Part one of a two-part series
Drs. Ken Zucker and Diane Ehrensaft have different approaches to treating kids who identify themselves more with the opposite sex. Read their answers to questions about gender identity issues and the ethics of their therapies.
Read part two of this series on gender identity issues.
Note: To protect the identities of these families, NPR has used only first names and has changed one of the children's names.
It wasn't until Halloween when her 2 1/2-year-old son decided to dress as Dorothy from The Wizard of Oz that Carol began to worry.
Bradley had always had a preference for girls' things. From his earliest days he had chosen girls' dolls, identified with female characters and gravitated toward female children. But Carol had never thought to care. As far as she was concerned, it wasn't a loaded gun; it wasn't a lit cigarette. She says it had really never crossed her mind to say, "I'd really rather you played with a truck."
Then, on Halloween, the calculus began to tip.
To simulate Dorothy's hair, Carol covered Bradley's blond crewcut with a brown tea towel. Bradley loved it. In fact, he became obsessed with his tea-towel hair. For months afterward he would wake up every morning and put the towel on his head. When Carol tried to remove it, he would protest.
"It was really obsessive," Carol says. "We really had to negotiate times when he just couldn't wear it anymore. ... He seemed to feel uncomfortable and nervous sometimes when he didn't have this hair, this tea-towel hair."
And as Bradley grew older, his discomfort with things male also grew. He would shun other boys -- he played exclusively with girls. Again, this concerned Carol, but she wasn't frantic about it.
It was a single event that transformed her vague sense of worry into something more serious. One day, Bradley came home from an outing at the local playground with his baby sitter. He was covered in blood. A gash on his forehead ran deep into his hairline.
"What had happened was that two 10-year-old boys had thrown him off some playground equipment across the pavement because he'd been playing with a Barbie doll -- and they called him a girl," Carol says. "So that sort of struck me, that, you know, if he doesn't learn to socialize with both males and females ... he was going to get hurt."
One Direction in Therapy
Carol decided to seek professional help. Bradley's school referred her to a psychologist in Toronto named Dr. Ken Zucker, who is considered an expert in gender identity issues. After several months of evaluation, Zucker came back with a diagnosis. Bradley, he said, had what Zucker called gender identity disorder.
Gender identity disorder is a label given to children who believe themselves to be born into the wrong biological body. This diagnostic label encompases a range of behaviors -- and the label itself is controversial. But, in general, what characterizes children like Bradley is that they are more than just effeminate boys, or masculine girls, who are gay. These are children who genuinely believe they are girls even though they have a male body -- or boys, even though they have a female body.
Zucker, who has worked with this population for close to 30 years, has a very specific method for treating these children. Whenever Zucker encounters a child younger than 10 with gender identity disorder, he tries to make the child comfortable with the sex he or she was born with.
So, to treat Bradley, Zucker explained to Carol that she and her husband would have to radically change their parenting. Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder. He explained that unless Carol and her husband helped the child to change his behavior, as Bradley grew older, he likely would be rejected by both peer groups. Boys would find his feminine interests unappealing. Girls would want more boyish boys. Bradley would be an outcast.
Carol resolved to do her best. Still, these were huge changes. By the time Bradley started therapy he was almost 6 years old, and Carol had a house full of Barbie dolls and Polly Pockets. She now had to remove them. To cushion the blow, she didn't take the toys away all at once; she told Bradley that he could choose one or two toys a day.
"In the beginning, he didn't really care, because he'd picked stuff he didn't play with," Carol says. "But then it really got down to the last few."
As his pile of toys dwindled, Carol realized Bradley was hoarding. She would find female action figures stashed between couch pillows. Rainbow unicorns were hidden in the back of Bradley's closet. Bradley seemed at a loss, she said. They gave him male toys, but he chose not to play at all.
"He turned to coloring and drawing, and he just simply wouldn't play with anything. And he would color and draw for hours and hours and hours. And that would be all he did in a day," Carol says. "I think he was really lost. ... The whole way that he knew and understood how to play was just sort of, you know, removed from his house."
