Ken Zucker and the Invention of Childhood Gender Disorders

There was never a good time to be a kid in a gender clinic

"In families where the mother is angry at men, a boy may identify with evil females, like Cruella in '101 Dalmatians.' "

–Kenneth Zucker (1994)

When I picked up a 1990s child psychology text recently, I couldn’t believe it had been published during my lifetime. The authors’ views on sex roles were stodgier than my grandparents’. Apparently while I was a little girl running around in gigantic Green Day t-shirts, reputable child psychologists were discussing whether mothers like mine suffered from “penis envy.”

Album art for Dookie by Green Day (1994)

Soon the tides would shift. According to gender doctors who took the stage in the 2000s, kids who wanted to be the opposite sex were innately transgender and their parents had nothing to be ashamed of.

I understand now why that “born in the wrong body” idea took hold so easily. It’s because the official thinking about gender-nonconforming kids that prevailed right up until then was archaic and mean. It pathologized mothers based on “conjecture” and dictated taking away little boys’ dolls.

If you cover your ears when trans activists shriek about the child psychologist Kenneth Zucker, I’m here to tell you some of their criticisms have merit. He tap-danced around the question of gay conversion therapy, rather than state plainly it was a bad idea, as recently as 1995. He stood up for confiscating dolls in 2008. Sure, it’s nice that he questions the practice of socially transitioning toddlers. But the enemy of your enemy is not someone you want counseling your child.

Zucker apparently still works with kids. He supports transitioning teens and he refers to sex as “assigned.” In other words, he’s a gender doctor(ate).

In this post I’ll show you how gender shrinks thought in the 1990s, with a focus on Zucker and the 1995 book he co-authored. I’ll also break down the fallacy at the heart of the DSM-IV’s entry for “Gender Identity Disorder.”

Terminology: I’ll note mental health professionals’ credentials as either MD (psychiatrist) or PhD (psychologist). “Shrinks” refers to practitioners of either discipline. 

A New Take on Trans

In the 1970s, gender doctors thought that some patients needed “transsexual surgery” because they were “transsexuals.” They believed that men who sought their services because they were fetishists (“transvestites”) or gay were not true transsexuals. This was a canard that gave gender doctors cover whenever patients experienced bad outcomes.

These clinicians believed transsexualism was an innate, almost holy quality that could not be influenced after early childhood. A 1977 pamphlet urged getting a “gender-disturbed child” into therapy by age five. 

By the early 1990s, shrinks like Susan Bradley (MD), Kenneth Zucker (PhD), and Ray Blanchard (PhD) — all based in Toronto — had brought realism to the field. They acknowledged that gender patients were almost all homosexuals or fetishists and that gender medicine was hard on the body even with high-quality medical care. But they still supported transition in many cases.

Several of this set focused on children. For example, Bradley, Zucker and others investigated the “physical attractiveness of girls with” GID (1996). They believed a child’s “gender identity” was malleable in the hands of the right therapist — but only until puberty. 

Bradley and Zucker’s Gender Identity Clinic in Toronto was founded in 1975. It treated children and adolescents, referring teens to an adult clinic for possible hormone prescriptions as early as age 16. In 2016, the journalist Jesse Singal described its practices:

“[T]he GIC did frequently help patients, particularly older ones, transition to and live as their felt gender, providing a wide range of services that included hormone referrals.”

“The ‘Wrong’ Sex” (1994)

In 1994, the New York Times surveyed the professional child gender scene in “The ‘Wrong’ Sex: A New Definition of Childhood Pain.” The word “wrong” didn’t actually appear in the piece, and it doesn’t sound to me like a term these shrinks would use — I wonder if the headline reflects activist influence in the air.

Welcome to a 1990s gender clinic:

“EVEN when he was just 3 years old, the boy spent hours preening himself in front of a mirror, dressed up in his mother's clothes, makeup and jewelry. He shied away from rough-and-tumble games with other boys, preferring to play dolls with girls. His favorite stories featured women: Snow White, Rapunzel and Alice in Wonderland.

