In a supervision group I recently led, Marsha, a therapist from Indiana, tentatively said, “A law here has passed the state legislature that bans all gender-affirming care for minors under 18. I have a 13-year-old trans girl client who just started puberty blockers, and if the governor approves this law, she’ll have to stop them by the end of the year. I don’t know how to talk to her and her family about this. I’m afraid she’ll become suicidal if she has to stop them.”
Marsha’s client had been assigned male at birth, but by the time she could talk, she’d insisted she was a girl. After three years of therapy and much agonizing deliberation, her parents allowed her to undergo what’s called a “social transition” at the age of eight. They called her Kendra instead of Ken and enrolled her in third grade as a girl. She wore girl clothes, grew her hair long, and became socially integrated as a girl. At age 12, however, her body was beginning male pubertal changes. She was distraught as she realized that, unchecked, her body would develop male musculature and shape, facial hair, and a deepening voice. This led to her experiencing a severe form of gender dysphoria, the sense that your physical form and presentation veer drastically from your internal sense of your gender. She was depressed and often thought of suicide—until she was put on puberty blockers, gonadotropin-releasing hormone (GnRH) analogues, a treatment that’s been available in the U.S. for more than 15 years.
More than 30 years ago, clinicians in Europe began using these medications to temporarily suppress puberty in gender-dysphoric children. Previously, puberty blockers had been used safely to treat precocious puberty and other conditions, but this was a unique application. The idea was that the development of any secondary sex characteristics, male or female, would be postponed, giving the child relief from dysphoria and an opportunity to confirm whether they want to begin cross-gender hormone treatments when they’re older. Children who decided they’d prefer living in their birth gender could be taken off GnRH analogues, and puberty would commence as normal. Children on blockers who retained their trans identity into middle adolescence would eventually be taken off the suppressor drugs and given hormones of their affirmed gender, which would cause them to develop that gender’s secondary sex characteristics. On puberty suppressors, Kendra would postpone adolescence. If she continued to affirm her female identity, she could ultimately decide to receive female hormones so her body would develop as a cisgender woman’s would.
In 2016, when I wrote “Welcome to the World of Gender Fluidity” for Psychotherapy Networker, most readers were still unfamiliar with childhood and adolescent gender dysphoria. By now, most likely know a trans kid or a family with a trans child. We’ve accumulated several decades of experience treating gender dysphoria effectively, with peer-reviewed research indicating that gender-affirmative care, which may include puberty blockers, cross-gender hormones, and other medical interventions, alleviates the depression, despair, and suicidality that can accompany gender dysphoria. This type of care can allow the child’s social integration as their affirmed gender. It can also ensure a measure of safety as an adult indistinguishable from cisgender people—a critical consideration, since trans people are bullied, attacked, and even murdered at alarmingly high rates, most commonly by strangers who read them as trans when they’re out in public.
Our supervision group did some brainstorming about how Marsha could approach Kendra and her parents about the implications of the bill being considered, but we were mostly at a loss. We hoped the bill wouldn’t pass. Then on April 5th, Governor Eric Holcomb signed it into law, making Indiana the 13th state to enact a ban on gender-affirming care for minors. On the same day, the ACLU filed a suit to stop the law. If it goes into effect on July 1 as planned, it will be illegal for Kendra to continue taking puberty blockers by the end of the year. What can a therapist in Marsha’s situation do to help a client like Kendra? Currently, state legislatures are considering more than 400 anti-LGBTQ, mostly anti-trans, bills. How many more Kendras and Marshas will we see in years to come?
Last week, I had a teletherapy session with a 24-year-old client. “It’s been so long since I transitioned that I hardly think about it anymore,” he said. “But lately, Margie, every time I turn on the news, I hear about a new law banning trans care or trans athletes, or a bathroom law or anti-drag-show legislation. Does everyone hate trans people? I’m afraid to go out in public!” A few days before that, a colleague told me a story about a trans college student who’d received a coveted internship in marine biology and turned it down because it was in Texas, a state debating 51 anti-LGBTQ bills. Daily, I talk to therapists watching many of their young trans clients sink into anger, disillusionment, fear, and depression because U.S. anti-trans sentiment is palpable and inescapable.