His drawings, however, also proved problematic. Bradley would populate his pictures with the toys and interests he no longer had access to -- princesses with long flowing hair, fairies in elaborate dresses, rainbows of pink and purple and pale yellow. So, under Zuckers direction, Carol and her husband sought to change this as well.
"We would ask him, 'Can you draw a boy for us? Can you draw a boy in that picture?' ... And then he didn't really want us to see his drawings or watch him drawing because we would always say 'Can you draw a boy?'" Carol says. "And then finally after, I don't know, a month or two, he just said, 'Momma, I don't know how. ... I don't know how to draw a boy.'"
Carol says she finally sat down and showed him. From then on, Bradley drew boys as directed. Male figures with anemic caps of hair on their heads filled the pages of his sketchbook.
Another Family, Another Approach
Three-thousand miles away, on the West Coast of the United States, another family noticed their small son's unconventional tastes.
Jonah was 2 when his father, Joel, first realized that no amount of enthusiasm could persuade his child to play with balls. Trucks languished untouched. Fire engines gathered dust. Joel says Jonah much preferred girl toys, even his stuffed animals were female.
"Like, I would always say, 'What's that guy's name?' and the response would always be, 'Oh, she's bunny, she's, you know, this or that,'" Joel says.
Like Bradley, as Jonah grew older, these preferences became more pronounced. Jonah is physically beautiful. He has dark hair and eyes, a face with China-doll symmetry, and a small and graceful frame. Occasionally, while running errands, casual acquaintances, fellow shoppers, passers-by, would mistake Jonah for a girl. This appeared to thrill him. And, Joel says, Jonah would complain bitterly if his father tried to correct them.
"What began to happen was Jonah started to get upset about that," Joel says. "Like, 'Why do you have to say anything!' … I remember one distinct time when we were walking the dogs and this person came up and said ... 'Oh, is this your daughter?' and I said, 'Oh, no, this is Jonah.'... And Jonah just came running up and said, 'Why do you have to tell! Why do you have to say anything!'"
Then around the age of 3, Jonah started taking his mother Pam's clothing. He would borrow a long T-shirt and belt, and fashion it into a dress. This went on for months -- with Jonah constantly adjusting his costume to make it better -- until one day, Pam discovered her son crying inconsolably. He explained to his mother that he simply could not get the T-shirt to look right, she says.
Pam remembers watching her child mournfully finger his outfit. She says she knew what he wanted. "At that point I just said, you know, 'You really want a dress to wear, don't you?' And [Jonah's] face lit up, and she was like, 'Yes!'"
(Joel and Pam now refer to their son as "she.")
That afternoon, Pam, her sister and Jonah piled into the family car.
"I thought she was gonna hyperventilate and faint because she was so incredibly happy. ... Before then, or since then, I don't think I have seen her so out of her mind happy as that drive to Target that day to pick out her dress," Pam says of Jonah.
Pam allowed Jonah to get two dresses, but felt incredibly conflicted about it. Even though Jonah asked, she wouldn't allow him to buy any more dresses for a year afterward, so Jonah wore those two dresses every day, nothing else, until Pam got sick of looking at them. After a year, she and Joel finally began to permit other small purchases. But every item, Joel says, provoked a crisis.
"We'd spend a few nights talking: 'Do you think the shoes are like a line that we should cross? Or, you know, the girly hat, or the girly jacket with the frills?' ... Like, what are we doing? Are we encouraging this? Are we doing something that we shouldn't be?" Joel says they would ask.
Joel and Pam also ended up in front of a gender specialist -- Diane Ehrensaft, a psychologist in Oakland. Joel remembers an early session when Pam talked about her concerns.
"I remember her talking to the therapist and saying something to the effect of, like, you know, 'I'd be OK if Jonah just was gay, I just don't want ... him to be transgender.' And the therapist just laughed, she said, 'You know, 15 years ago, I had people on this couch saying, 'I don't mind him being a little effeminate, as long as he's not gay,'" Joel says.
In fact, Diane Ehrensaft's approach could not have been more different than the approach of Bradley's therapist. Like Zucker, Ehrensaft is a gender specialist. She says she has seen more than 50 families with children who have what Zucker would describe as gender identity disorder.