“He hated being a boy, he said; he'd rather be a girl. He once told his therapist, ‘if you wear girls' clothes you could really become a girl.’

“The child was referred for therapy by his nursery school, not just because he insisted on dressing as a girl, but also because he was extremely shy and easily upset. The diagnosis that he received when his parents brought him for psychotherapy was gender identity disorder, the fervent desire to become a member of the opposite sex and distress at one's own gender.

“He was in therapy for four years. Now, at 10, he ‘likes himself as a boy, and doesn't really remember cross-dressing,’ said his therapist, Dr. Susan Coates [PhD], director of the Childhood Gender Identity Center at St. Luke's-Roosevelt Hospital in Manhattan.”

Was the boy’s real problem, if anything, shyness? Was that problem exacerbated by adults picking on his toys? Would he have gotten over the desire to be female without therapy?

Pediatrician Linda Linday clarified that GID should only be diagnosed in severe cases of dress-wearing:

"The problem is with the little boy who insists on dressing as a girl all the time and brings his Barbie doll with him wherever he goes, not the little boy who at dress-up time in nursery school one day puts on the Princess Jasmine costume and then jumps right into some game with other boys."

Like the best gender diversity consultants of his day, Zucker free-associated about a wide cast of dead people:

"Many cultures have found ways to deal with people wanting to live as the opposite sex … Native Americans had a tradition of men who lived as women -- 'berdache,' as the French called them. In other cultures, some men who became eunuchs may have gravitated to the role because they had the same tendencies."

Coates warned, probably without real evidence¹:

"But if you don't treat [GID] until 9 or 10, it's much harder to turn around. And beyond age 12 or so, there's a good chance they're on course to become a transsexual as adults."

If the reader still felt discomfited by the idea of “treating” gender nonconformity, the NYT ended with a reassurance:

“Those who treat gender identity disorder point out that it is the child's distress that signals the need for therapy, not necessarily the cross-gender activity itself. ‘Our society is trying to be more liberal in letting boys and girls try out opposite sex roles,’ Dr. Linday said.”

Culling the distressed from the liberal sounds wise and moderate. But look more closely at what that means.

DSM-IV and the Distress Fallacy (1994)

The fourth edition of the APA’s Diagnostic and Statistical Manual (DSM-IV) came out in 1994. Bradley led the subcommittee on GID, whose membership included Zucker, Blanchard, Coates, Richard Green (MD), and Stephen Levine (MD).

The diagnosis required the child to fit four of the following: wanting to be or saying they are the opposite sex, cross-dressing, “persistent preferences for cross-sex roles in make-believe play,” “intense desire to participate in the stereotypical games and pastimes of the other sex,” and “strong preference for playmates of the other sex.” They also had to be averse to their own bodies (peeing in a suboptimal position) or simply averse to toys/clothes associated with their sex.

In other words, the kids had to be gender-nonconforming. The only troubling behavior listed there is the kids’ self-loathing and insistence they are the opposite sex. But those items are troubling because they sound deluded, obsessive or self-loathing – traits with their own diagnostic categories. Anyway, a kid could be diagnosed with GID without either of those symptoms.

The final requirement:

“The [gender] disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning[.]”

The distress formulation was used throughout the DSM-IV to draw a line between lower and higher levels of severity. But “distress” played a different role in the GID entry: it created two types of gender nonconformity, innocuous and malignant.

The distress criterion was a cop-out that let shrinks avoid saying whether they thought gender nonconformity was bad. Their answer was: it’s bad if it causes distress or impairment. Case by case. But if a quality is not inherently bad, then how can it cause distress or impairment? 

There was no way to prove that a kid’s distress was (or wasn’t) caused by gender-nonconformity. It might be caused by other people being jerks, or some unrelated trait or incident, like the shy boy described in the NYT article. A child who happened to be gender-nonconforming was at risk of being referred to gender doctors for any problem.

