A Wolf in Wolf’s Clothing: K. J. Zucker and Cisgenderist Research Literature

Research has the power to influence policy and thus lives, and so the duty for care in the research (and researchers) we publish and platform is instrumental in the potential to facilitate great progress or terrible harm. A clear example of the latter would be the body of work by Dr. Kenneth J. Zucker and other members of his “Invisible College,” a connected system of authors in collaboration with each other. Zucker and his invisible college were prominently identified a decade ago as some of the most discriminatory, yet most frequently published and cited research surrounding gender identity (Ansara and Hegarty 2012). In the years since this finding, the harm of Zucker’s work has only become clearer with the closure of his gender identity clinic for youth where he was accused by some clients of engaging in conversion practices (Ashley 2022, 3–9). While issues around the investigation led to apologies from Zucker’s former employers and a settlement in his favor, it is nonetheless important to note that the clinic remained closed and concerns around Zucker’s practices—conversion or not—remained (The Canadian Press 2018).

 Despite the constantly accumulating evidence of harm, the power Zucker holds in influencing research and healthcare for trans and gender-nonconforming communities remains, including as the chair of the American Psychiatric Association (APA)’s work group that handles diagnoses related to gender identity in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the fifth edition text revision (DSM-5-TR), which was only released last year (American Psychiatric Association 2022, xviii). Yes, a researcher with years of documented accusations of cisgenderist bias and self-admission of approaches that could be considered conversion practices (Zucker, Bradley, et al. 2012) is at the helm of the work group that establishes the definitions of transgender and gender diverse experiences.

To illustrate this problem further, this article reviews published articles since 2010 where Kenneth J. Zucker was listed as first, second, or third author and was related to gender identity. The year 2010 was specifically selected as a starting point with the intention of covering at least one decade of published material, especially in order to explore the prevalence of cisgenderist ideology even after public and published critiques such as Ansara and Hegarty’s (2012; 2014). This time range also allowed for inclusions of early discussions that were informing the soon-to-be-released DSM-5, of which Zucker would chair the work group discussing gender dysphoria as a mental health diagnosis (American Psychiatric Association 2013; Zucker 2010; Zucker et al. 2013).

Throughout the articles reviewed, concepts and approaches are critiqued and the various ways cisgenderist ideology appears is explained. Informing my own critiques will be the previous literature on this issue, as well as other literature noting the severity of this kind of harm and what a proposed alternative could include. Most importantly, much of the supporting literature is often informed by researchers of diverse gender identities and theories that value autonomy and the rights of marginalized communities to speak as the experts of their own experiences. As a point of researcher reflexivity, I too am a researcher and practitioner within the trans and gender diverse communities and the communities Zucker and others often discuss. Critical analysis of where our stories come from is an ethical responsibility, and we owe it to communities that we work with to reflect on whether they’ve been given the chance to tell their own stories themself (Iantaffi 2020).

Establishing Basis for Critique

Understanding cisgenderism

To further understand the concerns illustrated throughout this review, it is important to outline the “what"s and “why"s of the critique—cisgenderism. In addition, we must have a shared understanding of the communities discussed. Throughout this discussion, terms will be used to describe various experiences of gender identity including “trans,” “transgender and gender diverse (TGD),” and “self-determined gender.” The terminology of “transgender” is likely the most commonly heard but may not be exhaustive nor comprehensive. Noting this, many have tacked on other phrasing to be more inclusive, including the recent verbiage of “transgender and gender diverse” utilized in the most recent edition of the World Professional Association for Transgender Health (WPATH)’s Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (herein referred to as “SOC8” or simply “Standards of Care”). WPATH defined TGD with the intention of broadly capturing “members of the many varied communities globally of people with gender identities or expressions that differ from the gender socially attributed to the sex assigned to them at birth” (Coleman et al. 2022, 511). As for the other terms, “trans” serves as a shorthand umbrella term for transgender and gender diverse experiences and “self-determined gender” is exactly as it states, where someone has determined their gender identity for themself rather than assuming the imposed identity that was assigned to them at birth. For identities outside of this experience, Ansara (2010) notes the term “cisgender,” which includes the Latin prefix of cis- meaning “on the same side.” This term captures experiences where the assigned gender someone receives happens to feel congruent with their own felt sense of gender identity. Expanding upon the concept of cisgender identity and experience, let’s now expand further and discuss specifically the concept of cisgenderism.

When thinking about concerns within this body of literature, framings such as “transphobia” or “anti-trans discrimination” may come to mind. While I’m not of the opinion that those descriptors would be entirely inaccurate, the specific framing of cisgenderism feels important for this discussion. Whereas discrimination or phobias are often ascribed to micro-level interpersonal interactions, cisgenderism is an all-encompassing ideology. Bias, discrimination, and hatred are the manifestation, where ideology is the why. Ansara frames the notion of cisgenderism eloquently, describing it as the “individual, social, and institutional attitudes, policies, and practices that assume people with non-assigned gender identities are inferior, ‘unnatural’ or disordered and which construct people with non-assigned gender identities as ’the effect to be explained’” (Ansara 2010, 168). 

Within the specific area of research literature, Ansara and Hegarty (2012) report several different mechanisms with which cisgenderist ideology can appear: misgendering (labeling one in a way that does not match how they have designated they would like to be referred regarding gender identity), pathologizing (framing gender diversity as deviant or disordered), and binarizing (describing sex and gender both as rigid and binary constructs, erasing and invalidating people of intersex experience and/or with gender identities outside of the binary of man and woman). Any and all of these practices contribute to cisgenderism because they take away the individual’s ability to define one’s experiences of gender and body for themself and views any attempt to do so as invalid and illegitimate (Ansara and Hegarty 2014).