The Anti-Trans Backlash
In the last 15 years, the number of trans and nonbinary children, adolescents, and young adults has exploded, as have treatment centers and providers that work with them. Predictably, this has led to a backlash against gender-affirming care for minors, a signature issue for the political far right. The ACLU is tracking 452 anti-LGBTQ bills. Thirteen states have passed laws banning any gender-affirming medical care—puberty blockers or cross-gender hormones—for minors, and more than 20 others are considering such bills. Some laws extend the age to 26 years, and the Missouri attorney general has issued an emergency order that will make it nearly impossible for any transgender person to access hormone treatment. Not only do these laws ban medical care, with stiff felony punishments for providers: they also mandate that people currently on such medications discontinue care. In some cases, they prohibit parents from seeking out-of-state care for their children.
People uninformed about transgender issues often have a knee-jerk, visceral reaction against medical interventions for minors. There are very real concerns to be debated—by professionals, families, and trans people, not by politicians. As Marci Bowers, the transgender surgeon and current president of the World Professional Association for Transgender Health, wrote in a Times op-ed recently: “To be sure, worthwhile questions about how best to address gender diversity, adolescent mental health, and teens’ expectations about gender remain. But answers to them will not be found in legislation that will harm—not protect—children, families, and their healthcare providers…. Why are legislators and politicians making medical decisions for patients and families instead of doctors?”
There are other types of laws being considered that affect all queer kids, some similar to Florida’s “don’t say gay” bill, which restricts classroom discussion of nonheteronormative sexualities and gender identities. Many states have passed legislation barring transgender girls from participating in girls’ sports. The anti-drag-show laws affect LGBTQ+ adults and target gay culture. Book bannings are at an all-time high: according to the American Library Association, more than 1,200 occurred in 2022, and we’re on track to exceed that in 2023. While some of the book bannings pertain to race and sexuality in general, most target LGBTQ+ concerns. In Florida, for example, one banned book, And Tango Makes Three, was a picture book about the male penguin pair at Central Park Zoo that raised a penguin chick.
What impact does this legislation, with its concomitant mood of nonacceptance, have on trans and gender-nonconforming young people? The Trevor Project survey indicates that 45 percent of respondents considered suicide in the past year, and that rates of anxiety, depression, and suicidal thoughts in the population have increased steadily from 2020 to 2022. If courts support the current laws banning gender-affirmative care, the upward trend in suicidal thoughts will likely be accompanied by an increase in suicide attempts. That only 40 percent of the 82 percent of respondents who desired psychotherapy can actually access care, due to barriers ranging from lack of availability to parental refusal to consent to treatment, exacerbates these mental health issues.
Unlike members of many other stigmatized groups experiencing minority stress from prejudice and discrimination, young queer people can’t often count on the support of family members who contribute to their victimization by refusing to believe, or even condemning, their gender identity or sexual orientation. The lack of family support is so pervasive that in the Trevor Project survey, only 37 percent of respondents considered home a supportive space, and only 32 percent of trans youth thought of their families as such.
A higher percentage felt school was a more affirming place—55 percent of LGBTQ+ youth and 52 percent of trans/nonbinary youth—but the educational organization GLSEN surveyed schools in 2021 and found that support for gay and trans students in schools, as indicated by the presence of GSAs (Gay Straight Alliance) and affirming school policies, is steadily declining. This is partly due to anti-LGBTQ+ legislation that forbids schools from using a child’s pronouns of choice and requires school officials to notify parents of a child’s divergent gender expression or sexual orientation. Provisions like these will magnify the harm caused to LGBTQ+ kids. Because only about a third consider home a supportive place, outing a gender nonconforming child to parents or caregivers risks harm, including abuse.
Go deeper with data from leading researchers. Read “Understand the Facts” here.
What’s the Controversy About?
Gender-affirming care for young people was available in the Netherlands since the late 1980s, but it was unknown here until this century. Few of us practicing therapy received any clinical training in working with people who identified with a gender different from their birth gender. If we did, we were told such individuals were psychiatrically disturbed.
Until the 21st century, the only treatment available for gender-nonconforming children in North America was an approach sometimes derisively called “throw away the Barbies.” Developed by psychologist Kenneth Zucker at the CAMH clinic in Toronto, Canada, it consisted of forcing gender-variant boys to conform to male stereotypes: parents were advised not to allow these boys to play with dolls or dress up in girl clothes, and to encourage them to play sports with other boys and wear primary colors. While it was believed that gender-dysphoric adults were beyond help from psychotherapy, and therefore were allowed to undergo medical interventions to alter their bodies, the approach with children was to “prevent a transsexual outcome.”
