6 Facts About Affirming Therapy for Trans And Gender Non-Conforming Youth

Here's what you need to know.
01/23/2017 12:23 pm ET Updated Jan 23, 2017

BBC2’s recent program about transgender youth featured a lot of scare tactics about what happens if transgender youth are affirmed in their gender identity. This was topped off scary music when talking about the alleged dangers of allowing transgender and gender non-conforming youth to express themselves. It also featured disgraced former head of the Gender clinic at Center for Addiction and Mental Health (CAMH) in Toronto, Dr. Kenneth Zucker.

The documentary left out crucial details, such as the fact that as far back as 2009 Zucker’s clinic was investigated by his employer, and warned to change their methods. When the 2015 follow up independent review found that little, if anything had changed since the warning he received 2009, he was dismissed. His explicit hostility to other experts in the field was evident at the 2016 WPATH Conference as well.

The program also left out the darker side of Zucker’s approach, which is effectively coercive behavioral modification to shame children into behaving in heteronormative ways. There are horror stories told supportive parents who have been threatened by the courts that if their gender non-conforming child so much as comes home with glitter-glue on a school art project, they will lose custody for failing to enforce “appropriate” gender stereotypes based on Zucker’s approach. Additionally, Ken Zucker has testified in custody cases against parents who embrace the affirming approach.

The most crucial details omitted, however, are the actual facts about what affirming therapy actually entails.

Fact #1: Affirming therapy does not railroad youth into transitioning

The entire point of the affirming approach to transgender and gender non-conforming youth is to NOT push them in any particular direction, but to give them a safe space to explore their identity and expression. Pushing them towards transition goes entirely against this concept.

Dr. Colt Keo-Meier, the lead author of Division 44 (LGBT issues) of the American Psychological Association’s guidance for treating transgender children, refutes this fear-mongering claim:

“The gender affirmative model supports identity exploration and development without an a priori goal of any particular gender identity or expression.

"Practitioners of the gender affirmative model do not push children in any direction, rather, they listen to children and, with the help of parents, translate what the child is communicating about their gender identity and expression. They work toward improving gender health, where a child is able to live in the gender that feels most authentic to the child and can express gender without fear of rejection.”

The fear that children will be scared to tell parents or therapists they are considering transitioning, not-transitioning, or changing their gender presentation in any direction is primarily espoused by proponents of Dr. Zucker’s model. It makes sense they would see it this way, since their own model relies on emotional coercion to get the behaviors and answers they are looking for. Understanding that a child might actually trust their parents and their therapists enough to tell them something they don’t want to hear is outside their paradigm.

Fact #2: Transition regret is rare, and competent affirming therapists aren’t the problem

Transition regret is rare. In the context of the BBC program, they provide anecdotal evidence rather than actual evidence from peer reviewed studies. In both the US and the Netherlands, youth who were properly screened, and placed on blockers, had a regret rate of taking blockers that is effectively zero. In a Dutch study, out of a cohort of 55 only two of the youth dropped out of taking blockers, and neither expressed regret at having taken them.

The answer is not to prevent all youth from transitioning, but to work ensure therapists understand how to screen for other conditions. This is the accepted standard for affirming therapists, who screen for other conditions as a normal part of treatment.

Fact #3: Autism and Gender Dysphoria are not synonymous

There does appear to be some statistical link between autism and gender dysphoria. However, the vast majority of autistic people are not transgender, and the vast majority of transgender people are not autistic. (i.e. autistic people are slightly more likely to be transgender, and vice versa). BBC2’s program tries to imply that autism causes gender dysphoria, which is demonstrably false in the vast majority of both transgender, and autistic people. If you diagnosed a transgender person as autistic simply because they are transgender, you’d be wrong 19 out of 20 times.

Affirming therapists are well aware of this, and the need to screen for conditions associated with gender dysphoria in youth, including ASD. The American Psychological Association Fact Sheet on Gender Diversity and Transgender Identity in Adolescents, which advocates an affirming approach, states:

“Domains to be assessed in current health and psychological functioning include: individual and family health history, level of distress of all family members, physical and mental health history, sources of social support, levels and sources of distress, education and employment history, legal history, substance use and abuse, history of physical and sexual abuse, self-esteem, trauma, co-occuring mental health disorders, hobbies and interests, strengths and resilience, as well as religious beliefs and background.”