How cisgenderism harms communities

The way that cisgenderism and cisgenderist ideology have the impact to harm communities should be painfully obvious. However, some detail and elaboration are always important. Especially when one does not have a marginalized experience, it is quite easy to not recognize the multitude of subtle and insidious ways in which the impacts of discrimination and oppression influenced by ideology may show up in someone’s life. As one example, literature shows time and time again that discrimination and other barriers (often that are informed by cisgenderism) create negative and harmful experiences for trans populations simply trying to access needed care or resources, if not barred from even attempting to access them at all (Kcomt 2019; Iantaffi 2020; Puckett et al. 2018). Even further, it’s shown that previous experiences of discrimination or even the anticipation of discrimination based on community anecdote and aforementioned findings will often lead trans populations to avoid needed care and resources altogether (Kcomt et al. 2020).

Beyond care that is simply ill-informed or poor quality, cisgenderism can also influence and encourage care that is actively harmful and violent toward trans communities. In the most prominent example, individuals who have come to self-determine a TGD identity or are questioning their gender are not turned away as in the previous example but rather admitted into services that will ultimately attempt to change the individual’s gender identity (Ashley 2022; Kinitz et al. 2022; Salway et al. 2021; Turban et al 2018). This practice falls under the larger umbrella of “sexual orientation and gender identity and expression change efforts (SOGIECE)” or “conversion efforts,” which describe attempts at changing sexual orientation and/or gender identity or expression, usually to the more socially-accepted identity such as heterosexual or cisgender (Kinitz et al. 2022). Other historical terms include “conversion therapy” or “reparative therapy” although the use of “therapy” to describe these practices is ill-fitting given the proven lack of efficacy and the immense harm that tends to manifest for participants in forms such as increased rates of depression and suicidality (Ashley 2022; 2023; Coleman et al. 2022; Kinitz et al. 2022; Salway et al. 2021; Turban et al. 2018). As noted, conversion efforts can also include attempts to change sexual orientation (why another historical term some may be familiar with would be “ex-gay therapy”). For this discussion, conversion efforts will generally be referring to attempts to change gender identity or expression unless otherwise stated to also include attempts to change sexual orientation.

What is perhaps most uncomfortable about discussion of conversion efforts within the field of mental health is the ensuing reckoning when we face the hard truth that these sinister and harmful practices are a legacy of our field. We often grimace at the thought of conversion efforts as imageries of torture and electroshock fill our minds and we try to let these graphic visualizations remind us that was then, and this is now. I would point out that literature illustrates that conversion efforts are still immensely harmful even without explicit means of physical torture (Ashley 2022; Kinitz et al. 2022; Muse 2015, 2020; Salway et al. 2021). It is difficult and painful, but the harm that mental health fields have historically enacted and currently enact against queer and trans communities is no less a reality. I have often framed that mental health fields’ legacy regarding conversion efforts have “haunted'' our work to this day. As I think more, I retract this framing; for something to become the ghostly specter capable of such haunting, it needs to have died first.

Why Zucker?

It’s undoubtedly a fair question. Ansara (2010) even notes that cisgenderism by its very nature is a systemic issue rather than a single individual’s efforts. I’m inclined to agree. Having said that, Ansara and Hegarty (2012) also note that Zucker writes some of the most impactful, yet cisgenderist literature in the field and also holds immense power in vital positions to affect policy such as the DSM-5 workgroup that oversees the diagnosis of gender dysphoria. While Zucker is not the sole source of cisgenderism in research, critique of his many contributions of cisgenderism in the literature is certainly a reasonable place to start. In addressing Zucker’s high-impact role within the greater system of cisgenderism in research, one may hope that this conversation may also facilitate meaningful change within the many areas Zucker’s work has influenced and continue to cite his concerning body of work. Perhaps this issue may also lead to some critical reflection on who is in the room when we decide things like the diagnostic criteria for gender dysphoria (or if it should be a diagnosis in the first place).

Arguments for affirmative and self-determined approaches

There are multitudes of reasons to suggest an affirmative, non-cisgenderist approach that lets individuals determine and define their experiences and sense of body and gender for themselves. Beyond the obvious aforementioned harm brought on by the alternative, using such an approach can have profound ability to provide individuals seeking transition and/or self-determination of their body and gender with the support they need (Ansara and Hegarty 2014; Coleman et al. 2022; Iantaffi 2020; Twist et al. 2021).

Supporting this further, Deci and Ryan’s (2008) self-determination theory notes that the ability for one to have the autonomy to self-describe within their experiences can have deeply beneficial impacts. The conversations discussed thus far can be explored with self-determination theory’s understanding of needs and motivations. In situations where someone’s autonomy is valued, the outcomes are better. This is highlighted further when looking at different motivational orientations in the theory. Looking at an autonomous orientation compared to controlled and impersonal orientations which lack autonomy, they note “consistently, the autonomy orientation has been positively related to psychological health and effective behavioral outcomes; the controlled orientation has been related to regulation through introjects and external contingencies, to rigid functioning, and diminished well-being; and the impersonal orientation has been reliably associated with poor functioning and symptoms of ill-being, such as self-derogation and lack of vitality” (Deci and Ryan 2008, 183). In short, it is clear that the decision to take someone’s autonomy to self-determination away from them in our therapeutic interactions will only result in a rapid decline in the quality of the outcomes.

Scope of Critique

Naming all of the above concerns on why cisgenderist research and practices are problematic and affirming, self-determination approaches are sorely needed, it is important to address perhaps the most salient source of these ongoing issues. As noted in a thorough review and analysis of research literature around gender identity, it was found that Kenneth J. Zucker was the most severe offender of cisgenderist ideology in research as well as having some of the highest impact regarding frequency of citation and amount of publication (Ansara and Hegarty 2012). In wanting to explore further in the decade since this issue was raised by Ansara and Hegarty, a collection of literature from Zucker was collected to review further. As mentioned earlier, the parameters included published works (both journal articles and editorials) where Zucker was listed as first, second, or third author since 2010 where the title explicitly mentioned discussion of issues around gender identity. Those parameters were applied to Zucker’s personal curriculum vitae that was publicly listed on his website, which became the compilation of literature to review (Zucker 2020a). In total, 29 published articles, letters, and commentaries were reviewed and will be critiqued.

