Don’t trick the customer

The problem with University of Toronto Professor Ken Zucker‘s Gender Identity Gender Identity Clinic for children and youth at the Centre for Addiction and Mental Health (CAMH)  in Toronto when it was closed in 2015 was that the client was the kid rather than the parent, and the customer shouldn’t be tricked. 

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Gender identity isn’t about dolls or stereotypes and being transgender has been recognized as part of gender diversity for years. Why didn’t the CAMH Gender Identity Clinic get the memo?

Dr. Ken Zucker was head of CAHM until it was closed following an assessment brought on by complaints related to the care clients received there. As head, Dr. Zucker held a leadership role in a public institution. Part of that role was to ensure that the centre provided the best care possible for his trans, gender-variant, and gender-creative clients, in accordance with Canadian and global standards. The authoritative standard of care for professionals in this field is published by the World Professional Association of Trans Health, WPATH.

Parents are rarely experts in transgender psychology. Part of Dr. Zucker’s role was to ensure that parents of Canadian kids referred to his team could count on the fact that the clinic he led compiled with Canada’s standards of care. In his second role as a trainer of future trans care providers, his role was also to ensure his students were equipped to follow Canada’s norms for transgender care. The ideas and preconceptions that were prevalent in the Gender Identity Clinic’s approach and daily operation informed many clinicians in training who are now looking after transgender children and youth. Dr. Zucker’s approach will continue to affect transgender Canadians for years to come.

Zucker’s clinic was no small concern. It was, I believe, the only sanctioned gatekeeper for puberty blockers, hormone replacement therapy, and many trans-specific services for most children and adolescents in a number of provinces including Ontario, Quebec, Prince Edward Island, Nova Scotia, New Brunswick, Manitoba, and Newfoundland. In an era when accessing transgender psychology for children was extremely difficult, the CAMH Gender Identity Clinic’s reach was profound.

For children living in those provinces, CAMH held a quasi-monopoly in the trade of assessing children to access the next steps. If a child or youth identified as transgender or was dealing with gender dysphoria in these provinces, Dr. Zucker’s clinic was a mandatory gate to be crossed.

After years of complaints by former patients of the clinic that there was a profound problem in the type of care provided there, the CAMH GID clinic was reviewed by an external committee in a December, 2015 report.

Copying verbatim from the report with emphasis on key components in highlighter,

The following is a summary of feedback provided by the reviewers:

  • Research knowledge and clinical guidelines have evolved, particularly in the last five years, and society’s understanding and acceptance of the diversity of gender expression and identity have changed. There appears to be a mismatch between literature research findings (including those from GIC itself), and clinical practice and approach.

  • Clinic assessments are long and, at times, appear to be clinically inappropriate for the child’s age. Questions were raised by the reviewers about the information shared regarding participation in research as documentation suggested that consent obtained may not have been fully informed.

  • The Clinic describes its approach as a model that employs play therapy, cognitive behavioural therapy or a combination of both as part of its treatment paradigm. Play and combination therapy do not reflect current approaches to the treatment of anxiety, a primary condition of many of the clients seen by the GIC and thus this practice may be outdated.

  • Feedback from families indicated that the clinic supported families very differently. Some families reported that services or referrals were not offered to them despite requests while other families reported receiving exceptional supports for long periods of time. In some instances, the reviewers expressed concern regarding the possible over-involvement of parents in a child’s treatment planning.

  • GIC is viewed by some as being overly-conservative in its patient referral times. A concern was raised with regard to the GIC criteria for diagnosing readiness for referral for gender-affirming hormones and the inherent risk of delays to referral.

  • It was noted that access to GIC is limited due to long wait lists. As the clinic tends to operate in separately from other CAMH supports and community providers, there is an issue with regard to timely and efficient transition of care to and/or from the community or to adult services.

Summarizing the findings, Zucker’s clinic was found to be out of step with modern practices, to listen too much to the desires of the parents over the needs of the child, to be inconsistent in the treatments of clients, to use criteria that raised alarm with the investigators, and to have failed to get the appropriate consent of clients on whom it did its research.

