Kelley Winters, Ph.D. January 11, 2022
Download full paper with tables in pdf format:
Recently released draft chapters for the WPATH Standards of Care, version 8, offer forward progress for access to confirming medical care for Transgender and Nonbinary adults. However, chapters on child and adolescent assessment and care are rife with conflicting and contradictory language that promotes archaic pscyhopathologized stereotypes of gender diversity and extensive psychogatekeeping to adolescent puberty suppression or confirming hormonal care. They employ patterns of misleading language to oblige long-term psychotherapy for Trans and Nonbinary youth—linguistic tactics that have been historically proposed to euphemize discredited, disaffirming or gender-conversion psychotherapies and circumvent laws and policies that prohibit their practice. On matters of human oppression, historical context matters.
Part 1. Weaponization of Misleading and Deceptive Language
In December, 2021, the World Professional Association for Transgender Health (WPATH, 2021) released draft chapters of the 8th Version of the Standards of Care (SOC8) for public and provider commentary. With 356 pages in the draft chapters and 148 Statements of policy and practice, version 8 is enormously bloated from the 112 pages and couple dozen treatment criteria in the SOC7. Of growing concern to Trans and Nonbinary communities and affirming providers, the draft SOC8 lacks consistency on fundamental ethical principles of Trans health care, such as depsychopathologization of gender diversity, medical necessity of confirming treatments for those who need them, harm reduction, trauma-informed care, and rejection of gender-conversion psychotherapies (SOC7). The new text contains stunning contradictions from chapter to chapter, statement to statement, and even sentence to sentence (ITH, 2021). More troubling, contradiction and ambivalence on established principles of Trans health care in parts of the SOC8 follow a pattern of inaccurate appropriation of Trans health terminology. These same language manipulations were previously presented by Drs. Kenneth Zucker and Richard Green (deceased) at WPATH and USPATH symposia—as tactics to euphemize and normalize psychological treatments that attempt to discourage or suppress non-birth-assigned gender identities and expression (known as gender conversion). These tactics were opposed with historically significant condemnation and nonviolent protest by Trans and Nonbinary communities at the latter conference. Yet such disaffirming tactics have apparently influenced key parts of the Adolescent and Child chapters of the draft SOC8.
At the 2016 WPATH Symposium in Amsterdam, Richard Green and Kenneth Zucker presented a workshop titled, “Gender Laws: The Case of Trans* Children and Adolescents,” on recent legislation in the U.S. and Canada to prohibit the practice of both sexual-orientation-conversion and gender-conversion psychotherapies on minor Trans and Nonbinary youth. In stark contradiction to the association’s position that “Such treatment is no longer considered ethical” (WPATH, 2011, p. 16), this session was a tutorial on how to circumvent such laws and policies. The stated purpose of their session was to promote childhood gender-conversion practices by limiting the impact of laws and policies that prohibit them: “Contribute to the debate and political actions that may keep such regulations within appropriate limits” (WPATH, 2016).
Appearances by Green, a psychiatrist and attorney, and Zucker, a psychologist, at the WPATH Symposium drew concern among Trans communities and affirming providers (Williams, 2017). Both held prominent historical roles in promoting mental illness stereotypes and harmful gender-conversion practices for young Trans and gender diverse children. Green (1987) is most remembered for his role in the notorious “Sissy Boy” experiments at UCLA in the 1970s. Zucker is possibly the most prolific researcher and promoter of gender-conversion psychotherapies, intended to make gender diverse children cisgender or to prevent them from being Trans. (Zucker, 1990; Winters, 2008; Speigel, 2008). Regressive Trans health practices and policies at Zucker’s home institution, the Toronto Centre for Addiction and Mental Health (CAMH, 2015; formerly known as the Clarke Institute of Psychiatry) earned the name, “Jurassic Clarke,” throughout Trans communities (Denny, 2013). Closure of Zucker’s Child and Youth Gender Identity Services program at CAMH (2015) was widely seen as a positive historical inflection point in global Trans health care (Ansara, et al., 2016).