GID wasn’t a discrete condition. It was a concoction of other disorders, cultural prejudices, and homosexuality. It was the mirage that formed when a gender-nonconforming kid was in distress.

Did clinicians in the field all mean the same thing when they diagnosed a kid with GID? Maybe not. In 2009, Zucker acknowledged:

“Since the DSM-IV criteria for GID in children were published, there have been no formal reliability studies of the GID diagnosis for children. By this, I mean that there have been no studies that have reported inter-clinician agreement on the diagnosis. This is a serious deficiency in the literature.”

“Gender Identity and Psychosexual Problems in Children and Adolescents” (1995)

Bradley and Zucker were colleagues and collaborators affiliated with the University of Toronto and the Clarke Institute, which treated kids for GID. In 1995 they published a book marketed to clinicians as “a comprehensive overview of the most recent clinical work and research on the topic” of child/adolescent GID.

The authors employ the Mr. Potato Head model of sex and refer to it as “assigned”:

“In contemporary sexology, the term sex refers to attributes that collectively, and usually harmoniously, characterize biological maleness and femaleness.” 

Note the acknowledgment that gender researchers make up their own definition of “sex” rather than defer to biologists’. How would they feel if biologists redefined one of their terms, like gender identity? I guess they figure biologists will never have any reason to discuss gender identity.

The authors don’t define “gender identity.” They state that a “child’s acquisition of gender identity is … more than a cognitive milestone; it is also surrounded by affective significance.” But what is it? They mention one scholar defined “core gender identity” as “a young child’s developing ‘fundamental sense of belonging to one sex.’” I think that’s what the authors run with, but they don’t explicitly say so.

Parts of this book could almost be a debunking of the child GID field (I read for certain topics, not all 400+ pages). Over and over, the authors note serious flaws in studies, like lack of control groups; they puzzle over contradictory, weak, or paradoxical findings; and they admit that theories are “conjectures” unsupported by evidence. Here’s a sample.

“Rationales for Intervening”

Why not leave GID kids alone? The authors cite four reasons in chapter 9. 

First, “reduction of social ostracism.” If a boy is bullied for his femininity, gender doctors can train him to fit in better. This strikes me as obscenely un-American, but then, the authors practice in Canada.

Second, “treatment of underlying psychopathology.” This is the “red flag” theory of doll-playing — sometimes a kid comes in for GID and it turns out he has a different problem. But if your goal is to help kids in distress, hauling in all the future gays isn’t a very targeted way to do it.

Third, prevention of GID in adulthood, which would drive the patient toward the meat grinder of gender medicine. Appealing idea, but how do you prevent young people from wanting genital surgery? Mystery. “There are simply no formal empirical studies” showing therapy works.

Personally, if I were trying to prevent transsexuality I’d target military men.

Fourth, prevention of homosexuality. Some parents want gender therapy for their kids because they think it will make them grow up straight. The authors treat this delicately:

“Given that most parents, not surprisingly, prefer that their children not develop a homosexual orientation, the contemporary clinician must carefully think through the ethics of instituting treatment for this reason and the empirical evidence that treatment can have this effect.”

The authors discuss this for three pages, with much of that space given to justifications for trying to prevent homosexuality. They finally acknowledge “there are simply no formal empirical studies” showing it works. A paragraph later, they spin it as: “it is unknown whether such treatment can affect later sexual orientation[.]”

The authors don’t refer to evidence that homosexuality is based in biology, even though they cite it elsewhere, and they don’t warn the reader that trying to turn a gay kid straight is humiliating and deceptive.

Why so mealy-mouthed? Maybe they’d lose patients if word got out that they weren’t ex-gay therapists. Pro-conversion groups like NARTH frequently cited Zucker’s work (I don’t know whether he encouraged them or if they cited him accurately).

Zucker discussed parents’ desire to cure gayness in 2022 on Gender: A Wider Lens. Referring to his years at GIC, he claimed “we made it very clear [to parents] that changing a child’s sexual orientation was not a goal of any therapeutic plan that we were going to propose.”