The committee issued a number of recommendations. Again, copied verbatim from the report:

In following the extensive review process, the reviewers made seventeen (17)
recommendations which focus on future service models as the reviewers recognized the
tremendous need for specialty services for this community. The recommendations
made by the reviewers are:
1) The current assessment and treatment approaches need to be revised. Gender
variance versus gender dysphoria should be distinguished and explained. The
aim to reduce suffering can be achieved with a client-centred and family
supportive approach. To move towards this goal, it is recommended that WPATH,
CPATH & AACAP guideline-informed care paths be utilized, across the age
spectrum. Some specific examples include, but are not limited to:

a) Explain these at the start of assessment (informed consent/harm
reduction/client-centred)
b) Refrain from treatment of the child that targets reduction of gender-variant
behaviors or use of language that pathologises these.
c) Refrain from allowing parent alone to choose the treatment path
d) Educate parents and children about gender expression, gender identity,
gender variance across the lifespan
e) Assist all families with communication and acceptance within and outside
the family
f) Liaise with schools to provide advice on inclusion and obtain collateral
about social adjustment and any protection needs
g) Refer teens taking hormone-blockers for gender-affirming hormone
treatments when ready and eligible in collaboration with endocrinologists
involved.
h) Staged sexual history interview using suggested approach:
i. Age-appropriate questions (pre-pubertal sexual history is not
required)
ii. One may rule out paraphiliae with 2 screening questions: “How do
you feel about yourself when you dress in your preferred
clothing?” Follow-up, if unclear, “Does it affect your sexual
confidence or your overall self-confidence?”
iii. Inquire about attraction and whether sexually active late in the
assessment
iv. Inquire only about safe sex practice use at assessment
v. Inquire about details of sexual practices only when assessing for
treatment that can affect sexual function and inform patient about
the reason for these questions (informed consent).

2) More careful delineation of who is the client: focus on any clinical distress
associated with gender dysphoria in the child. The family members should
become the focus as needed for education and any work toward acceptance of
their child. Do not treat family members individually for mental health concerns,
but rather, collaborate with other providers, where needed.

3) When assessing for comorbidity and psychosocial outcomes, correlates and their
relationships should be examined in the context of the effects of gender
dysphoria. These would include, but not limited to:

• Anxiety
• Depression
• Disruptive mood dysregulation
• Self-harm and suicide
• Substance use disorders
• Personality disturbances
• Work in the sex trade
• Underemployment
• Underachievement of academic potential

4) A review of the use psychological testing, even in research context with attention to:

a. Option to decline
b. Informed consent on use of IQ tests as not standard practice
c. Separate consent for research and clinical use of all information
d. Employ Gender-specific scoring of any psychopathology measures

5) File consent forms on chart and renew periodically (i.e. every 30 days for consent
to share of information or annually for consent to treatment, in keeping with other
CAMH forms and procedures). Forms should state option to revoke consent at
any time and specify that clinical care would not be affected by the change in
consent. This should include separate consent for any photographs, which
generally should be requested only after careful reflection on the client’s needs
and with full informed consent from child and teen and parent.

6) Community engagement will be key in determining future directions (including
physical location) of this specialty service. Whereas such a service need not
necessarily to be housed at CAMH (in a hospital), it is imperative that it maintain
an academic mandate.

7) Key organizations and institutions to consider for the engagement process could
include Rainbow Health, Justice for Children and Youth, The Provincial Youth
Advocate’s Office, The Provincial Council for Maternal & Child Health, Children’s
Mental Health Ontario, LHINs, MCYS Lead agency/ies, as examples.

8) Collaborate with CAMH academic partners, resources, Chairs and Centres (i.e.
The McCain Family Centre re Collaborative Care opportunities)

9) Develop a clear, implementable QI strategy, utilizing CAMH decision support as
appropriate.