The following year, the USPATH subsidiary of WPATH scheduled two presentations by Dr. Zucker at its first symposium in Los Angeles. His first, titled “Gender variations during childhood” (2017), drew nonviolent protests led by Trans Women of Color—including Trans Advocates for Justice and Accountability co-founder Dani Castro and TransLatin@ Coalition CEO Bamby Salcedo (Blumrosen, 2017; Jacobs, 2017). At issue were Zucker’s history of promoting gender-conversion psychotherapies on trans and gender diverse children (Zucker, et al., 2012; Herriot, 2020), the discredited axiom of 80% “desistance” of childhood gender dysphoria (Drummond, et al., 2008; Newhook, et al. 2018; Newhook, et al. 2021), and WPATH’s decisions to provide a recurring platform for discredited gender-conversion practices and psychopathologized biases.
Zucker’s second USPATH presentation, “The ‘Active Exploration’ Model,” in a session titled, “Gender diverse pre-pubertal children deconstructing the trinary conceptualization of treatment of moving towards an affirmative individualized approach,” was canceled from the conference program. However, his published abstract and the title for the session were deeply troubling in their intent to blur, obfuscate, or “deconstruct” the differences between extremely disparate practices of (1) Zucker’s punitive gender-conversion psychotherapies (Speigel, 2008), (2) the so-called “Dutch Approach” (de Vries and Cohen-Kettenis, 2012) of “watchful waiting” (keeping prepubescent gender incongruent children in birth-assigned/closeted gender roles), and (3) respectful, gender affirmative support (Ehrensaft, 2018). The presenters’ abstract stated,
participants will…understand that applying a distinct approach to a specific gender diverse child is difficult and more of a theoretical conceptualization than a realistic possibility considering the complexity and overlap that exists. (Zucker, 2017)
This erasure of the differences between coercive gender-conversion therapies and respectful affirmation crosses the line from pretense to propaganda. In hindsight of similar tactics and duplicitous language in the draft SOC8 chapters on child and adolescent care, the 2016 WPATH session and the 2017 USPATH session abstract represent history that needs to be remembered.
Part 2. When “Active”/“Therapeutic Gender Exploration” is a Loophole for Punitive Discouragement
Gender exploration, in plain language, is a positive process for all youth, cis, Trans, and/or NonBinary, and should be encouraged without shame or disapproval (Ehrensaft, et al., 2018). In contrast, Zucker’s (2016) WPATH presentation condemned laws and medical policies that prohibited gender-conversion treatments. He emphasized that many had exclusions for exploration, to allow youth to freely explore their own gender identities. Zucker suggested that these exclusions be exploited as a loophole to circumvent such laws and policies by simply relabeling disaffirming or punitive treatments as “identity exploration.” His astonishing outburst that followed, left little ambiguity:
So, I asked a lawyer the following: ‘The bill says treatment cannot seek to change the gender identity of a patient under 18 years of age but it is OK to engage in identity exploration. What’s the difference?’ The lawyer had a very detailed analysis: ‘No one the fuck knows.’ (Zucker, 2016)
In truth, persecuted Trans youth know the difference with certainty. Most of Green’s 2016 WPATH presentation was read from a manuscript later published in the J Am Acad Psychiatry Law (2017). He did not duplicate Zucker’s remarks about the gender “identity exploration” loophole tactic to evade prohibitions on gender-conversion practices, but Green’s law article emphasized it:
…the ‘identity exploration and development’ permitted in the recent legislation has not been tested and may be a gray area for exchange among therapists minors and parents.
In his USPATH session abstract, Zucker (2017) went so far as to label his Clarke Institute/CAMH gender-conversion approach for Trans and gender diverse children as “The ‘Active Exploration’ Model.” The implication is that punitive gender-conversion psychotherapies that “seek to change the gender identity of a patient” might be exempted from legal or professional prohibition if simply given misleading titles that appropriate “exploration” language of affirming care.