Treatments & Outcomes

The authors survey the various gender treatment protocols in chapter 9. Note: when they say “child,” they mean pre-pubescent kids, not all minors.

After three pages on behavior therapy (e.g., punishing cross-sex behavior, rewarding conformity), the authors acknowledge the studies on it lacked control groups and sum up:

“What do we know about the long-term outcome of children with GID treated by behavior therapy techniques? Unfortunately, not very much.”

After four pages on psychotherapy, the authors acknowledge it’s never been tested against an untreated control group and many of the studies involve confounding variables. They’re also all short-term:

“What do we know about the long-term outcome of gender-disordered children treated by psychotherapeutic techniques? Again, not very much. There have been no published long-term follow-up reports assessing gender identity or sexual orientation[.]”

Before admitting this, the authors discuss the theories that maternal distance or “excessive closeness” can cause swishiness in little boys, and suggest a “multimodal approach” might help to “heighten[] parental concern regarding the boy’s femininity[.]”

Treating the parents? “[S]ystematic information on the question is scanty.”

Group therapy: “detailed information was lacking” but some of the boys made friends with each other.

The Real Reason to Treat

After acknowledging the lack of evidence for intervening with GID kids, the authors explain why they do it:

“In our clinical experience, we have found no compelling reason not to offer treatment to a child with gender identity disorder.”

It’s the same logic that drives doctors to keep offering me hormonal birth control.

The authors conclude:

“It has been our experience that a sizable number of children and their families achieve a great deal of change. In these cases, the GID resolves fully, and nothing in the children’s behavior or fantasy suggests that gender identity issues remain problematic.”

Would the kids have outgrown their issues (or non-issues) anyway? Do the authors mean the kids became content with their nonconformity, or stopped nonconforming? Why should I trust someone who just claimed the pill has no side effects?

The authors don’t mention the concept of iatrogenic harm. To be fair, the definitive book on how Bad Therapy harms kids just came out last week.

They conclude this chapter by accusing their critics, who don’t think therapists should treat GID, of “nihilism.”

Glimpse into an Ongoing Study

Zucker’s reputation today among gender-criticals is built on the claim that he helps gender-dysphoric kids desist. Would they desist anyway without him? A few months ago I had the chance to ask one of Zucker’s acolytes whether he’d proven his methods by comparing the outcomes of treated patients to untreated patients. This person didn’t answer and instead lashed out at me for daring to question an expert. My frustration led me to buy this weird book.

The study I’m looking for may have been conducted after this book’s 1995 publication. I’m just saying Zucker didn’t have it then, twenty years into his practice.

In chapter 10 the authors discuss a study they’re currently working on. Its protocols are loose. For example, the 45 kids are seeing a variety of therapists (apparently unaffiliated with the study) at different ages, some inconsistently. A 14-year old girl is classed with prepubescent kids because she’s “severely retarded[.]” I hope she didn’t ultimately transition; the authors don’t discuss whether intellectually disabled patients should be treated differently.

The authors override a 19-year old’s report that she’s a zero on the Kinsey scale (totally hetero):

“[T]here was compelling evidence that she was in fact involved in an enduring lesbian relationship, so for conservative reasons she has been classified as homosexual [6].”

Why is that “conservative”? I think gayness is implicitly considered a bad outcome, so the authors are showing how honest they are by not even splitting the difference and giving her a 3.

The authors interview the teen subjects about their dates, fantasies, sex dreams, and masturbation habits. These case reports are detailed and gross.

Supporting Teens

In chapter 11 the authors discuss how they treat teens with GID:

“Treatment is largely supportive, the intent being to help the adolescent clarify his or her gender identity and, when appropriate, to provide support in surmounting the many hurdles on the path toward sex reassignment.”

The authors mention research suggesting desistance is possible at this age but dismiss it. In their own ongoing study of GID kids (unclear if it’s the same one discussed in chapter 10), 19 of 44 have already been referred to a clinic where they can receive cross-sex hormones.

