Olivia might feel otherwise later in life. "If your parents have brought you to Dr. Zucker to figure out your gender, and they are already perhaps less than supportive or [at] least nervous and confused, and then you sit in a play space with an authoritative doctor suggesting you play with a truck, what do you think the child would do?" asks emergency-room physician Madeline Deutsch, who is transgender. "I suspect that we will see a large number of Dr. Zucker's former patients in their thirties, forties, or fifties seeking gender reassignment, only to regret having not been able to do so decades earlier."
Traditional epidemiologic studies have assumed the prevalence of transgender people to be rare: somewhere in the neighborhood of 1 in 10,000. But recent studies show the numbers are much higher than previously thought (or are higher now than they used to be): 1 in 200, or even, in one recent sample of middle schoolers, 1 in 100. This means that only a tiny sliver of what may be a relatively large population of transgender people are showing up at clinics to make a medical transition. It speaks to the fact that in between living fully in one's birth gender or undergoing all of the cross-gender interventions that Western medicine has to offer is a whole range of options that Zucker's approach doesn't account for.
"The proliferation of gender categories that represent people's desires and experiences and identifications, those are fairly new," Bryant says. So "to look at kids today who are gender-nonconforming and try to make some prediction about what they're going to be when they grow up is really fraught. The things that they are going to be when they grow up don't exist right now."
Because of this proliferation, critics like Bryant say, Zucker is basing his work on an outdated conception of gender, suggesting parents radically change the way their children live-not let them play with the toys they choose, or wear the clothes that make them most comfortable, or play with the friends they most connect with-on the basis of a dubious guess that some tiny percentage of them will one day want to have sex-reassignment surgery. Or, worse, on the basis of societal prejudice: because the world will not accept them for who they are. This seems as unsettling as Zucker's parents moving to the suburbs and conforming for the good of the cause. It's fair to ask: Whose cause, exactly?
Although the DSM is strictly a diagnostic manual-it does not make treatment recommendations-implicit in the very existence of a diagnosis is the suggestion that it warrants treatment. This is largely the concern that transgender activists and mental-health professionals had when they heard that Zucker would be chairing the DSM's Sexual and Gender Identity Disorders work group.
Zucker's approach "has this default assumption that not identifying with the sex you were assigned at birth is in some way psychopathology," says Karl Bryant. "It treats the gender of the child [as] a problem that merits some kind of correction."
But transgender advocates concede that the new diagnostic criteria represent an improvement over the old. In the previous DSM, for instance, the bar seemed lower for diagnosing boys than girls: To meet the criteria, boys need only have a "preference for" wearing girls' clothes, whereas girls had to "insist on" wearing boys' clothes. In the new DSM, the language is more analogous. The new DSM, which will be published in May, also recognizes the limitations of the gender binary, noting that a child could express either "a strong desire to be of the other gender" or "some alternative gender different from one's assigned gender."
Still, whether the diagnosis should be in the DSM at all remains a contentious issue. Because hormone--replacement and sex-reassignment therapy cost tens of thousands of dollars, transgender people are in a bind: They need a diagnosis to get health-insurance coverage for their transition-related medical care. Zucker and his colleagues tried to address some of the community's concerns by renaming the diagnosis "gender dysphoria." This means that it's not the identity that is a disorder but rather the distress that may result from that identity. A gender-variant kid-a boy who likes to wear dresses, for instance-wouldn't automatically meet the criteria, unless the behavior caused him "clinically significant distress or impairment." In other words, unless he were suffering.
The name change alone was a big deal, says psychiatrist Dan Karasic of the University of California, San Francisco, because it implies that "the distress of gender dysphoria is the pathology as opposed to gender identity."
Zucker likes to say that the DSM is "agnostic" with regard to the origins of one's suffering, but the question of where the distress originates is not a small one. Many kids in Zucker's clinic come in with psychiatric and psychosocial issues. A quarter of them have been involved with child protective services and a quarter have attempted suicide. Zucker concedes that "experiences of ostracism, social rejection in the peer group, et cetera, does account for some" of the distress. But, he says, "I personally think that it's too simplistic to say that it's the peer ostracism or the stigma that explains it all. We see a lot of adolescents whose families are pretty supportive," he continues. "They're not being rejected. Their friends are chill. But they're still very unhappy and very distressed and miserable. So even with external acceptance, the incongruence between somatic sex99.Somatic sex: (noun) the sex implied by one's physical body. People with gender dysphoria suffer a disconnect between their somatic sex-their physical sexual characteristics-and their gender identity. and felt gender is still very painful."
For the most part, following his interpretation of the standards of care, Zucker will not recommend puberty suppressors or cross-gender hormone therapy for anyone whose psychiatric issues aren't addressed first. His critics say this misses the point: Transitioning is addressing their psychiatric issues. By offering hormone therapy and other medical interventions, "you treat not only the medical hormonal deficiency and help them attain the body that they wish, but you are very likely to erase a whole bunch of psychopathology that's all secondary," says Norman Spack, an endocrinologist who runs the Gender Management Service at Boston Children's Hospital. Spack says he has seen major depression, anxiety-even mild Asperger's-resolve after kids are able to transition.
While I was in Toronto, a teenage patient of one of the other psychologists in the clinic came in for a follow-up visit. This person had the body of a female but covered his breasts in layers of binders and was so afraid to be read as a female that he wouldn't leave the house, even for school-he attended high school online and ventured out only for his appointments and, once a week, to the in-person component of his curriculum. He told his psychologist, one of Zucker's colleagues, that if she wouldn't refer him for hormone therapy, he would kill himself. The colleague stopped by Zucker's office to ask him what to do.
The standards of care say someone is ready for hormone therapy when he has lived successfully as his preferred gender for a period of time. Did this person qualify, if he never left the house? Is his extreme distress the result of his gender dysphoria? Or is the depression clouding the psychologists' ability to get an accurate read on his gender identity? All these questions were theoretical, though. In the next room was a real patient who was suffering, and Zucker did what he thought was best: He referred him to the endocrinologist to begin hormone therapy.
*The names of Zucker's patients and their family members have been changed to protect their privacy.