The draft Child and Adolescent SOC8 chapters contain similar language of “gender exploration” therapies and “therapeutic exploration of gender diversity” in contexts that are open to interpretation as a disaffirming treatment loophole. Examples are highlighted yellow in Tables 1, 2, and 3.
However, the draft chapters are confusing and contradictory. They also use exploration terms in affirming contexts of “protected space to explore” and “afforded opportunities to continue to explore,” where gender exploration is led by the youth, not imposed by a psychotherapist. In a positive example, the Child chapter begins with some exemplary text that repeats WPATH policies of depsychopathologization and opposition to gender-conversion psychotherapies:
…childhood gender diversity is not a pathology or mental health disorder…conversion therapies for gender diversity in children (i.e., any “therapeutic” attempts to compel a gender diverse child through words and/or actions to identify with, or behave in accordance with, the gender associated with the sex assigned at birth) are harmful and we repudiate their use. (WPATH, 2021)
Statement 8 in the Child chapter contains positive, affirming language as well. On the other hand, Statement 2 correctly asserts that, “Gender diversity is not a mental health disorder,” but adds an ominous “however” and an implication that gender exploration requires a presumption of mental disorder and “highly recommended” mental health expertise.” Statement 5 text asserts that the clinician, rather than the individual child, “needs to explore gender-related issues.” Both imply that “gender exploration” means extensive psychotherapeutic treatment.
In the wake of the Zucker/Green gender-exploration loophole, Statement 13 is troubling. It recommends that health providers and parents “support children to continue to explore their gender,” even those already established and well-adjusted in their authentic, non-birth-assigned gender roles. Fortunately, the supporting text to Statement 13 clarifies that “not all children wish to explore their gender. Cisgender children are not expected to undertake this exploration and therefore attempts to force this with a gender diverse child, if not indicated or welcomed, can be experienced as pathologizing and cisnormative.” However, the fine print of this clarifying text will easily be overlooked by disaffirming providers and health system policymakers. For them, the word, “support,” in the actual Statement 13 can be twisted to compel long-term psychotherapy to “explore” returning to the birth-assigned gender. Further clarification in the statement itself is urgently needed.
The draft Adolescent chapter (WPATH, 2021) also includes some language that respects WPATH’s official opposition to gender-conversion psychotherapies:
We recommend against efforts aimed at trying to change an adolescent’s gender identity and lived gender expression to become more congruent with sex assigned at birth, also referred to as reparative and conversion therapy. (Statement 5)
However, contradictions appear in the supporting text, where the Zucker/Green “exploration” loophole is mimicked:
It is important to note that therapeutic exploration of gender diversity, and potential factors driving a young person’s experience and report of gender incongruence, is not considered a reparative therapy effort in the context of supporting an adolescent with self-discovery, so long as there is no a priori goal to change or promote one particular gender identity or expression. (Statement 5)
In other words, this statement ambiguously allows disaffirming, punitive long-term psychotherapies that place the gender identities of Trans or Nonbinary adolescents on trial—so long as the clinician plays along with chosen pronouns and does not admit to an “a priori goal” of cisgender outcome.
Finally, the SOC8 draft fails to disclose the historical context of Green’s and Zucker’s tactic to circumvent laws and policies prohibiting gender-conversion psychotherapies. The Adolescent and Child chapters require substantial revision to clearly eliminate the Green/Zucker “exploration” loophole. All references to gender exploration or self-discovery should specify that:
any exploration/self-discovery should be led by the client, with neither pressure, coercion or compulsion involved, on the part of providers. The provider should also assure themselves that there is no pressure, coercion or compulsion on the part of parents or other significant persons in the client’s family. (Winter, 2021)
Part 3. When “Social Transition Model” is code for Scaremongering Childhood Gender Authenticity
A second theme in Zucker’s and Green’s 2016 WPATH presentations and Zucker’s 2017 symposium announcement was gaslighting parents and providers who affirmed prepubertal Trans and Gender Diverse children in their authentic social gender roles. They weaponized the term, “social transition,” associating it with frightening, exaggerated risks. Green and Zucker conflated correlation with causation, suggesting that social transition, in itself, was responsible for gender incongruence and Transgender outcomes.
