Thoughts on ‘Transgender Kids: Who Knows Best’

I haven’t posted for a while, but I feel like I’ve got a lot to say today.

I don’t really want to get into discussing Zucker and the reasons why he’s controversial, nor about the best therapy for trans children. There are other people who know more about this than me, who can discuss it better than me.

Instead I want to focus on the documentary itself – what messages did it give, and how did it do that? In my view, part of the reason this was such a poor documentary is that in fact it wasn’t entirely clear what this was a documentary about, and it ended up mixing together several rather poorly-explained issues. I can see several possible strands to the documentary’s narrative, but only the fourth was done effectively. And if the fourth was what the BBC was intending – well, I don’t really know where we go from here. Other than to say complain.

Strand 1 – Closure of Dr Zucker’s clinic

If this was a documentary investigation of the circumstances that led to Dr Kenneth Zucker’s clinic being closed, and giving a voice to Dr Zucker’s views on that, then I would have expected some detail on the circumstances of that closure. Who decided to close the clinic? How were decisions taken? When? What meetings took place? Who was at those meetings? What criticisms are there of the process followed, and are there rebuttals to those criticisms? Absolutely fundamentally: what were the officially stated reasons for closing this service and rendering Dr Zucker unemployed?

Contrary to what was implied, “transgender activists” did not fire Kenneth Zucker for not being gender affirming enough. How could they? They weren’t his employers, and I suspect that even in Canada, trans people are not powerful enough to merely point at a medical service and say “Close that” and it happens. (If they were, I get the impression that this clinic would probably have been closed rather earlier than it was). Campaigners and service-users make plenty of calls for public figures they don’t like to be sacked every day of the week, but that doesn’t usually happen.

As I understand it, the Toronto Centre for Addiction and Mental Health (CAMH) ran the clinic. CAMH became aware that the practices at this clinic were controversial and commissioned a review, undertaken by professionals, who took steps such as seeking the views of other medical practitioners in this field and listening to the views of current and former patients. A report was published, and the review process culminated in management deciding to remove Dr Zucker from post, and wind the service up. It appears from other accounts that Dr Zucker thinks the review process was biased, and at least one allegation in the original report may have now been retracted. I do not know enough about the details of these events to discuss them.

But if the closure was the issue under debate, then the documentary should have given me those details on how and why the clinic was closed. The BBC should have had interviews with someone  from CAMH. Or if no-one from CAMH was prepared to go on the telly, refer to press statements issued by CAMH at the time and make it clear that CAMH now refused to comment. Talk to the reviewers. Get hold of a copy of the review report. Discuss what the allegations were, what’s been retracted, what still stands. Test the credibility of some of the disputed allegations. Look at relevant national and international guidelines on good practice for clinics, and consider how the concerns raised might or might not have contravened those guidelines. None of this happened. It seems pretty poor journalism to do a piece on the closure of a health service without looking at the formal reasons given by decision-makers for closing it (or indeed, without really acknowledging that there were decision-makers involved and instead imputing everything to “activists”).

Strand 2 – Debates over the best approach for supporting gender diverse young people

This was certainly what the title of the programme seemed to imply the programme was doing. But if the programme was looking at debates over medical care for prepubescent gender diverse kids, it needed to (a) explain what the debate was, and (b) stay focused on the subject.

Gender affirmative care is not and never has been focused upon preparing young children for medical intervention. As far as I am aware, gender affirmative practitioners are well aware that some young kids who turn up at gender identity services will not go on to transition, and would seek to make it clear to those kids that it’s okay to not to be trans too. Every practitioner would seek to tailor their approach to the child and family involved. No practitioner would want a child to have medical intervention which is not in their best interests, nor put a young child on an irreversible path to medical transition before they are capable of making a decision. There are no medical interventions (hormonal or surgical) which anyone advocates being given to a trans child not yet in puberty.  These are not ways in which Dr Zucker’s approach differs from gender-affirmative practice, and they are not principles which I think any vaguely competent, ethical practitioner working with children would disagree with. (Additional clarification  14/1/17: Although not discussed at all within this documentary, intersex children and young people do require protection from inappropriate surgical intervention).