Ehrensaft, however, does not use that label. She describes children like Bradley and Jonah as transgender. And, unlike Zucker, she does not think parents should try to modify their child's behavior. In fact, when Pam and Joel came to see her, she discouraged them from putting Jonah into any kind of therapy at all. Pam says because Ehrensaft does not see transgenderism itself as a dysfunction, the therapist didn't think Pam and Joel should try to cure Jonah.
"She made it really clear that, you know, if Jonah's not depressed, or anxious, or having anything go on that she would need to really be in therapy for, then don't put a kid in therapy until they need it," Pam says.
Ehrensaft did eventually encourage Joel and Pam to allow Jonah to live as a little girl. By the time he was 5, Jonah had made it very clear to his parents that he wanted to wear girl clothes full time — that he wanted to be known as a girl. He wanted them to call him their daughter. And though Ehrensaft does not always encourage children who express gender flexibility to "transition" to living as a member of the opposite sex, in the case of Jonah, she thought it was appropriate.
Last year, when he started kindergarten, Jonah went as a girl. He wore dresses, was addressed as "she" by his classmates and teacher. He even changed his name, from Jonah to Jona, without the "h." It was a complete transformation.
Joel and Pam were initially anxious, but Joel says their worry soon faded.
"They have these little conferences, and, you know, we were asking, like, 'How's Jonah doing? Does she have problems with other kids?' and the teacher was like, 'God, I gotta tell you, you know, Jonah is one of the most popular kids. Kids love her, they want to play with her, she's fun, and it's because she's so comfortable with herslef that she makes other people comfortable," Joel recalls.
It was shortly after that that Joel and Pam started referring to their son Jonah as "she."
Two Families, Two Therapists, Two Approaches
The treatments practiced by Zucker and Ehrensaft are radically different and, therefore, are liable to produce radically different results. In fact, Zucker and Ehrensaft are representatives of a broader divide in the mental health community over the appropriate treatment for children like Bradley and Jonah.
This divide is so intense that there is very little common ground. There is little common ground even in the ways that the issue is conceptualized. Therapists like Ehrensaft tend to view kids like Bradley and Jonah as transgender, and see transgenderism as akin to homosexuality.
Thirty-five years ago, homosexuality was considered a mental illness — a pathology so severe that it required aggressive therapeutic intervention. According to Jack Drescher, former chairman of the American Psychiatric Association's committee on gay and lesbian issues, one treatment was to try to condition homosexuals out of their sexual preference by attaching them to electrical shock machines and shocking them every time they were aroused by homosexual pornography.
Today, however, the APA's position is that therapies that try to turn homosexuals into heterosexuals are unethical. Homosexuality is now considered to be a normal variant of human behavior, so though a therapist might treat a person because they struggle with the stigma associated with homosexuality, therapists who practice in accordance with the guidelines established by the association don't treat the behavior itself.
Because Ehrensaft sees transgenderism as akin to homosexuality, she says, she thinks Zucker's therapy — which seeks to condition children out of a transgender identity -- is unethical.
But that isn't how Zucker sees it. Zucker says the homosexuality metaphor is wrong. He proposes another metaphor: racial identity disorder.
"Suppose you were a clinician and a 4-year-old black kid came into your office and said he wanted to be white. Would you go with that? ... I don't think we would," Zucker says.
If a black kid walked into a therapist's office saying he was really white, the goal of pretty much any therapist out there would be to make him try to feel more comfortable being black. They would assume his mistaken beliefs were the product of a dysfunctional environment -- a dysfunctional family or a dysfunctional cultural environment that led him or her to engage in this wrongheaded and dangerous fantasy. This is how Zucker sees gender-disordered kids. He sees these behaviors primarily as a product of dysfunction.
The mistake the other side makes, Zucker argues, is that it views gender identity disorder primarily as a product of biology. This, Zucker says, is, "astonishingly naive and simplistic."
Zucker has come to believe that taking the view that kids are born transgender ultimately produces more transgender people.