10) Update and create a governance model including an Executive and/or Advisory
Committee (which should include as a minimum: clients (youth and/or family),
CAMH Public Affairs, Legal, Ethics, community stakeholders, CAMH adult GIC,
trainees)

11) Develop clearer, more streamlined processes for access to and flow through the
clinic, and transfer to community resources and adult services, as appropriate.
This should be consistent with Access CAMH, and CYF intake processes and
procedures. Better collaborations/partnerships when dealing with crisis and
CAMH CYF GIC Executive Summary concurrent mental health situations are advised – especially so the burden of treatment does not fall onto clinic trainees.

12) Consider adding Social Work or other professionals with expertise in family
therapy to the GIC team.

13) Community supports should be included in recommendations and
psychoeducation to families and youth. These would include choice of services
for hormone therapies, and surgery assessment, where appropriate, for example.

14) GIC staff to take training courses in more streamlined and efficient record
keeping, chart organization and report preparation.

15) GIC team members are highly encouraged to review CAMH policies re: informed
consent, and email correspondence with families.

16) When dealing with GIC controversies in a public forum, GIC members are
encouraged to work with CAMH Public Relations to effectively deliver messaging
which also considers reputational risk to the institution, and employs clientcentred
language. GIC staff may benefit from media training.

17) GIC and CAMH as a whole are encouraged to develop a campaign towards
collaborative creation of “safe spaces” for transgender children, youth, families,
and community caregivers.

In short, the recommendations were to

  1. Separate contracted treatment from optional research
  2. Center the interests of the child over the wishes of the parents
  3. Effectively join the 21st century by updating clinical approaches
  4. Stop ignoring CAMH ethical rules
  5. Stop telling kids that being transgender is a bad thing.

The public function of the clinic was to assess children and youth and support them through transition. His clinic was contracted to do this. His research work is a separate issue which in this piece I have no interest as long as he fulfills the ethical requirements put forward by the institution where he does the work. I do not have information on whether he sought permission from an ethical review board or not.

If Zucker’s clinic wanted to perform research using children by investigating the outcomes of conversion therapy, the type of intervention aimed at controlling sexuality or gender identity in the client through which children are given positive feedback for complying with or adhering to gender norms and negative feedback for disobeying their parents’ gender norm expectations, then Dr Zucker should have applied to the ethical standards board of the organization he works under.

Dr Zucker’s clinic would also have had to declare to the parents that this is not the accepted practice and that his therapy diverged fundamentally from WPATH and CPATH recommendations, as well as being in opposition of just about every professional body in Canada. In fact, there are no governing or professional bodies in Canada which support the idea of doing anything to ‘treat’ gender identity other than let it play out and let the affected person find their own way. The American Psychiatric Association, the ASA, publishes the Diagnostic and Statistical Manual of Mental Disorders, the DSM. Psychiatrists are now expected to use version 5, DSM-5. The ASA removed homosexuality and gender identity from the list of mental illnesses in the DSM years ago, recognizing that diversity of gender identity and sexual orientation is a simply part of our natural world.

In fact, it is considered unethical in North America to try to change someone’s sexual orientation or gender identity – at any age, and for any reason.

The state of the art has been for many years now to allow children to be themselves and let them explore their identity. If it persists, the children are spared the trauma of being constantly denied something they know to be true in their deepest core. This spared trauma is reflected in the research which identified the drop in suicide rate of queer children and youth supported by their parents when compared to the suicide rate of trans kids who are unsupported by their parents. The list of endorsements by professional and relevant groups for supporting trans kids in schools provides a clear indication of where Canada’s relevant professional bodies sit on this subject of supporting trans kids and youth.

Of course, nobody would agree to therapy that goes against widely held fact-based practices. Of course, all parents want what they think is best for their child.

And this is what is incredibly insidious here. Just like the religious quack psychologists who promise to de-gay or de-transgender their kids using faith-based techniques that we all know cause myriad negative outcomes, the primary influencing argument of Zucker’s clinic was that it was highly esteemed and world famous and that Zucker was a highly respected doctor in his field.