Cisgenderist Language and Framings in Literature

Noting the framing of cisgenderist ideology by Ansara and Hegarty (2012; 2013; 2014), language is one of the most substantial ways that ideology can be identified. In their original study of cisgenderism in research literature, specific categories of cisgenderism including misgendering, pathologizing, and binarizing were used (Ansara and Hegarty 2012). A similar framework is used in exploring this literature, noting how many of the citations contained misgendering, pathologizing, and binarizing as defined by Ansara and Hegarty in a symbolic follow-up to that study and see what (if anything) has changed in recent years within Zucker’s writing. In addition, specific passages are called upon as examples and to discuss further critique.

As one note, it’s also imperative to acknowledge the limitations around analyzing ideology and practice through use of particular language. Language is both contextual and ever-evolving and so there will always be some degree of nuance to be considered in these circumstances. However, best attempts are made throughout when exploring passages to use surrounding context clues to ensure understanding of what Zucker and his co-authors are trying to say, such as trying to explore what language is being used to describe a subject’s identification and what is being described as their sex at birth. Having said that, Zucker and others also use sex-based and gender-based terminology interchangeably quite often, which is its own form of cisgenderism and adds to the further complication in this analysis.

Misgendering

In the original study, misgendering was defined (for children, but applicable generally) as when the researchers “categorised a child into a gender category or gendered behavioural description with which the child themselves did not identify” (Ansara and Hegarty 2012, 142). Of the 29 articles reviewed, explicit misgendering language was used in 20 of them, resulting in approximately 68.97% of the articles having misgendering language (Bedard et al. 2010; Heylens et al. 2012; Khorashad et al. 2020; Lawrence and Zucker 2013; Pasterski et al. 2015; Singh, Bradley, and Zucker 2011; Singh, McMain, and Zucker 2011; Steensma et al. 2014; VanderLaan et al. 2017; Zucker 2010, 2012, 2017a, 2018b, 2019; Zucker, Bradley, et al. 2012; Zucker et al. 2011; Zucker et al. 2013; Zucker, Lawrence, and Kreukels 2016; Zucker et al. 2019; Zucker, Bradley et al. 2012). To be clear, these articles had explicitly identifiable instances of misgendering where the ways participants would likely wish to be identified based on the stated self-determined gender identity or expression were not being used. It is also important to note, however, that some articles perhaps included misgendering but were less clear. 

In one example, Zucker et al. (2017) used “gender-based” and “sex-based” language (“boy” vs. “male,” “girl” vs. “female”) interchangeably in ways that obfuscate any chance of knowing. In one passage, it states, “… found that gender-related themes were significantly more common for the gender-referred boys than that of the male siblings, but the difference between the gender-referred girls and that of the female siblings was not significant” (Zucker et al. 2017, 2). Without any clarification, the reader is not sure if gender-referred “girls” and “boys” was referring to the gender they had self-designated or just using gender-based terms interchangeably with sex-based terms, which would then be misgendering the children of the study. Beyond the possible concern of misgendering (which I find to be the likely instance given the pattern), the lack of clarity, detail, and care in explaining something as nuanced and contextual as gender identity is alarming, especially from a lauded “expert” on the topic.

For the mentioned articles with explicit misgendering, much of the recurring theme was around only using one’s sex to describe them despite their self-designated gender being different than that of the one assigned to them at birth based on their sex. In using the sex-based language only, this often appears sanitized and neutral, hiding behind a façade of “sticking to the science.” Having said that, this still manifests in an outright refusal to allow these people to be seen the way they want to be seen. In some instances, however, the researchers use sex and gender language interchangeably, which then results in misgendering that is all the more violent as it appropriates and falsifies the individual’s gender in addition to their sex, rather than just ignoring it. One such instance is Heylens et al. (2012) where they research and discuss sets of trans twins (framed historically and in this article as “transsexual” and/or having “gender identity disorder”). In discussion of “female transsexual twins,” they are referred to as “sisters” and with she/her pronouns, whereas the “male transsexual twins” are referred to as “brothers” and with he/him pronouns. Another significant example is in Zucker et al. (2011), where many of the case vignettes mentioned are constantly misgendered throughout with incorrect pronouns and other gendered terms (as well as several inappropriate and unnecessary comments on people’s bodies, weights, and how they would be “perceived by others”) The only exception to this is where one case vignette specifically has the sudden change to correct pronouns, but only after the individual has legally changed their name and taken other transition-related steps, sending the subtle but nonetheless harmful message that respecting one’s self-determined gender is only appropriate once a threshold deemed acceptable by the researcher has been crossed and subjective criteria met (Zucker et al 2011, 75).

Pathologizing

The next example of cisgenderist language is pathologizing, which is, as the name suggests, making something out to be pathological. In this specific instance, pathologizing is verbiage or framing that marks “self-designated gender as a ‘disorder’” (Ansara and Hegarty 2012, 142). In fairness to Zucker and colleagues, the reality that gender dysphoria is still a diagnosis in the DSM is an important context in this discussion of gender diversity as pathology (American Psychiatric Association 2013; 2022). In fact, it’s a context that he himself has stated his awareness of despite still choosing to include it based on his justifications (Zucker and Duschinsky 2016). With that being noted, the discussion of pathologizing language will not include language necessitated by the fact that gender dysphoria is still a diagnosis, although the discussion of gender dysphoria as a diagnosis to begin with (and subsequent pathologizing impacts) is still a valid debate. Some examples of language not included that in other contexts would be pathologizing would be simply naming gender dysphoria as a “diagnosis,” “disorder,” etc. in reference to its diagnostic categorization, or use of other associated words such as “symptoms,” “treatment,” and the like. What will be explored rather than gender dysphoria (and by extension, transness) as a disorder at all will instead be verbiage or framing that describes the people with gender dysphoria or self-designated gender as deviant or disordered in their behavior or the way they are viewed by the researcher(s).