Because I lived and worked in the queer community, I was aware of the work of several therapists who disagreed with this pathologizing view and were pioneering an approach that came to be called “gender-affirming treatment.” Mostly, my knowledge came from reading Arlene Lev’s Transgender Emergence, published in 2004.
At the Institute for Personal Growth (IPG), the outpatient psychotherapy practice I founded in 1983, we’d always seen a handful of transgender clients, mostly middle-aged married men just coming to accept a female gender identity they’d long suppressed. Then, in the 1990s, we started to see college students and young adults who were transgender, and in 2007 we got our first referral of a trans teen, Shannon. Because she was the center’s first trans minor coming for treatment, I took the case myself.
Shannon was a 14-year-old biological male who’d been insisting she was a girl since she was a toddler, wearing girl’s clothes, playing with girl’s toys, and associating with girls. Her parents had assumed—and accepted—they were raising a gay boy. When she declared at age 12 that she was a girl, her mom felt blindsided. She looked for information and guidance but found little pertaining to minors. By the time she was 14, Shannon wanted to start presenting as a female to her peers at school and in the community. That’s when her mom called IPG.
I was terrified. From my work with adults, I knew about the medical treatments, the hormone therapy, and the surgeries, and I knew that if Shannon continued to identify as a female, she’d look forward to largely irreversible medical interventions that would drastically alter her body and life. My previous clients had mostly been past reproductive age; they either already had children or didn’t want them. But Shannon would face a future where she’d be unable to reproduce, and this seemed to me an incredibly weighty decision for a minor to make. I lost sleep over this and hired a more experienced therapist to supervise me. I remember being both disturbed and reassured that this counselor wrestled with some of the same doubts as I did.
In retrospect, Shannon’s case was one of the easier ones: she clearly met the criterion of “persistent, consistent, and insistent” gender dysphoria and successfully socially transitioned at school, where she faced a little bullying but received far more support. In fact, she was elected queen of her junior prom.
She started gender-affirming hormones at age 16 after banking and freezing sperm, and her genital surgery took place days after her 18th birthday. Today, she’s a happy, well-adjusted woman approaching 30, with no indication that she’s ever regretted her decisions.
Nonetheless, I still wrestle with some of the same issues I struggled with when I worked with Shannon—namely, the ethics and wisdom of allowing adolescents to decide on medical interventions that will drastically alter their lives. But I now accept the complexity of these issues as an inevitable part of the gender-affirmative care model. Developed in the Netherlands, this model is currently practiced in the more than 50 clinics for minors in North America.
Clinicians using this approach accept the current gender expression of children they work with and help them discover and define how they experience their own gender, which may involve presenting as their affirmed gender socially, including at school. If they maintain their identification with their chosen gender over an extended time period, usually years, they’re eligible for the medical intervention of puberty blockers at puberty. These medications extend the period where a young person lives as their affirmed gender before deciding on the direction they want to take permanently.
Most kids put on puberty blockers maintain a transgender identity, but sometimes the time-out period allows them to discover that they don’t in fact want to transition. Matthew, a child seen at IPG, said, “I’d wanted to be a girl since I was little, but I had to live as a girl for a while to realize that I’m not a girl; I’m a feminine gay boy.” A young person on puberty blockers who consistently desires to be a different gender becomes eligible to receive cross-gender hormones, which trigger pubertal changes as their desired gender, between the ages of 14 and 16. When they’re no longer minors, they may decide to undergo gender-affirming surgeries.
Peer-reviewed research in the Netherlands, where these medical interventions have been used for over 30 years, indicates they’re highly successful. They’re endorsed as a first-line approach in the U.S. by all the major medical and mental health organizations, including the American Academy of Pediatrics. But some caveats remain. First, puberty blockers can cause loss of bone mass over time. This reverses itself when the drugs are discontinued, but it requires monitoring. More seriously, young people who move seamlessly from puberty blockers to cross-gender hormones will be infertile. If puberty blockers are delayed until the child is fertile (possibly distressing the child), —there’s the potential to retrieve and freeze eggs or sperm. For sperm, this can be costly; for eggs, it’s costlier, more difficult, and still experimental.
While I will probably always be uneasy with the ethics of expecting adolescents to make irreversible decisions about their fertility, these medical interventions have become the focus of the legislation banning gender-affirming care, now enacted in 14 U.S. states and being considered in many more.
Watch Margaret discuss the clinical skills you need for your LGBTQ+ clients in this current legal/political climate.