The parents, sadly, never had the opportunity to evaluate the issue on their own of whether they should use the endorsed approach or this one doctor’s privately-held views which have resulted in profound criticism. The parents have never had the chance to look into what happened to the people whose gender identity or sexual orientation have been oppressed. They don’t have access to the research on brainwashing or de-gaying done in the 1970s that led all investigators to reject the path due to the carnage they cause.

In fact, the profession itself continues to suffer from a profound under-representation of transgender experts doing research on things that concern them. After all, nobody in a senior position today in Psychiatry or psychology could possibly be transgender because that was firmly believed to be a mental illness at the time of their training. Imagine discovering yourself to be mentally ill while practicing as a psychiatrist. I doubt that ends well.

…and this comes from the DNA of this clinic which comes from the profoundly pathologizing times. We should not forget that this is where the long-contended term autogynophelia was coined by Zucker’s predecessor as CAMH GID head Blachard (who did, arguably, fight for publicly-funded transsexual surgery).

CAMH does great things and I am told by trans-specialized psychologists I know that Zucker has contributed greatly to the body of knowledge of trans psychiatry. But what he did not do well and what caused the shutdown of his clinic is put his clients first instead of prioritizing the wishes of their parents.

The role of transgender care providers in Ontario, as entrusted to CAMH, was to perform a number of gate-keeping functions for several other provinces. The provinces were assured that CAMH followed Canadian expectations and standards, hence WPATH and CPATH’s . CAMH’s gender identity clinic for children failed to maintain controls and keep standards in place which assured that this took place as standards of care and research evolved past where Ken Zucker was willing to go because of his own privately held views that most kids who exhibit transgender behaviour are not, in fact, transgender. Many, many children were negatively affected by this clinic. A number of them, now adult, complained and advocated sufficiently hard to compel the Ontario Legislature to ban conversion therapy thanks to a private-members bill put forward by Ontario New Democrat Member of Provincial Parliament Cheri Di Novo. They made enough trouble to force a review of the CAMH Gender Identity Clinic for children and youth. The review found sufficient problems with the clinic’s practices that it was closed.

CAMH did the right thing by following the recommendations of the review committee to wind down the clinic and re-opening it as a centre which serves the members of the trans community in a way that meets current norms.

Now, Canada is left to clean up the mess and address the distress by those who Zucker’s approach harmed. Let’s learn from the things the CAMH GIC did well and the places where it underperformed.

Research on gender identity and sexual orientation is a valid field of study. If there are errors in approach, they need to be identified so we can learn from our past mistakes.

There is no doubt that the validity of our identities is a sensitive issue for transgender Canadians. Every transgender person alive today in Canada spent the majority of our lives feeling the humiliating sting of being denied validity, let alone equality, by experts and leaders expressing their authority with smiling, well-meaning smirks.

Zucker’s interest in the question of whether trans-identifying children revert to cisgender identity is an interesting one that should be studied ethically and without bias or pathologization unless there is proof of the issue. 

Despite their tepid efforts to manage it, the University of Toronto has offered a rich crop of anti-transgender innovation over the years ranging from Jordan Peterson‘s refusal to say “they”, to Ken Zucker’s predecessor Ray Blanchard’s obsession with what (trans) women think about during sex, to the CAHM mess at hand. If meaningful research that leads to the expansion of our body of knowledge is to be salvaged from the post-bill-C16 ripples happening in its microcosm, Zucker’s contrarian views may yet yield interesting research if academics can separate their own personal bias from our thirst for truth.

If any research is done to investigate transgender desistance and factors influencing it, the work must not be coercive. Our children must be allowed to be whoever they are and parents need to respect that their children are who they say they are. If I have any advice to give to parents struggling with this, it is to listen to your child, encourage self-identity, and try not to reward gendered behaviour, hard as that is. The number of youth I know who have desisted is small but not zero. There is a difference between keeping an eye open for the possibility a youth will not follow through and with providing corrective feedback to undo somebody’s identity, malleable as it may be.  Considering that we spend so much energy as parents empowering our children to be their best selves, it is profoundly disingenuous to stifle their emerging gender identity.

* Please report any inaccuracies to the author.

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