"By declaring the child as transgendered at, say, age 3 or age 4 or age 6, and then saying in a sense, 'Go with the flow,' ... that will impact, I believe, on how the kid's gender identity differentiates," he says.
In other words, allowing a child like Jonah to transition in kindergarten will essentially track him into becoming a transgender adult. And for Zucker, no child under the age of 10 or 11 can be definitively labeled transgender. He says that kids' gender identities are flexible. And that even a child like Jonah, who appears to be absolutely consistent from the ages of 1 and 2, can change.
But Ehrensaft says this position is too absolute. While she agrees that it's important to be very, very careful about applying a transgender label to a young child, it is at least possible. And Ehrensaft is clearly as disapproving of Zucker's form of therapy as he is of hers. She says it's wrong to take away a child's toys, to police the people he spends time with, the pictures he draws — even the colors he draws with.
"To me, this is coercive therapy," Ehrensaft says. "And I don't think we should be in the business of coercing people. ... I would say all the kids I've worked with who have gone through that kind of treatment, they have not come out better; they've come out worse."
For Ehrensaft, the lessons of the early therapeutic approaches to homosexuality — therapies that sought to "cure" the patient of homosexual desires -- are clear.
"If we allow people to unfold and give them the freedom to be who they really are, we engender health. And if we try and constrict it, or bend the twig, we engender poor mental health," she says.
The Problem with the Color Pink
It does seem to be the case that, at least in the short term, Carol's son Bradley is struggling in some ways with Zucker's therapy. Carol says it was particularly hard at the beginning.
"He was much more emotional. ... He could be very clingy. He didn't want to go to school anymore," she says. "Just the smallest thing could, you know, send him into a major crying fit. And ... he seemed to feel really heavy and really emotional."
Bradley has been in therapy now for eight months, and Carol says still, on the rare occasions when she cannot avoid having him exposed to girl toys, like when they visit family, it doesn't go well.
"It's really hard for him. He'll disappear and close a door, and we'll find him playing with dolls and Polly Pockets and ... the stuff that he's drawn to," she says.
In particular, there is one typically girl thing — now banned — that her son absolutely cannot resist.
"He really struggles with the color pink. He really struggles with the color pink. He can't even really look at pink," Carol says. "He's like an addict. He's like, 'Mommy, don't take me there! Close my eyes! Cover my eyes! I can't see that stuff; it's all pink!' "
Still, Carol says, Bradley has made some progress. Today, he is able to play with boys. He has a few male friends, and has said that he now enjoys boy things. And there are other signs of change.
"I mean, he tells us now that he doesn't dream anymore that he's a girl. So, we're happy with that. He's still a bit defensive if we ask him, 'Do you want to be a girl?' He's like 'No, NO! I'm happy being a boy. ...' He gives us that sort of stock answer. ... I still think we're at the stage where he feels he's leading a double life," she says. "... I'm still quite certain that he is with the girls all the time at school, and so he knows to behave one way at school, and then when he comes home, there's a different set of expectations."
Despite these difficulties, Zucker clearly feels it's important to at least attempt change. He points out that the burden of living as the opposite gender is great, and should not be casually embraced.
"We're not talking about minor medical treatments. ... You're talking about lifelong hormonal treatment; you're talking about serious and substantive surgery," he says.
Jonah, Now Jona
For their part, Joel and his wife Pam say they are clearly happy with the choice they've made. Joel says he now thinks of Jonah as his daughter, and he says that she — Jona — is thriving.
"She's so comfortable with her own being when she's simply left to be who she is without any of these restrictions being put on her. It's just remarkable to see."
In terms of which of these therapies is more prevalent in the United States, Ehrensaft says there is absolutely no doubt.
"Zucker's," she says.
Ehrensaft hopes this will change. She says that professional opinion on this subject is in incredible flux -- that the treatment of transgender children is becoming a kind of civil rights issue, in the same way that the psychiatric treatment of homosexuals became a civil rights issue in the 1970s.
In the meantime, though, Zucker's approach continues to thrive. He says nearly 80 children are on the waiting list at his clinic in Toronto.