Explicit pathologizing beyond language associated with the diagnostic status of gender dysphoria was found in 24 of the 29 articles reviewed. This resulted in about 82.76% frequency of this cisgenderist practice in the reviewed articles (Bedard et al. 2010; Heylens et al. 2012; Khorashad et al. 2020; Lawrence and Zucker 2013; Pasterski et al. 2015; Singh, Bradley and Zucker 2011; Singh, McMain, and Zucker 2011; Steensma et al. 2014; Zucker 2010, 2012, 2015, 2017a, 2017b, 2018b, 2019, 2020; Zucker, Bradley, et al. 2012; Zucker et al. 2011; Zucker et al. 2013; Zucker and Duschinsky 2016; Zucker, Lawrence, and Kreukels 2016; Zucker et al. 2017; Zucker et al. 2019; Zucker, Wood, et al. 2012).

Language with this pathologizing impact can be quite blatant or prove to be more subtle. An instance of the subtle pathologizing language can be directed once again to Heylens et al. (2012, 752), where discussing prevalence of individuals self-determining genders other than ones assigned to them at birth was framed as “higher risk of being transsexual.” In another example, Singh, Bradley, and Zucker (2011, 151) begin the article using “extreme gender variant behavior” in the very first sentence before going on to describe their approach in contrast to the one they are critiquing as “therapeutic approaches that attempt to ’normalize’ the child’s extreme cross-gender behavior (perhaps with the goal of aligning the child’s gender identity with his or her birth sex)” explaining that the “extreme” behavior is something to be corrected.

The only “extreme” here is the ideology and bias exhibited in these writings. In another article, Zucker (2012) claims that some patients he had seen confirm suspicions that some trans and gender diverse individuals will falsify being intersex (framed in the article as “physical intersex conditions” and/or “disorders of sexual development”) and calling them “intersex posers.” His argument was that, perhaps, this might result in their gender dysphoria or trans identity being seen as more valid by themselves or those around them, painting these patients as dishonest and manipulative. This particular assertion is gravely concerning especially when considering the well-documented trope of transgender people as deceitful and deceptive, which often results in violence and even murder that historically has been legally permissible with factors like the “Trans Panic Defense” used in legal arguments to justify killing a trans person (Wodda and Panfil 2015).

Binarizing

A third type of cisgenderist language and framing is binarizing, which Ansara and Hegarty (2014) describe as presenting concepts (in this case, sex and gender) as rigid, binary concepts. This especially proves problematic because neither sex nor gender are binary and to frame it in such a way erases countless experiences of sex and gender diversity (Twist et al. 2021). Examples of binarizing could include listing sex and gender as binary constructs explicitly, using binary pronoun structures like “he/she” or “his/her,” framing sex or gender as binary through framing such as “opposite sex” or “the other gender,” and research that only included male/female categorization without specific acknowledgement of that structure as a binary limitation and specifying that it was not including experiences outside of sex or gender binary. Of the 29 pieces reviewed, 21 contained binarizing language once again resulting in approximately 72.41% of the collected literature (Bedard et al. 2010; Heylens et al. 2012; Khorashad 2020; Lawrence and Zucker 2013; Pasterski et al. 2015; Singh, Bradley, and Zucker 2011; Singh, McMain, and Zucker 2011; Steensma et al. 2014; VanderLaan et al. 2017; Zucker 2010, 2017a, 2020; Zucker, Bradley, et al. 2012; Zucker et al. 2011; Zucker et al. 2013; Zucker, Lawrence, and Kreukels 2016; Zucker et al. 2017; Zucker and VanderLaan 2018; Zucker, Wood, Singh, and Bradley 2012; Zucker et al. 2019; Zucker, Wood, Wasserman, VanderLaan, and Aitken 2016).

Overall summary of cisgenderist language

It is abundantly clear that the pattern of cisgenderist language in forms of misgendering, pathologizing, and binarizing has continued to be prevalent in Zucker’s work. Through this review, only two articles out of the total 29 were not noted to have any explicit instance of misgendering, pathologizing, or binarizing (Zucker 2013; 2018a). Having said that, the referenced articles that did not contain any cisgenderist language were very short corrections on data that was more-so addressing procedural concerns in the research being discussed. One could then argue, perhaps, that there was not much room for cisgenderist language and wonder to ourselves how gender and sex would have been discussed and framed had it been mentioned. Far more serious than how few didn’t have any cisgenderist language is how many contained all three, which was 16 of the 29 publications, summing up to about 55.17% (Bedard et al. 2010; Heylens et al. 2012; Khorashad et al. 2020; Lawrence and Zucker 2013; Pasterski et al. 2015; Singh, Bradley, and Zucker 2011; Singh, McMain, and Zucker 2011; Steensma et al. 2014; Zucker 2010, 2017a; Zucker, Bradley, Owen-Anderson, Kibblewhite, Wood, Singh, and Choi 2012; Zucker et al. 2011; Zucker et al. 2013; Zucker, Lawrence, and Kreukels 2016; Zucker et al. 2019; Zucker, Wood, Singh, and Bradley 2012). For an overall glance at the body of literature and prevalence of cisgenderist language, refer to Table 1 where each citation is noted along with whether each type of cisgenderist language was present and an example quote and page number with italics emphasizing concerning language.

Non-cisgender Sexuality & Eroticism as Deviant and Disordered

Moving now from the general language concerns into ideological themes, the first of several is the pattern in which sexuality and eroticism of transgender and gender diverse people is pathologized as deviant and disordered. This becomes especially concerning when the literature is describing phenomenon as pathological where the same level of pathology is not given to the same phenomenon for cisgender individuals. 

As a starting example, Khorashad et al. (2020, 1195) states, “All the transgender males were androphilic, all the transgender females were gynephilic (preferentially attracted to members of their own biological sex), and all of the clinical controls were heterosexual (none were transgender or had a diagnosis of gender dysphoria).” What’s interesting here is regarding the treatment of sexual orientation: the transgender individuals were described with -philia based language, whereas the cisgender controls were described as “heterosexual.” One could argue that the clinical language of androphilia or gynephilia can have a pathologizing connotation compared to heterosexual or homosexual. Granted, I don’t think “homosexual” would have been the ideal alternative in this case as I’d argue it’d still misgender the transgender participants based on their self-determined gender identities, but it also would not be that difficult to just say “male-attracted” or “female-attracted” as a clear descriptor that is neither pathologizing nor misgendering of the transgender participants. 