In short, the suggestion that the affirming model of therapy ignores autism, or any other potential co-morbidity as a factor, is simply untrue. As a result, Dr. Zucker expects audiences to believe him when he says that he doesn’t practice reparative therapy, but to disbelieve affirming therapists who say they carefully screen their patients for contributing factors.

Fact #4: Affirming therapy has demonstrated highly successful outcomes

A number of recent studies of transgender and gender non-conforming American youth treated under an affirming model have shown excellent outcomes. The youth are both well-adjusted in their gender identification, and in terms of overall mental health. Indeed, one study showed no significant statistical difference between the overall mental health of affirmed transgender youth and in the general population. Similar outcomes were also observed in Dutch populations.

There is no shortage of bad statistics for transgender youth who are not supported. These statistics date back decades, during which time Dr. Zucker’s model was the predominant one. This begs the question: why would someone who claims to care so much about transgender youth be so adamantly opposed to a new treatment that is proving to be so dramatically successful?

Fact #5: The “80% of youth desist” figure used against affirming therapy is no longer credible

The “80% desist” figure is used by Dr. Zucker to support his “Drop the Barbie!” methods is used to argue that affirming therapy will lead gender non-conforming youth down a path that leads to a transition they neither want nor need.

Dr. Zucker is one of the most widely cited figures by anti-LGBT groups because his position (that you can change gender identity) supports efforts to legitimize reparative therapy on LGBT people, and he has not publicly objected to his views being used to support such. Indeed, earlier in his career he used to promote his methods by claiming that both gender identity and sexual orientation could be prevented with behavioral modification in childhood.

However, there are many fundamental flaws with the 80% figure:

· It is based on the definitions from the DSM-IV TR, which had a much broader definition of Gender Identity Disorder in youth (i.e. children who were gender non-conforming were classified as disordered regardless of whether or not clinically significant distress was present)

· The Dutch study it was drawn from (in part) counted patients who dropped out of the program (and unaccounted for) as desisting

· Zucker himself admitted during the 2015 investigation into CAMH that 70% of his patients were “sub-clinical” to begin with.

· It does not take into account the effects of assessing for level of insistence, consistence, and persistence in the child’s assertion of their gender identity.

· The studies supporting the desistance narrative lacked a control group, therefore there is no way of knowing whether or not the treatment had any effect on the desistance rate, or mental health outcomes.

Conversely, there is little to suggest that affirming therapy alters the desistance rate either; nor should it. The aim of affirming therapy is to support patients without an a priori belief that any particular gender identity or expression is the optimal outcome. This is the same philosophy employed (successfully) with lesbian and gay youth for decades.

Fact #6: Affirming therapy does not regard being transgender, or gender non-conforming, as a bad outcome

Affirming therapy does not treat “heterosexual cisgender as the most acceptable treatment outcome.” A child who is happy, well adjusted, confident, and supported in their gender identity, sexual orientation, and gender expression is the desired outcome of affirming therapy.

This is very much in line with the direction medical understanding of transgender people is going. The World Health Organization is expected to de-list being transgender as a mental illness in the ICD-11, understanding that being transgender is a natural variation in human gender. This is the same line of reasoning which the APA went down in 1974 when it removed homosexuality from the DSM.

Conversely , Dr. Zucker’s clinic in Toronto was shut down in part because his methods, and philosophy were nearly 30-40 years out of date in many cases. The report concluded he treated cisgender, and gender conforming as the best outcome. He also treats transgender identities as innately disordered, resulting from Freudian environmental influences such as,” overprotective mothers, emotionally absent fathers or mothers who are hostile toward men.” This description of the causes of “transsexualism” dates to the 1960’s and 70’s by Dr. Robert Stoller.

While Dr. Zucker claimed this 2015 CAMH report was politically motivated, as far back as 1995 in his book that straight (and implicitly gender conforming) were his therapeutic goals stating: “a homosexual lifestyle in a basically unaccepting culture simply creates unnecessary social difficulties.”

Conclusion:

Affirming therapy is becoming the dominant model given the greater understanding that transgender people are a natural variation in human gender. The resistance to it comes primarily from those whose religious beliefs oppose the acceptance of transgender people in society, and those who promoted model of behavioral modification which set cisgender, heterosexual, and gender conforming as an ideal for human behavior and sexuality.

It is understandable to want to protect ones’ life work. However, the affirmative model is supported both by the growing understanding of gender identity as natural and idiopathic, and by the expanding body of peer reviewed research showing better outcomes than those achieved under earlier models.

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