The authors drop a caveat as they’re wrapping up:

“In our experience, attempts at psychotherapy with these adolescents have not yielded dramatic changes in gender identification. We do, however, have one case of a young man who presented at age 16 requesting sex reassignment and at follow-up 2 years later, with no treatment, reported that he had relinquished his desire to change sex[.]”

No treatment, huh! They note he was involved in “a church group” — I wonder if they’re insinuating, as the ACLU has done, that people only renounce their trans identity for religious reasons and religious reasons are invalid.

Understand the Mothers

The authors don’t want to be accused of blaming mothers. Chapter 7:

“[E]ven if one establishes unequivocal evidence for the importance of parental variables, this should not be construed as blaming. … Rather, from a clinical point of view, one is interested in understanding.”

To be clear, the authors don’t establish unequivocal evidence for the importance of parental variables. This section consists mostly of case studies and clinicians’ observations. Confirmation bias is everywhere — the researchers believe in nurture over nature, and that there’s something wrong with the kids in question, so they’re always looking for a flaw in the parenting.

The authors acknowledge the limitations of some of this research up front:

“It is clear, then, that the final word has not been written about the role of early reinforcement patterns. However, important lines of inquiry have been opened[.]”

In one case study, a mother was depressed because her own mother was dying. “She began to retreat to her bedroom for time alone, and recalled that it was at this point that her son began to play with dolls extensively in his room.” 

Was the boy macho before this? Would the adults have been cool with his isolation if he were doing something masculine alone in his room? I don’t have answers, but it’s important that we’ve opened up a line of inquiry: perhaps mothers should pretend to be happy all the time. To prevent transsexuality.

In some cases laid out here, the mothers do seem abusive. Maybe they are to blame for their sons’ interest in Disney divas. But if a boy role-played as Snow White, I’m afraid the authors would dig just as hard to find his mother’s mistakes. (Yes, this section discusses the boy who vamps as Cruella DeVille. Apparently it was just one kid, not an epidemic of sissy boys in fur coats trafficking dogs.)

Robert Stoller (MD) looked at mothers’ history of tomboyishness. The authors describe his results:

“[The study] implicates a form of familial transmission in GID, albeit a paradoxical one: That is, a relatively masculine woman ‘creates’ a markedly feminine son, which is a pattern inconsistent with a social learning/modeling paradigm. Stoller’s observations, however, of the mother’s underlying penis envy, rage, and hostility provide a clue to this paradox–namely, that the mother cannot tolerate masculinity in her son[.]”

The authors explore research that undermines this penis-envy explanation but also defend it. It’s confusing: they call Stoller’s thesis a paradox and show his findings couldn’t be replicated – why address this janky study at all? I suspect a lot of this chapter is filler because the authors don’t have much solid evidence to work with.

The authors finally find a settled point: “there is ample clinical evidence that boys with gender identity disorder have greater emotional closeness with their mothers than with their fathers.”

Don’t most young kids have closer relationships with their mother because mothers tend to be the primary caregivers? There’s no mention here of control groups.

A feminine boy’s drawing of his mother. She appears to be exhibiting Cluster B traits.

Diverse Views on Gays

Having already discussed “biological influences on sexual orientation,” in chapter 13 the authors turn to more whimsical theories about gayness “in order to give the clinician working with homosexual adolescents an appreciation of the diverse views on this topic.”

They start with Sigmund Freud. Vaguely acknowledging “critical scrutiny” of the “psychoanalytic approach to homosexuality,” they nevertheless plunge into it because “an understanding of sexual development cannot ignore [that approach’s] important theoretical contributions.”

For example: 

“[Freud] postulated that homosexuality could develop as a negative oedipal resolution resulting from castration anxiety. In males, this anxiety was thought to produce a symbolic flight from ‘penis-less’ women and a search instead for objects with penises …”

Gender doctors rejected this theory not because it’s fantastical but because “investigators began to provide evidence that gender identity is normally established by age 3 (i.e., prior to oedipal resolution)[.]” The authors credit John Money and others with discovering this tear in the gender/Freud continuum.