A similar example appears in VanderLaan et al. (2017), where they are discussing the transgender women (described in the literature as “male-to-female transsexuals”) and the comparison group of cisgender men. They write, 

Information regarding the sexual orientation of transsexual patients was obtained during semi-structured interviews with a psychiatrist (patients attended group and/or individual medical appointments on a biweekly basis). On the basis of this clinical information, all transsexuals were categorized as sexually attracted towards men. For the comparison group of men, they were asked to self-report their sexual orientation identity. All men self-reported a heterosexual sexual orientation identity (i.e. gynephilia, sexual attraction towards women). (VanderLaan et al. 2017, 530)

While this passage was a bit more fair in their equal distribution of pathological language (the transgender women are referred to as “androphilic” elsewhere and even in the title), what’s interesting is that the cisgender men participants were able to self-report their sexual orientation identity while the transgender women in the research had their sexual orientation identity categorized and imposed upon them. Because the classification was also based on these clinical interviews, one could also infer the tone here that not only did these transgender women have their sexual orientation identity imposed upon them and unable to self-describe, they also had to “prove it,” whereas the cisgender men participants were able to self-report heterosexuality and have it taken as fact.

What is most disturbing in this pattern of transgender and gender diverse sexuality and eroticism deemed as pathological is the peddling of concepts like “transvestic fetishism,” “autogynephilia,” and “autoandrophilia” to describe some of the experiences in the literature. In the large portion of the literature that contains these concepts, transvestic fetishism refers to arousal that forms from dressing in clothing (theoretically) of a different gender, whereas autogynephilia and autoandrophilia are sexual arousals to being perceived as female or male, respectively (Heylens et al. 2012; Lawrence and Zucker 2013; Steensma et al. 2014; Zucker 2010, 2019; Zucker, Bradley, et al. 2012; Zucker et al. 2011; Zucker et al. 2013; Zucker and Duschinsky 2016; Zucker, Lawrence and Kreukels 2016; Zucker et al. 2017). 

The issue here is not cisgender people who truly experience these types of attractions and arousals, as that is valid. My concern here is that almost all of the literature mentioned discusses transvestic fetishsim, autogynephilia, or autoandrophilia in the context of “co-occurring” with gender dysphoria (or gender identity disorder, depending on the time of publishing), meaning trans people with these experiences. For example, let’s picture what the literature would describe as a “gender dysphoric male with transvestic fetishism and/or autogynephilia.” In most cases, I would guess that this person is likely a transgender woman or person of another transfeminine identity. This person is experiencing feelings of attraction and arousal by dressing in clothing of “a different sex,” which likely would mean feminine clothing (and is already messy because if this is a feminine-identified person, the fact that considering feminine clothing as “crossdressing” indicates that one is seeing this person as male and a man at the end of the day which is cisgenderist). In addition, this person is aroused by the idea of being perceived as female. Is this transfeminine person a transvestic fetishist with autogynephilia, or are they just aroused by feeling attractive? Even more simply, are they just feeling good in what they’re wearing and how they’re looking? Plot twist: transgender people are allowed to feel hot. Do we hear our cisgender friends and colleagues talk about an outfit that they feel really good in or maybe a sexy little ensemble they got for date night later and call them a cisvestic fetishist? No! Do we call a cisgender woman who enjoys that she is read as female autogynephilic? No! We don’t ascribe these traits to cisgender people because it’s to be assumed that one is allowed to feel good and attractive and yes, even sometimes sexy. Not for trans people, however. That’s deviant and if they try, it’s pathologized.

Conversion Practices

Perhaps one of the darkest facets of Zucker’s legacy and one that continues to baffle me is the lack of accountability is his endorsement of and association with practices that could be interpreted as conversion efforts. If we look at conversion practices across literature, the overwhelming theme is the attempt to change one’s sexual orientation or gender identity (Ashley 2020, 2022, 2023; Coleman et al. 2022; Kinitz et al. 2022; Salway et al. 2021; Turban et al. 2018). In 2015, an external review of the Centre for Addiction and Mental Health (CAMH)’s Child, Youth and Family Gender Identity Clinic (CYF GIC) raised concerns that, in tandem with other factors, led to the CAMH to close the clinic and remove Zucker from their employ. In the aftermath, concerns were raised about the process and the dubious reliability of some but not all details, which led to CAMH taking down the external review in favor of an executive summary (Colero 2016) and ultimately reaching a settlement with Zucker although still standing by their decision to cease clinic operations because of the remaining concerns around the clinic’s problematic approaches (The Canadian Press 2018). While the external review was taken down and the executive summary from CAMH appears to be lost to time and website redesigns (from reputable sources, anyways), testimony from individuals and families who utilized the CYF GIC confirm that the approaches of Zucker and his clinic were harmful and attempting to change their gender identity and/or expression (Lowthian 2017; Muse 2015, 2020).

Even with testimony and the fact that CAMH nonetheless found issue with clinic operations, the best evidence for Zucker’s practices being considered conversion efforts comes in his own admission of the practices, not to mention his continued advocacy for the practice. Zucker et al. (2012) discusses a biopsychosocial model for “treating” gender identity disorder where the discussion on assessment explores all of the possible reasons a child could be experiencing gender dysphoria as something brought on by parents thinking cross-gender behavior is “cute,” a product of internalized gender bias, resulting from co-occurring psychopathology, or even projection of a parent’s psychopathology onto the child. Interestingly, a child simply determining their gender for themself isn’t given nearly the weight or likelihood. Regardless of etiology, conversion efforts are laid out as a very plausible and possibly encouraged approach, stating:

If the parents are clear in their desire to have their child feel more comfortable in their own skin, that is, they would like to reduce their child’s desire to be of the other gender, the therapeutic approach is organized around this goal. (Zucker et al. 2012, 383)

