In the wake of a new apology from a mental health organization, Dr. Kenneth Zucker has repeated his claims that the decision to close his gender identity clinic was political rather than based on research.

“It takes energy, it takes education, and it takes empathy, and listening to the parent’s concerns as well, for them to understand that it’s actually that rejection that’s [more likely to] lead the kid to a … worse outcome.”

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The former chief psychologist of the gender identity program at one of Canada’s largest mental health facilities was catapulted into headlines in 2015 when a complaint prompted a review of his now-closed clinic by the Centre for Addiction and Mental Health (CAMH) in Toronto.

The review occurred at the same time as a law was passed in the Ontario legislature banning so-called conversion therapy for minors, a discredited practice that falsely claims to change someone’s gender or sexual identity. The center’s report stopped shy of characterizing Dr. Kenneth Zucker’s practice as conversion therapy, but it did conclude his methods were “out of step” with the latest research findings and that they warranted sweeping reforms. Zucker’s clinic, which was housed inside CAMH but operated largely independently, closed later that year; the decision was met with support from nearly 1,400 stakeholders, including clinicians and researchers in the field of transgender health.

Since then, Zucker has often characterized the closure of his clinic as a campaign based in “politics.” He repeated the claim at the beginning of October this year, when CAMH issued an apology for including an erroneous allegation of professional misconduct in its review. However, neither Zucker nor the publications covering him have said much about the validity of the research that informed the review’s recommendations to reform the clinic. Mischaracterization of the research as political rather than scientific has been used by religious and conservative groups such as the National Catholic Bioethics Center and the American Conservative in their campaigns to sanitize conversion therapies.

When reached for comment, Zucker reiterated that he denies practicing conversion therapy. However, he also acknowledged previously describing a possible objective of his own practice as including working to “reduce their child’s desire to be of the other gender” if that’s what the parents want. (The American Academy of Pediatrics describes gender identity conversion therapy as methods that “are used to prevent children and adolescents from identifying as transgender or to dissuade them from exhibiting gender-diverse expressions.”)

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CAMH’s apology to Zucker specifies two errors from the review as part of a $586,000 settlement: the erroneous allegation, and releasing the report without consulting him. A statement from a CAMH spokesperson said that the apology contained “all the details” of the case.

Julia Serano, a biologist who spent 17 years as a research scientist at the University of California, Berkeley, and has also written ethics papers on gender diversity, explained to Rewire.News that the consequences of conversion therapy, also sometimes called “reparative” therapy, were being discussed long before the closure of the CAMH clinic: “Stories of how unsuccessful and traumatic these gender-reparative approaches can be were initially told by trans adults outside of the traditional gender clinics and research settings.” She mentioned an autobiography by Dylan Scholinski, The Last Time I Wore a Dress, which detailed his abusive institutionalization as an adolescent for rejecting feminine gender roles in the 1980s; and Gender Shock, a 1996 book by Phyllis Burke that detailed the methods employed to force gender-role conformity on children and teenagers.

“Over time,” Serano said in an email, “it became clear to trans health professionals that gender-reparative approaches were more harmful than previously recognized, and that children have far better outcomes if their genders are affirmed rather than disaffirmed.”

Dr. Aron Janssen, child psychiatrist and director of the gender and sexuality service at NYU Langone’s Child Study Center, agreed: “This is a field where there is a limited amount of evidence for any single approach. So we have to work with the information that we have, and the information we have is that supporting and validating these kids’ experiences makes the biggest difference in reducing risk and improving outcomes.”

As a clinician, Janssen treats gender role-nonconforming, gender questioning, and transgender youth with an approach supported by the kind of research cited in the CAMH review. “Our goal is that we want to support the gender health of every child who comes into our care,” Janssen told Rewire.News. “Everybody develops a sense of gender identity, everybody develops a sense of sexuality, and the affirmative approach says there is no outcome that is privileged over the other .… Treatment will be quite divergent depending on what the child’s and family’s needs are.”

Zucker criticized what he thought those protocols meant. He referred Rewire.News to an October policy statement by the American Academy of Pediatrics (AAP) that he claimed was “leaning toward” social transition as the preferred approach, including for young children: “I haven’t read the whole thing to see if they actually explicitly say with 5-year-olds you should consider a gender social transition, but it seems that’s sort of where they’re leading.” (In prepubescent children, social transitioning may involve changes in clothing or hair style, but by definition it does not include biomedical intervention.)

Dr. Jason Rafferty, one of the authors of the AAP policy statement, rejected that characterization. “The role of this as a policy statement [was] to advocate for better networks of support for the pediatricians addressing some of these issues in areas that really are low-resource,” he told Rewire.News. “We explicitly state that there’s no path, there’s no timeline, that it’s very individual for each patient who comes in. We go over that again and again in the paper that it comes down to the pediatrician-patient and pediatrician-family relationship. It’s very individual and personalized in terms of what’s decided upon.”

Zucker referred to another article in Clinical Practice in Pediatric Psychology that he claimed implies that “the first line of treatment should be a gender social transition.” Dr. Diane Chen, one of the authors of that paper, told Rewire.News that was incorrect. “I would not agree with that,” wrote Chen. “As you’ll see from the ‘ongoing controversies’ section for pre-pubertal youth, we discuss the relative harm of encouraging social transition.” The paper recommends instead that parents of children considering or undergoing social transition keep their statements to their children open-ended with respect to their eventual adolescence and adulthood.

A common myth about the type of service described by the AAP, and the service Dr. Janssen offers, is that youth are rushed into referrals for hard-to-reverse or irreversible transition procedures. “If someone comes in and their child is saying, ‘I’ve been thinking about this for the last two weeks,’ it’s not like anybody’s going to make a recommendation that child goes on a some sort of irreversible intervention,” Janssen told us. “It’s more like: Let’s understand this and let’s see how this develops over time.” Any biomedical intervention for an adolescent would only be recommended after they meet the criteria for gender dysphoria in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which requires a strong desire to be another sex that persists for at least six months.

And Rafferty pointed out that the question of medical interventions is irrelevant before adolescence: “Many medical interventions that are available are not even indicated before puberty would start …. We know that in pre-pubertal kids, gender exploration is a normal part of development.”

Zucker confirmed that during his practice at CAMH he sought input from the parents in “shaping” their child’s outcome, including parents who didn’t want their children to be transgender. Both Serano and Janssen had concerns with that notion. “Almost all of the difficulties that transgender people face stem directly from societal transphobia and the fact that trans people are marginalized in our culture,” said Serano. “Many trans people who have been subjected to gender-reparative therapies found them to be unnecessarily invasive and traumatic, as it simply forced them to repress their genders and remain closeted. This is why many of us consider such approaches to be unethical today.”

Janssen allowed that such parents might be hoping for a safe life for their kids, but he doesn’t think that response aligns with the evidence: “It takes energy, it takes education, and it takes empathy, and listening to the parent’s concerns as well, for them to understand that it’s actually that rejection that’s [more likely to] lead the kid to a … worse outcome.”

In a statement provided to Rewire.News, the center said, “CAMH stands by its decision to close the child and youth gender identity clinic following an external review which concluded the clinic was not meeting the needs of gender expansive and trans children and their families. We believe our modernized approach to delivering services to youth better supports diverse patients through best practice and timely care.”

Zucker confirmed with Rewire.News that he still offers services similar to his CAMH clinic at his private practice.