At the WPATH Symposium in Amsterdam, Green (2016, 2017) suggested that forcing gender incongruent children into birth-assigned closets could reduce, rather than exacerbate, distress. He stated, “Short term benefits of reduced cross-gen expression could include reduced distress with discontent over birth sex and reduced stigma from peers over cross gender expression.” He then offered a stunning endorsement of gender-conversion practices that demonized “transsexual outcome” as a “risk” of affirming social gender authenticity in childhood:
A longer term risk of childhood transition include promoting a transsexual outcome that might have been averted/diverted with…social and treatment obstacles.
Green also repeated a stereotype from the so-called “Dutch Approach” (de Vries and Cohen-Kettenis, 2012; Steensma, et al., 2011) that social pressure to remain in non-birth-assigned gender roles was inexplicably more powerful than the ubiquitous punishment of global societal transphobia and would prevent cisgender children from returning to their birth-assigned roles, once changed. He speculated about “…potential problems associated with returning to live as a person of the birth sex,” as an “intermediate term risk.” I have termed this the “Magic Sticky Flypaper Theory” (Winters, 2014).
Zucker, in his (2017) USPATH session abstract, misrepresented social role affirmation of Trans and Gender Diverse children as a clinical approach “to the treatment of gender diverse children.” He referred to childhood gender authenticity as “The ‘Social Transition’ Model.” This linguistic sleight-of-hand implied that allowing prepubescent Trans and Gender Diverse children to simply be themselves without punishment or shame was a medical intervention instead of a human right. In fact, Zucker had previously referred to social gender role authenticity among Trans children as both an “experiment” and a cause of being Trans in adulthood:
My impression is that the early gender transition approach will result in more children persisting in their desire to live as a member of the other gender, which is, in effect, a rather interesting social experiment of nurture (Drescher, 2013).
In contrast, no one considers affirmation of cisgender-privileged children in their socially authentic gender roles as a “treatment approach,” “model,” or “social experiment.” It is taken for granted as a societal norm and a given, for healthy development.
Tables 1 and 2 list examples of disparagement and fearmongering of childhood gender authenticity, or social transition, in the draft Child chapter (highlighted orange). They are disturbingly similar to Green’s and Zucker’s earlier assertions at WPATH and USPATH symposia. For example, Statement 14 exaggerates “risks of a social transition.” It repeats the Magic Sticky Flypaper stereotype, raising “fear that a child will be locked into a [non-birth-assigned] gender expression” and “concern…that a child may suffer negative sequelae if they detransition.” The statement also repeats the causality fallacy (highlighted pink), warning of “potential developmental effect of a social transition in a child.” In other words, Statement 14 spreads fear, uncertainty, and doubt that allowing social authenticity for young Trans children would turn cisgender youth Trans.
Part 4. When “Thorough Comprehensive Biopsychosocial Assessment” is HyperPsychoGatekeeping
In the USPATH session abstract, Zucker (2017) appropriated an innocently-toned term, “comprehensive assessment,” to suggest long-term psychotherapy for Gender Diverse pre-pubertal children on the presumption that Trans and Gender Diverse children have underlying mental pathology:
Through comprehensive assessment that is both affirming of a child’s assertion, yet takes into account the complexity of a multitude of other dynamic factors–some known and some unknown–focusing the treatment on psychological, social, and emotional development will inherently involve evaluating the degree to which a child’s gender nonconformity is impacting these other aspects of the child’s developing sense of self over time.