In discussing how to facilitate that process, they suggest interventions of enforcing cisnormative behavior and more same-sex peer relationships in hopes to influence the child to align with the assigned gender identity and expression preferred by the parents and clinicians. They note the following for limiting “cross-gender” behavior:

In our work, we emphasize that authoritarian limit setting is not the goal (limit setting per se is not the goal of treatment, but part of a series of interventions); rather, the goal is to help the child feel more comfortable in his or her own skin. (Zucker et al. 2012, 388)

Beyond how the child can and cannot express themselves, the recommendations expand to who the child is allowed to have as friends. Describing this, they write “In the naturalistic environment, we typically target the improvement of same-sex peer relations, since peer relationships are often the site of gender identity consolidation (Maccoby, 1998; Meyer-Bahlburg, 2002)” (Zucker et al. 2012, 389). Throughout the discussion of treatment, the discussion of “comfort” is presented, especially noting the idea of the child being comfortable in their own skin. I validate Zucker et al. (2012)’s supposed goal of the child’s comfort in their own skin. However, one could also suggest that autonomy over one’s expression and identity would be the efficient route to feeling comfortable in one’s skin. This begs the question, perhaps this was more about the comfort of the parent(s) and clinician(s)? If the concern is once again about the comfort of others versus the individual’s experiences and needs, it denies them the autonomy to self-determine their own experiences and identity (Deci and Ryan 2008; Ryan and Deci 2008).

Last but certainly not least in Zucker et al. (2012)’s endorsement of conversion practices, or at least abetting ambivalence, they respond to questions within the same publication issue around “prevention of adult transsexualism” as a treatment goal, they respond that they “do not have a particular quarrel with the prevention of transsexualism as a treatment goal,” only adding that it “should be contextualized” before ending with the statement, “If a child grew up comfortable in their own skin, but was generally miserable otherwise, one could hardly argue with unabashed enthusiasm for the prevention of transsexualism” (Zucker et al. 2012, 391).

In the years since Zucker et al. (2012) and despite the growing criticism of conversion practices no doubt made clearer by increasing legislative actions and the closure of the CAMH FYC GIC in 2015, heels were dug in further. Zucker, Lawrence, and Kreukels (2016) reference changes in the recent Standards of Care that deemed conversion practices unethical. They bemoan their displeasure with the critiques of conversion practices and mourn the chance to engage in them, lamenting:

It is recognized that GD can remit in some cases (Marks et al. 2000); perhaps psychotherapy could facilitate such remission - or a reduction in GD symptoms, with greater congruence between gender identity and expression and assigned sex - in some subset of the diverse group of adults whose gender problems now qualify for a diagnosis of GD. Unfortunately, these possibilities have not yet been investigated, and such investigations are strongly discouraged in the SOC-7. If a client with GD decided that overt cross-gender expression carried too great a risk of unacceptable consequences and requested a psychotherapist’s help in trying to make their gender identity and gender expression more congruent with their assigned sex, would the therapist’s participation always be unethical, as the SOC-7 seems to assert? If so, the SOC’s position would seem to conflict with the client’s right to autonomy and self-determination. (Zucker, Lawrence, and Kreukels 2016, 237)

What is most damning in this passage is the conflation of conversion efforts and helping clients toward a self-determined gender identity or expression that would appear more consistent with their sex assigned at birth. Even now, the primary component that defines the unethical practices being referred to is the intent to change one’s gender identity or expression (Coleman et al. 2022). If a client were to come to the understanding that their gender identity is one that is similar to the one that had originally been assigned to them, they have the right to autonomy over their identity. If a client were to decide that being visibly perceived as gender diverse resulted in oppression or threat of violence that they could not bear, they have that very same right to move with autonomy toward a gender expression that is less visibly gender diverse and perhaps safer, even if their intrinsically-known identity and ideal expression have not changed. In these instances, the client has determined the gender identity or gender expression they want for themselves, rather than have it imposed upon them by the clinician or others. That self-determination rather than imposition is proven to be far more helpful than the harmful impacts of if we were to take that autonomy away (Deci and Ryan 2008). It is so deeply concerning that this nuance is lost on practitioners like Zucker (2020) when they argue for equal consideration of conversion practices because of the possibility of detransition. A troubling question is raised when a practitioner cannot differentiate between someone self-designating a gender aligned with their assigned sex and their own biased imposition that someone moves in that direction. One could argue that it’s hard to tell when someone does or does not want something when your assumption is that everyone should want it.

Rapid-Onset Gender Dysphoria (ROGD)

Another concern has been Zucker’s validation and endorsement of rapid-onset gender dysphoria (ROGD) as an emerging clinical phenomenon (Zucker 2019), despite the discussion among researchers and organizations alike that have warned of ROGD’s lack of evidence and suspected use of discriminatory fear-mongering tactics (Coalition for the Advancement and Application of Psychological Science 2021; World Professional Association for Transgender Health 2018). While it is no surprise that this terminology was latched onto given his continued assertion of early-onset and late-onset specifiers of gender dysphoria (Zucker 2018), it is no less concerning. 

Critique of the original study that led to the discussion of ROGD noted the immense bias in the way that the research was structured by only recruiting parents from notorious anti-transgender websites (Ashley 2018). He even acknowledges the controversy and the comments he’s seen that point out how deeply problematic the sampling was by using members of hate websites for research on marginalized populations. Rather than take a stand for methodological integrity, he sits back and muses on the blatant empirical violence as if it’s just any other academic discourse or debate, chiming in with “One could say, therefore, that the paper has indeed had an impact” (Zucker 2019, 1987).

Another example of Zucker’s concerning practices around the concept of ROGD is regarding a recent article by Diaz and Bailey (2023) that Zucker approved for publication in his journal, Archives of Sexual Behavior. Not only did this article once again utilize incredibly flawed methodology similar to practices previously critiqued by Ashley (2018), but the article also explicitly states that they were denied approval by an institutional review board despite having human subjects and Zucker determined that its publication was “ethically appropriate,” despite the significant ethical violation of conducting research like this without that approval or oversight to prevent harm (Diaz and Bailey, 2023).