Within the programme, Dr Blanchard seemed to state that there were indeed a core group of kids who would go on to transition regardless of intervention. Dr Zucker and another colleague of his suggested that for young children, it was simply impossible to distinguish children who would go on to transition from the wider pool of children attending gender identity services. As I understand it, this is different to the views of some gender-affirmative practitioners, who do believe that they can assess which children are most likely to go on to transition. The discussion on this issue was not presented in a particularly balanced way. However, I don’t think this is the core of the issue since, as I have already said, there seems to be widespread agreement that approaches should be tailored to the child and family, and that irreversible medical interventions should not be undertaken with young children.

The most significant controversy with regard to pre-pubescent children is whether the focus of therapy should be making it clear to the child that they are free to explore what makes them most comfortable with regard to identity and expression, including potentially taking steps like changing hairstyle, clothing etc., and telling that they are accepted regardless (affirmative approach) or whether attempts should be made to encourage the child to change their behaviour and self-identity to be more in line with their birth sex, and hence discouraging or preventing the child from doing things like dress in ways not conventionally consistent with their birth sex (reparative approach). The British Association for Counselling and Psychotherapy, the World Professional Association for Transgender Health standards of care 7 (which all UK gender clinics work to), and the law in Toronto have all stated that actively attempting to change gender identity, or dismissing it, or making someone feeling ashamed about themselves is not merely an unorthodox or unconventional approach – it is unethical and potentially harmful.

Dr Zucker was clearly rhetorically opposed to affirmative practices, but denied he undertook a reparative approach. However, the “dog food” quote seems to imply that he thought young children’s gender expression could and should be limited to some degree. There were some anecdotal accounts about individual children Dr Zucker had worked with, given by both Dr Zucker and others, in which the description of the approach taken didn’t seem hugely controversial with regard to those individual children. However, nothing in the programme really explained to me what Dr Zucker’s general principles were, and what he felt was the fundamental difference between what he did and either the affirmative approach or the reparative approach. I felt the programme left it ambiguous (possibly deliberately) whether Dr Zucker was himself opposed to controversial reparative therapeutic practices, or whether he felt such practices were  sometimes acceptable but he just didn’t like the terminology. If Dr Zucker is of the view that these types of interventions are harmful, and that he feels he has been entirely falsely accused of practices which he would never seek to justify, that should have been explicitly stated within the programme. If he is not of the view that they are harmful, or (more likely) felt some such practices may be suitable in some situations, this should have been clearly outlined, and the areas of disagreement explicitly highlighted, including specific reference to issues such as ethical standards of practice, clinical guidelines issued by professional bodies etc.

Another significant problem was the frequent references to trans adolescents and adults, which was done in a way which tended to conflate interventions for young children with those for adolescents and adults. Even practitioners with a fairly sceptical approach to treating young children, such as Dr Zucker and Dr Blanchard, do support some older adolescent and adult trans patients accessing medical transition interventions such as blockers and (later) cross-sex hormones and surgery. So why did the programme include a section on an eighteen year-old having surgery, and a section on someone who had had surgery at twenty and regretted it? Since no-one was suggesting that pre-teens should be offered surgery, what relevance did this have to a debate about trans children? Since Dr Zucker and Dr Blanchard were not (as far as I know) suggesting that adults should never be offered surgery, what relevance did these interviews have to discussing their views? The purpose of including these sections seems to have been to either imply that medical care for trans adults was also contestable under the same sorts of arguments as those made by Dr Zucker (false, and if this was being asserted, it should have been addressed much more thoroughly), or to suggest that providing gender affirmative therapy to children inevitably leads to surgery (also false).

I want to make it clear that I absolutely think people who have undergone elements of medical transition and regretted it should be given a voice, and should not be subject to harassment for talking about their experiences. Gender services should learn from these cases, and I would hope that the trans community can support people in these situation, and if this hasn’t happened, we should work on improving. However, this discussion was simply irrelevant to talking about the decisions for pre-teen children. It was included without adequate context to explore the issues raised; and it may have falsely given the impression that surgery for young children was being advocated by some parties (reinforced by clearly false statements about surgery for primary school children from Emily Maitliss of Newsnight made prior to the programme).

Strand 3 – “Born in the wrong body” and “brain sex”.