Unpacking the language of this statement, it is clear that “assessment” is misleading code for “focusing the treatment”; that a child’s gender identity is disparaged as mere “assertion”; that gender diversity is assumed to be a developmental disorder; and, once again, that allowing social gender nonconformity, itself, is a causal factor to adult Trans outcomes. Even more troubling, the word, “affirming,” is colonized and re-contextualized to its opposite meaning.
Tables 2 and 3 list frequent examples of “thorough” / “standardized” / “extended” / “comprehensive”/ “biopsychosocial” “assessment” that appear in the draft Child and Adolescent chapters (WPATH, 2021) of the draft SOC8 (highlighted blue). These statements and assertions are consistent with Zucker’s USPATH assessment dictum and contradict the WPATH depsychopathologization policy. In the Child chapter, they recommend that Trans and Gender Diverse children, not yet eligible for any related medical interventions and only seeking authentic social gender affirmation, continually prove and re-prove their competence and gender identities in compulsory long-term psychotherapy. Statement 5 emphasizes a protracted process of “multiple assessment domains” and “multiple forms of information gathering.” These include “standardized measures related to: gender…,” which are often archaic, offensive, and traumatizing to Trans subjects. Statement 6 repeats the causality fallacy, suggesting that gender diverse children need “assessment” to “consider development factors” and presuming that gender diversity is a developmental pathology. In contrast, if a cisgender child were subject to such punishing psychotherapeutic interrrogation and presumption of sickness for simply needing to express their birth-assigned gender, concerns of abuse would be raised.
The Adolescent chapter (WPATH, 2021) recommends protracted “comprehensive biopsychosocial assessment” of gender diverse adolescents by “mental health professionals,” and not just when specialized mental health support is indicated by evidence. Once again, the draft SOC8 disregards the WPATH Depsychopathologization principle and presumes that gender diversity and need for puberty suppression and confirming care constitute mental disorder. Moreover, WPATH principles of harm reduction, medical necessity, and informed consent protocols (allowing a greater role by medical doctors and clinical staff to perform assessments) are contradicted by the SOC8 requirement that this long-term “assessment should occur prior to any medical interventions being considered (e.g., puberty blocking medication…),” and not concurrently when necessary. Tragically, the Adolescent chapter introductory text also gaslights and disparages culturally competent community and non-profit health clinics that successfully employ harm reduction and informed consent treatment protocols, outside of an ideological psychopathology framework. Both of these policy regressions will place more adolescents experiencing natal puberty in crisis and will cause more mature youth needing confirming hormonal care to seek it on the streets and internet.
WPATH’s highest priority for the SOC8 should be placed on substantial revision of the Adolescent chapter, with emphasis on consistency and comportment to core principles of depsychopathologization of gender diversity, medical necessity of care, harm reduction, trauma-informed care, and clear, unconditional rejection of gender-conversion psychotherapies in all of their obfuscated forms.
I have long observed that WPATH leadership and the Standards of Care have been a battleground between policymakers who see gender expansive people and cultural traditions as a dimension of natural human diversity and those who see gender diversity as mental sickness to be contained or controlled (Winters, 2008). In spite of this chasm of medical ethics, Standards of Care prior to the version 8 draft have followed a trend of slow progress toward better understanding and acceptance of gender diversity and more affirming and culturally competent approaches to care. The SOC have gradually evolved from a blunt instrument of denial of medical care toward the direction of an actual standard of medical and mental health care for an underserved population. However, this arc of forward progress seems to have stalled in much of the draft SOC8—especially those sections applying to pre-pubertal children and adolescents. WPATH can do better than this. For the sake and survival of the next generation of Trans, Nonbinary, and Gender Diverse children and youth, WPATH must do better.
See link at top of page to Download full paper with tables in pdf format:
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also commonly cited as:
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Copyright © 2022 Kelley Winters