Treatment of Sexual Orientation in Relation to Sex and Gender

Another area of concern that has risen from this literature is the ways that sexual orientation, assigned sex, and gender identity and expression have been described in relation to one another. One critique to discuss is the ways that some of the literature conflate sexual orientation and gender identity, a type of criticism that Zucker (2018) has already expressed his disdain for. Nonetheless, I don’t think this critique is unfounded. A core of this critique is the amount of literature where Zucker has an apparent fixation (dare I say, “fetish?”) with the sexual orientation of transgender and gender diverse people in his research and coercively integrates their sexual orientation as part of their gender identity. Throughout much of the literature, transgender and gender diverse people are categorized by their sexual orientation (and often misgendered in the process with labels of sexual orientation tied to their sex and likely would align with their own self-description of their sexual orientation) in ways that treat the sexual orientation as such an important and differentiating context that “homosexual” versus “nonhomosexual” or “gynephilic” versus “androphilic” are effectively made out to be different gender identities altogether (Khorashad et al. 2020; Lawrence and Zucker 2013; VanderLaan et al. 2017; Zucker, Bradley, et al. 2012; Zucker et al. 2013; Zucker, Lawrence, and Kreukels 2016). Humans are not one single identity and additional context of how people of certain gender identities and sexual orientations is a wonderful context to explore, but the way the literature goes about it is not in line with modern understandings of the ways that sexual orientation, gender identity, assigned sex, and other aspects of self are separate and unique facets that create complex and nuanced individuals (Twist et al. 2021; van Anders 2015; van Anders and Schudson 2017).

It’s also important to note once again that the specific selection of sexual orientation language in the literature is problematic. The desire to use sex-based terminology in defining sexual orientation is often based on the notion that assigned sex rather than gender identity feels more scientifically grounded (van Anders 2015). However, sexual orientation in day-to-day life and how we form attraction is often based more on gender-based terms, given that we are often more so seeing one’s gender expression to determine our attraction rather than their assigned sex - meaning their genitals (with no disrespect to naturalist communities who may be seeing genitals of potential partners just as quickly as their gender expression). Calling a spade a spade, attraction also tends to be sex-based because we have been conditioned to see a certain type of gender expression and assume what that person’s assigned sex is and, more specifically, what their genitals probably look like. That assumption is the core of cisgenderism (Ansara and Hegarty 2012, 2013, 2014). The use of sex-based language in those ways objectifies these transgender and gender diverse people by reducing them to their genitals and misgendering them in the process.

Overall Concerns

The core of many of these critiques is the apparent bias and refusal to grant transgender and gender diverse people the autonomy to self-determine their identities and experiences that is vital to appropriate, productive, and beneficial care (Deci and Ryan 2008). This is demonstrated further by the prioritizing and valuing of parental needs and viewpoints over the children’s. Zucker, Wood, Singh, and Bradley (2012, 374) note this stance from the very beginning of their approach during the assessment process where the parents are asked what their goals are for their child’s gender identity and even noted that, while very few, some assessments “were conducted only with parents.” What precedent does it set about an individual’s right to self-determine their identity and experiences if an entire assessment can be made of them without their ever being in the room? Regarding the notion of waiting to see and having children stay within their assigned gender to see if feelings of dysphoria desist (Zucker 2018), I pose this question: if the idea is to “wait-and-see,” why is a cisgender identity viewed as a neutral default space? If the idea is about suppression of undue influence toward a specific identity, wouldn’t one suggest no toys at all? No clothes? No friends? Is this about neutral exploration, or an attempt to correct course before it’s too late? Is this about helping children be comfortable in their skin, or controlling them so others can be comfortable in their ideology?

Noting the patterns of language and ideology in this literature, it is no stretch to argue that Zucker and his colleagues struggle to view transgender and gender diverse people as having the right to autonomy to self-determine their gender identities and experiences, and simply cannot be bothered to listen to the communities he is claiming to help. Ironically, Zucker (2017 2523) notes that we should be “humble, not dogmatic.” It’s an interesting choice of words to see come up in a collection of literature with a clear pattern of claiming one knows more about others’ own experiences and identities than they do.

The need for more self-determined approaches to gender-related care rather than the imposing nature of Zucker’s work is all the clearer when we examine increasing visibility of individuals detransitioning or retransitioning—or “desisting,” as Zucker would put it. Detransition and retransition are quite rare experiences among those who receive transition-related care and far more of them are often related to discrimination, pressure, and accessibility reasons barring or discouraging continuation rather than what would be considered traditional regret and deciding that transition or the identity itself was not right for them (James et al. 2016). For many people who do detransition or retransition, a self-determination approach would be far more hopeful both as they navigate their current de/retransition as well as could have been more helpful during their initial transition and possibly avoiding courses of action that would be regretted later had they had that support (Pullen Sansfaçon et al 2023).

Critical Reflections for the Field of Research

Now the question is, “where do we go from here?” To that, I offer several thoughts and call for reflections that require some introspection as we move forward.

Research will never be intrinsically apolitical

Many may find a sense of neutral comfort within the “objective” realm of “hard science,” but this complacency is flawed. Time and time again, data shows us that the way that research is designed and conducted can have immense impact on the data, and influence and positionality of the researchers themselves can all the more warp what that data will say and how it could be used (Knott-Fayle et al. 2022). Research does not exist in a vacuum and can significantly inform approaches and policy which can be profoundly beneficial or gravely detrimental (Kcomt 2019; Kcomt et al. 2020). Neutrality is a comforting lie we often tell ourselves in research, and that lie is often utilized as a crutch to frame important critiques of discriminatory and unethical research and practices as political matters rather than human ones (Zucker and Duschinsky 2016). It’s no doubt easier to write off criticism this way. It’s just some activist with a political call-out, not a person who’s been harmed or faces harm because of one’s actions.

We can continue to embrace the comfort of this false neutrality, absolutely. We can also choose to stand for the things that matter. Just remember, not choosing is still a choice.