I’m a trans man. I do not believe I was born in the wrong body. My hands are mine, my face is mine, my ears are mine, my nose is mine. My weird feet with too long big toes are mine. And yes, even some anatomical bits that are not conventionally associated with being male are mine. And I don’t believe I have a “blue brain”. Nor am I particularly stereotypically masculine. I don’t like trucks, or football, and I throw up if I drink beer. I believe that there are no hard and fast differences between male and female brains, and that gender is complicated and almost certainly a mix of different factors. Oh, and I have a long-term boyfriend, and have only ever had relationships with men, so I really don’t think I’m a confused lesbian either.

Not all trans people share my views. There are loads of interesting and informative discussions that could be had on the subject of trans identity and gender. A straw man argument of “Trans people are so silly to believe they were born in the wrong body. They’d be fine if only they’re realise boys can like pink too/it’s okay to be gay” is not one of those informative discussions. In fact, it’s frankly insulting to a wide variety of trans academics and activists (yes, including people with titles like Professor and Doctor, based at big universities you will have heard of, publishing in peer-reviewed journals) who have put forward nuanced, eloquent arguments on these subjects.

Also, for the sake of balance for my trans friends who do hold essentialist beliefs, the BBC has in the past been quite happy to wheel out scientists who do believe there are fundamental, innate sex differences in the brain and usually make it clear that there are multiple different scientific views on the subject. It seems to be only when trans issues are being discussed that we get told that the “experts” say that innate gender identity is impossible, and that trans people who believe otherwise must be wrong.

Ultimately, I don’t think these arguments are actually particularly relevant to debates about supporting kids. Researchers are still debating whether or not there’s a gay gene, and if so, whether it explains all same-sex attraction and behaviour in all people. The fact that there is a debate, and that there is a fairly strong case for saying that the idea of a gay gene is a bit simplistic, would be unlikely to get cited on the BBC nowadays as a justification for trying to turn gay kids straight. So why is this straw man argument wheeled out to try to question support for gender diverse children?

Strand 4 – Hatchet job on trans people

Ultimately, I think that’s what this documentary comes down to. It wasn’t a rational, nuanced, carefully made debate on any of the subjects above. As I’ve indicated, it jumped around between topics, didn’t even stay focused on the issue of children, and was often based upon attacking straw men opinions supposedly held by “trans activists” (what, all of us? If the programme-makers seriously believe that trans activists are of a single hive-mind on trans issues, then they have little experience of trans activism). It was the wheeling out of multiple tropes that trans people have been wearily challenging for years. Julia Serano wrote a very good article a while back outlining pretty much everything that was wrong with this kind of debate – indeed it’s tempting to believe that the producers of this documentary read Julia’s piece and deliberately decided to make a documentary which would fall foul of as many points within it as possible.

I find it hard to believe that this can all have been sheer incompetence. That something so ham-fisted was made and – what? No-one at any stage thought about ‘What message is coming across here about trans people and is that fair’? No-one thought ‘Hey, this is a documentary about care for young children, so why have we set up interviews discussing the experiences of people who had surgery as adults’? No-one thought ‘Hey, let’s ring up CAMH and try and clarify what this whole “getting fired” business is really about’? No-one thought to have a quiet word with a couple of contacts with some knowledge of the area (not necessarily trans people: health, social care or third sector professionals working in this field would have done), just to check the basic premise wasn’t too far off? Someone went ahead and wrote a write up for the website on an obviously controversial subject which didn’t even reference the fact that they were including opinions from more than one perspective? But if it isn’t incompetence, then the BBC deliberately went ahead and commissioned, screened and promoted a documentary about trans issues which they knew would be subject to serious questions over bias and fairness, with regard to a) children and b) a group that the Leveson Inquiry and the Women and Equalities Parliamentary group have already acknowledged get a rough deal in the media. I think that’s worse.

To be honest, the fact that this is the BBC makes it hurt more. For a start, I pay for the BBC. And I suppose, despite past problems with BBC coverage of trans issues, I was still naïve enough to believe that the BBC is in some way a little bit better, a little bit more rational and balanced. That the BBC has some interest in equality and fairness, rather than just putting out sensationalist nonsense to get the punters in on a Thursday night. I think that belief died last night.