Treatment of Gender-Dysphoric People
Gender atypical humans have existed since prehistoric times, and gender diversity is common in the animal kingdom, but it was only in the 20th century that medical interventions developed to alleviate gender dysphoria through body modifications. In the 1960s, endocrinologist Harry Benjamin introduced hormone treatments and advocated a medical model of care, but his work and the gender clinics that arose at Johns Hopkins and other universities were quickly co-opted by psychiatry. The psychiatric view held that “transsexualism” was a serious mental disorder best addressed by psychotherapy, and that only when adults failed to respond to therapy should they be treated with hormones and surgery. Up until roughly 10 years ago, gender-diverse children were treated with some form of coercive gender-conversion therapy aimed at curbing their atypical behavior.
Just as gay activists had fought decades before to have homosexuality removed from the DSM, trans activists in the 1990s and early 21st century fought for changes in psychiatric nomenclature and standards of care. In 2013, the American Psychiatric Association finally renamed gender identity disorder “gender dysphoria,” noting that gender atypicality was not a mental disorder and gender dysphoria was only a disorder to the extent that it caused distress. Gender-affirmative therapy, founded on the premise that gender diversity was normal, rather than an illness to be cured, became the dominant paradigm. The “throw away the Barbies” approach was condemned as inhumane. Just as the growing cultural tolerance of gay people in the ’70s and ’80s led to more people coming out at younger ages, the number of transgender people coming out of the closet and seeking care has skyrocketed, as has the number of children and adolescents declaring a gender identity different from the one assigned to them at birth.
Some professionals still maintain that gender dysphoric people are mentally ill, and that our treatment priority with children should be to prevent them from becoming transgender adults. In 2018, Lisa Littman of Brown University published a paper describing a phenomenon she called Rapid Onset Gender Dysphoria (ROGD) after interviewing 256 parents who reported that their adolescent children had proclaimed themselves transgender after being influenced by peers and the internet. She speculated that the phenomenon of social contagion might be influencing teen girls in particular to adopt a trans identity. The study was roundly criticized—notably because Littman had interviewed none of the children—but the idea of ROGD was promoted by those who believed the gender-affirmative model had gone too far.
Although one could dismiss the old-school professionals clinging to notions of psychopathology and the parents who are unwilling to accept their trans children, not all criticism comes from suspect sources. In 2021, psychologists Laura Edwards-Leeper and Erica Anderson wrote an op-ed in The Washington Post titled “The Mental Health Establishment Is Failing Trans Kids.” Both women have held leadership positions in the World Professional Association for Transgender Health; one was involved in the creation of the first pediatric gender clinic in the U.S., and the other is herself transgender. They argue that in some cases, gender-affirmative therapy has become the rubber stamp for a young person’s self-diagnosis, and that what should be a lengthy, thoughtful exploration has instead become a prescription for puberty blockers or hormones.
I’ve watched the trans and nonbinary youth clientele of IPG mushroom from a few dozen a year in 2007 to a few dozen a month in 2023, and I’ve had the opportunity to interact with, train, and supervise scores of therapists treating these young people. Although I’ve personally encountered only a few instances where a pediatric evaluation seemed hasty and sloppy, Edwards-Leeper and Anderson may have a point. I’ve had two minor clients demand letters for medical intervention at the first session who fired me when I refused to write them. (I later heard they got letters elsewhere.) I’ve heard stories of children cleared for medical intervention after a single consult, and I increasingly hear stories about pediatric endocrinologists willing to put kids on puberty blockers or even cross-gender hormones with no psychological evaluation at all. Because parents are often familiar with the horrible suicidality statistics among trans and nonbinary teens, many quickly agree to, or push for, medical treatments without a comprehensive assessment.
Given the rapid increase in the number of young people seeking care and the lack of training available to providers, it would be surprising if no mistakes were being made. Many gender-nonconforming teens have other mental and emotional problems, ranging from depression and anxiety to PTSD, eating disorders, and self-harm; and it’s not always clear how these issues interact with gender identity, if at all. There’s also a now-confirmed overlap between gender atypicality and neurodiversity: many trans young people are on the autism spectrum. No one knows why this link exists, but it confounds diagnosis. Parents of autistic children tend to believe their child’s gender dysphoria is a transient fixation, and providers with little to no training in neurodiversity are unable to evaluate these claims.