For gay teens comfortable in their sexuality, “treatment should focus on development of a positive gay identity [and] support with respect to acculturating into the gay community[.]”

I don’t see evidence that these authors or the therapists they’re addressing have expertise in gay identity or “the gay community.” Nor do I understand why a content gay teenager should receive psychological treatment from a gender doctor.

Feels and Figures

The book features charts that convert self-reported behavior, feelings, and identity into numbers, all while assuming that masculine and feminine are objective concepts.

Mathiness

Zucker in the 21st Century

Zucker remained eminent long after that book was published in 1995. But by the early 2000s it seemed he lacked authority on the ground. Throughout the US, therapists were encouraging parents to “socially transition” their children who wanted to be the opposite sex (stay tuned). They not only indulged the kids’ non-stereotypical interests, but actually pretended they were the opposite sex. This was anathema to Zucker’s teachings.

These ascendant gender clinicians scorned old hands like Zucker for good reasons (the unscientific takes on sexuality and parenting) and bad reasons (the hesitation to socially transition children). 

Starting around 2006 the media covered the feud. By now Zucker was the head of the Gender Identity Service at Toronto’s Center for Addiction and Mental Health.

Here’s Hanna Rosin writing in the Atlantic in 2008 about one of Zucker’s patients: 

“When he was 4, the boy, John, had tested at the top of the gender-dysphoria scale. Zucker recalls him as ‘one of the most anxious kids I ever saw.’ He had bins full of Barbies and Disney princess movies, and he dressed in homemade costumes.

“Once, at a hardware store, he stared up at the glittery chandeliers and wept, ‘I don’t want to be a daddy! I want to be a mommy!’”

John’s parents took Zucker’s advice:

“They boxed up all of John’s girl-toys and videos and replaced them with neutral ones. Whenever John cried for his girl-toys, they would ask him, ‘Do you think playing with those would make you feel better about being a boy?’ and then would distract him with an offer to ride bikes or take a walk. They turned their house into a 1950s kitchen-sink drama, intended to inculcate respect for patriarchy, in the crudest and simplest terms: ‘Boys don’t wear pink, they wear blue,’ they would tell him, or ‘Daddy is smarter than Mommy—ask him.’”

At the time of publication, John was a gay 13-year old who liked to dance (but was secretive about it) and the family was pleased with Zucker’s services.

Trans activists got Zucker fired in 2015. The journalist Jesse Singal soon debunked their most incendiary charge against him. The ordeal made Zucker a martyr. Now gender-criticals treat Zucker like an authority even though he’s gender-credulous.

I understand the value of citing Zucker as an “expert” who questions the new trans orthodoxy. But I’d love to see journalists and podcasters ask him sharp questions. If you’re skeptical of pediatric gender medicine then you should be skeptical of Kenneth Zucker. He’s supported the medical transition of teenagers throughout his career. As to how he achieves desistance in younger kids, it’s not clear to me (after listening to about three hours’ worth of his recent interviews/talks) what methods he’s been using lately or how their outcomes compare to other methods’.

Zucker presented at a Genspect conference in March 2023. After pointing to data that suggested socially transitioning children locked them into cross-sex identity, he listed that as one of four possible treatment options for gender dysphoric kids. His conclusion:

“I do not believe that any of these approaches needs to be privileged over the others until we have more data.”

No, we should not wait for more data before shutting down crazy ideas like telling kids they are the opposite sex.

And we shouldn’t listen to “experts” who think sex is a matter of “maleness and femaleness.”

1. Michael Biggs in 2022: “The assertion that ‘GID persisting into early puberty appears to be highly persistent’ rested on slender evidence (Cohen‐Kettenis et al., 2008, p. 1895). The only relevant cited source described adolescents who had been first assessed at ages ranging from 13 to 18, a range extending well beyond early puberty (Smith et al., 2001). This source did not support the hypothesis that the probability of gender dysphoria persisting to adulthood jumped suddenly on the cusp of age 12, from under 50% to virtually 100%.”