What (and who) is given credibility

As humans, we are collections of stories. Stories come to us both from what we are told and also what we come to experience. Iantaffi (2020) prompts us with the important question of whose stories continue to inform us. Research and those who conduct it are their own instances of story and storyteller. As a storyteller, Zucker has clearly shown what stories he finds valuable and credible in how he chooses to retell them in his own stories as seen in this collection of literature. Are those stories, in turn, ones that we value in determining our own understandings of trans and gender diverse communities’ needs? Should communities themselves have more credibility and ownership over their stories? The history of who has been given the platform and credibility to tell their (and others’) stories is clear, but does it need to be that way?

Enabling continued harm

As we look to these patterns of harm, concern grows more salient when we also recall the context of power. Not only does this body of literature cast a dark shadow of cisgenderism over us, the fact remains that researchers such as (and particularly) Zucker continue to hold and wield immense power and influence in determining approaches to care for transgender and gender diverse communities, including writing the literal definition of their experiences (American Psychiatric Association 2013; 2022). The literature discussed has barely even scratched the surface of Zucker’s body of work, and thus makes sense on paper that the power and influence could be interpreted as earned and justified. Nonetheless, barely scratching the surface has still raised so many concerns and calls to question whether that power and influence can be used responsibly? What choice is the research community making in continuing to turn away from these issues and continue to enable cisgenderist power and influence in the study of gender care and fail to seek any accountability or growth?

Conclusion

The work to be done is immense, and it will be a long road ahead in advocating for transgender and gender diverse communities. However, the important things are never easy. It is difficult to face and acknowledge the deep-seeded problems within this body of literature. To look at our mistakes and harmful impacts can feel shameful and uncomfortable. It’s likely that this has not been pleasant to explore and sit with. Nonetheless, we have a choice with what we want to do knowing these issues and concerns and where we go from here. What can the future of research and care look like when we approach it with a respect for others’ autonomy to self-determine their own identities and experiences?

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Zucker, Kenneth J., Susan J. Bradley, Allison Owen-Anderson, Sarah J. Kibblewhite, Hayley Wood, Devita Singh, and Kathryn Choi. 2012. “Demographics, Behavior Problems, and Psychosexual Characteristics of Adolescents with Gender Identity Disorder or Transvestic Fetishism.” Journal of Sex & Marital Therapy 38 (2): 151–89. https://doi.org/10.1080/0092623x.2011.611219.

Zucker, Kenneth J., Susan J. Bradley, Allison Owen-Anderson, Devita Singh, Ray Blanchard, and Jerald Bain. 2010. “Puberty-Blocking Hormonal Therapy for Adolescents with Gender Identity Disorder: A Descriptive Clinical Study.” Journal of Gay & Lesbian Mental Health 15 (1): 58–82. https://doi.org/10.1080/19359705.2011.530574.

Zucker, Kenneth J., Peggy T. Cohen-Kettenis, Jack Drescher, Heino F. L. Meyer-Bahlburg, Friedemann Pfäfflin, and William M. Womack. 2013. “Memo Outlining Evidence for Change for Gender Identity Disorder in the DSM-5.” Archives of Sexual Behavior 42 (5): 901–14. https://doi.org/10.1007/s10508-013-0139-4.

Zucker, Kenneth J., and Robbie Duschinsky. 2016. “Dilemmas Encountered by the Sexual and Gender Identity Disorders Work Group for DSM-5: An Interview with Kenneth J. Zucker.” Psychology and Sexuality 7 (1): 23–33. https://doi.org/10.1080/19419899.2015.1024472.

Zucker, Kenneth J., Anne A. Lawrence, and Baudewijntje P. C. Kreukels. 2016. “Gender Dysphoria in Adults.” Annual Review of Clinical Psychology 12 (1): 217–47. https://doi.org/10.1146/annurev-clinpsy-021815-093034.

Zucker, Kenneth J., A. Natisha Nabbijohn, Alanna Santarossa, Hayley Wood, Susan J. Bradley, Joanna Matthews, and Doug P. VanderLaan. 2017. “Intense/Obsessional Interests in Children with Gender Dysphoria: A Cross-Validation Study Using the Teacher’s Report Form.” Child and Adolescent Psychiatry and Mental Health 11 (1). https://doi.org/10.1186/s13034-017-0189-9.

Zucker, Kenneth J., and Doug P. VanderLaan. 2018. “Corrections to Øien, Cicchetti, and Nordahl-Hansen’s (2018) ‘Gender Dysphoria, Sexuality and Autism Spectrum Disorder: A Systematic Map Review.’” Journal of Autism and Developmental Disorders 48 (12): 4038–4038. https://doi.org/10.1007/s10803-018-3748-x.

Zucker, Kenneth J., Doug P. VanderLaan, and Madison Aitken. 2019. “The Contemporary Sex Ratio of Transgender Youth That Favors Assigned Females at Birth Is a Robust Phenomenon: A Response to the Letter to the Editor Re: ‘Shifts in Assigned Sex Ratios at Gender Identity Clinics Likely Reflect Change in Referral Patterns.’” The Journal of Sexual Medicine 16 (6): 949–50. https://doi.org/10.1016/j.jsxm.2019.03.406.

Zucker, Kenneth J., Hayley Wood, Devita Singh, and Susan J. Bradley. 2012. “A Developmental, Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder.” Journal of Homosexuality 59 (3): 369–97. https://doi.org/10.1080/00918369.2012.653309.

Zucker, Kenneth J., Hayley Wood, Lori Wasserman, Doug P. VanderLaan, and Madison Aitken. 2016. “Increasing Referrals for Gender Dysphoria.” The Journal of Adolescent Health 58 (6): 693–94. https://doi.org/10.1016/j.jadohealth.2016.02.015.

Acknowledgments

The author would like to acknowledge that their work would not be possible without the efforts of transgender, gender-nonconforming, and two-spirit scholars and researchers who’ve come before and/or continue to work alongside them, who continue to pave the way for trans people to tell their own stories and share their own lived experiences. Such scholars include but are not limited to Y. Gavriel Ansara, Florence Ashley, Alex Iantaffi, Meg-John Barker, Roger Kuhn, and countless others not named here.