Adding to the controversy are the voices of detransitioners, many from biological girls who tell their stories on YouTube about transitioning to male in their teens or early 20s, when they received hormone therapy prescribed with little or no therapeutic exploration of gender identity. Anti-trans law proponents claim research has shown most gender variant children turn out to be gay or lesbian adults, not transgender. Forty-year-old studies make this claim, but those studies include all children who display gender atypical behavior—“sissy” boys and “tomboy” girls—not just those with a variant gender identity. Studies restricted to children who declare themselves a gender other than their birth gender show much lower rates of desistance, with reversion to nonbinary more common than return to birth gender. Still, the fact that detransitioners exist is reason for caution. While there’s no evidence beyond the anecdotal for ROGD, the internet and peers could influence some vulnerable adolescents who’ve always felt like outsiders and might hastily align with an apparent explanation of their failure to fit in. As a parent who survived three children going through rocky teen years, I’m well aware that kids can be fickle and changeable.
It’s unfortunate that almost no rational discussion of these issues occurs among professionals who practice gender-affirmative care. Although puberty blockers and cross-gender hormones have been shown to alleviate distress, with few regrets among those who receive them, they’re still serious, and we need to consider their use carefully. But because of the oppressive history of trans care and the current political climate, most gender-affirmative providers feel an obligation to espouse the party line and dismiss dissenters’ views as pure transphobia. When Anderson and Edwards-Leeper published their op-ed, for example, they were roundly criticized by most of my peers. I wish this hadn’t happened, but I understand why: even slightly critical views will be amplified and distorted by anti-LGBTQ+ politicians.
How You Can Help
Recently, my colleague Eric and I squeezed ourselves into child-size chairs set up in a circle in the middle of a brightly colored classroom. We were sitting with his client’s teacher, school principal, and a group of parents. “We’re here to talk to you about Adrienne,” Eric said. “I’m her therapist, and I’ve worked with kids like her for several years.” Adrienne, who’d attended this school for kindergarten and first grade as Adam, was about to enter second grade as the girl she knew herself to be. Adrienne’s parents and school had asked us to talk to the parents of other kids in her class to help make her transition as seamless as possible. For an hour and a half, we offered information and answered questions. By the end, everyone seemed reassured and accepting, and Adrienne’s social transition turned out to be uneventful.
Educating people in your community—schools, parent groups, medical professionals, and even coworkers in your group practice—can help trans individuals who are routinely misgendered, misunderstood, and ignored. If you have trans and nonbinary young clients, how you support them will depend on where you live. If you’re like Marsha, the therapist for 13-year-old Kendra, and live in a state that’s enacted a ban on gender-affirming care, you can make sure their support system is particularly strong. Do what you can to ensure their families are informed and supportive. Connect them to other LGBTQ+ youth near them, and encourage them to find online peer support. Give them online resources like the Trevor Project, which maintains a 24/7 professionally run hotline for LGBTQ+ youth; Trans Lifeline, which has a peer-run hotline for youth and one for family members; CenterLink, which has a directory of local gay centers; and Discord, which has over 200 trans online communities.
Stay informed about legislative developments in your state. Your clients may choose to seek out-of-state care if their state doesn’t prohibit it and their parents have the financial resources. Volunteer organizations like Elevated Access offer transportation to those who must travel for care. If your state is considering anti-trans laws, contact your legislators. Even if you live in a state like New Jersey, as I do, where anti-trans laws are unlikely to receive support, you’ll probably see increased levels of fear, anger, and anxiety in young queer clients. You can reassure them that these bills are unlikely to pass, but it’s important to validate their anxiety as realistic and understandable.
Another way you can help is by making your workplace LGBTQ+ friendly. Have books, magazines, and pamphlets in your waiting room that demonstrate inclusivity. The Family Acceptance Project’s website has printable flyers for parents with trans and nonbinary kids; keep some in your waiting room to signal your allyship. On your paperwork, make space for preferred name as well as legal name and for affirmed gender and pronouns as well as birth gender, and make sure your staff uses the correct name and pronouns when referring to or corresponding with clients. Put policies in place that protect and support LGBTQ+ staff as well as clients.
People’s attitudes are influenced by those close to them, and if everyone around you—family, friends, community members, colleagues, clients—understands you’re a trans ally, they’ll consider allyship themselves. You can create a ripple effect that will help support young trans and nonbinary clients and alleviate some of their well-founded anxieties and fears.
Main illustration © JOJOF
Second Photo © FG Trade
Margaret Nichols, PhD, CSTS, is a psychologist, sex therapist, and author of The Modern Clinician’s Guide to Working with LGBTQ+ Clients. She has more than 40 years of experience doing therapy with sex-, gender-, and relationship-diverse people, and she identifies as queer.