In response to President Trump’s executive order prohibiting the use of federal funds to support “gender affirming care” for persons under 19, Abigail Shrier triumphantly declared that “the gender fever finally broke.” Though Trump’s order represents the end of pediatric gender medicine’s cultural and political hegemony, Shrier concedes that it does not abolish “affirming care.”
Indeed, the executive order faces two legal challenges on constitutional grounds, and federal judges have already placed it on temporary hold. Even if the order stands, institutions not reliant on federal funds can still render these controversial practices. Moreover, the order sets up a clash between federal and state policy in blue states, many of which have passed “shield laws” protecting access to medical transition for minors. While Trump’s directive will likely make medical transition for minors harder to access—some hospitals have preemptively complied with it—the order has no bearing on state laws, which, in practice, direct the counseling and psychological professions to affirm the “gender identities” of minor clients. While medical transition may be taken off the table until some clients turn 19, other legal forces continue to uphold the tenets of gender ideology and encourage psychological and social transition.
For example, last September, Kentucky governor Andy Beshear issued an executive order prohibiting the practice of “conversion” therapy for “LGBTQ+” youth. Conversion therapy is broadly understood as any intervention that attempts to change an individual’s sexual orientation or “gender identity.” In so doing, Kentucky becomes the 23rd state—and by far the reddest—to implement such a ban.
The language of Beshear’s ban exempts some open-ended “identity exploration and development” therapy, but it remains vague enough to leave mental-health providers in an uncomfortable position, especially if they have ethical qualms about the “gender-affirmative” model. Such providers now must worry about false accusations of lawbreaking, risking penalties and licensure loss. This creates a chilling effect on the counseling professions, reducing the pool of thoughtful clinicians willing to risk their careers to work with sex-distressed minors. As international critics have argued, such laws conflate normal, ethical psychotherapy for gender distress with “conversion” practices.
Kentucky’s executive order is meant to help kids suffering from sex distress. Instead, anti-“conversion” laws like this turn therapists into the handmaidens of gender ideology, and the psychological professions into another waystation along the “transgender conveyor belt”—a patchwork of state, and until recently federal, law that nudges sex-distressed youth toward social and medical transition.
Beshear’s order is based on the idea that conversion therapy is harmful to sex-distressed kids, an assertion backed by medical groups like the American Medical Association and the American Psychiatric Association, which have determined that conversion practices cause “significant long-term harms to LGBTQ+ youth.” These claims, however, take the evidence too far. The harms of conversion practices among gay adults have been studied and rightly condemned. But advocates of the gender-affirmative treatment model have engaged in a sleight of hand, applying these study findings on gay adults to gender-confused children. On top of this, they have misleadingly rebranded “conversion” efforts for sexual orientation to include “gender identity” under the banner of “Sexual Orientation and Gender Identity Change Efforts.”
As James Cantor observes in a 2019 fact check of the American Academy of Pediatrics: “there are no studies of conversion therapy for gender identity.” Cantor goes on to add that applying conversion efforts to gender identity is a misnomer because “the majority of children ‘convert’ to cisgender or ‘desist’ from transgender regardless of any attempt to change them.” Some newer studies have appeared since Cantor’s report, but because of limitations in their design, they can only establish an association between reporting poor mental health outcomes and not feeling subjectively affirmed by a therapist, without showing that one causes the other. Moreover, these studies are reliant on subjective “recall of conversion efforts” among adult participants, not minors.
Why, then, do advocates maintain that psychotherapy for gender confusion is intrinsically harmful? Implicit in the logic of “conversion” bans, and the gender-affirmative treatment model generally, is the notion that everyone has a “gender identity,” and that it is immutable. Once someone declares a cross-sex identity, all nuance goes out the window, and affirmation becomes the only acceptable interpretive lens to explain a person’s psychic distress. The problem with this belief in practice is that it flattens the therapeutic needs of patients with unique developmental and psychiatric histories. Armed with this dubious mental shortcut, every gender-affirming therapist gets to bat a thousand.
Yet many patients need not to be blindly affirmed. Up to 85 percent of dysphoric kids outgrow their dysphoria by the completion of adolescence. Though desistance rates are not well understood among today’s cohort of primarily dysphoric female adolescents, recent analyses of health insurance records conducted in the United States and Germany show that less than half of the study samples continue to have a dysphoria diagnosis six years after receiving one. Among 15–19-year-old girls, specifically, in the German study, 72.7 percent ceased having a dysphoria diagnosis.
Affirming such kids would be a failure of the clinician’s duties. As the Australian psychiatrist Robert D’Angelo points out, the focus of psychotherapy, in theory, is not the patient’s gender identity but rather the patient’s distress related to gender. Affirming a patient’s gender identity without developing a comprehensive understanding of his or her distress is a clear dereliction of professional duty. Moreover, both D’Angelo and Joanne Sinai and Peter Sim, clinicians all, argue that true informed consent requires that patients understand their own motivations for seeking treatment.
As Sinai and Sims write, psychotherapy can help a patient gain insight into, and think through, the myriad factors that culminate in their experience of sex distress. They also point out that it is possible to “mislabel” internal experiences as gender dysphoria, a concern quietly echoed by a member of the World Professional Association for Transgender Health, who lamented the lack of clinical tools “that capture the way internal signals can sometimes be misread as related to gender when they’re not.”
Negative emotions with a variety of underlying causes can easily be interpreted as dysphoria. This is particularly true as dysphoria emerges as today’s defining idiom of distress. If mental-health clinicians practice affirmation only, however, then over-treatment and iatrogenic harm—cures worth than the disease—are virtually guaranteed.
Trans activists continue to deny the mounting evidence of multiple developmental pathways to trans-identification. The trans activist Florence Ashley, for example, argues that “attempts to identify the cause of the person’s expressed gender—including under the pretext of gender exploration” in themselves constitute “conversion therapy.” Yet studies of detransitioners have found that the most common reasons cited for detransitioning include realizing that dysphoria was caused by another mental health issue or trauma, and changes in understanding of what it means to be male or female.
Conversion bans like Kentucky’s may drive capable mental-health workers away from helping such kids. International dysphoria researchers recently argued in a peer-reviewed paper that, in nations that have passed conversion laws, “therapists who provide neutral, conventional, exploratory therapy, which is mandated by professional ethics—and by evidence-based guidelines in Finland, Sweden, and the United Kingdom—are consequently unable to address the needs of gender dysphoric youth.”
Consider the case of Stephanie Winn, a successful marriage and family therapist in Oregon who was investigated by her licensing board because of multiple accusations of violating her state’s conversion-therapy law, including by online gender activists whom she had never treated. The cases were ultimately dismissed, but the experience drove Winn from the profession. In an interview, she said that while she maintains her license to practice, she no longer works with gender-distressed youth and young adults.
Winn also previously told The Daily Caller that she “hear[s] from therapists all the time that simply will not work with minors or will not work with trans-identified/ gender-dysphoric/questioning people, for fear of the consequences.”
As many European countries adopt psychosocial interventions for dysphoria as the first line of treatment, champions of the affirmative-care paradigm often draw a false equivalence between “affirming” medical interventions and psychotherapy by noting that the quality of evidence is weak for both. While this may be true, affirming medical interventions also come with high risks—the irreversible effects of puberty blockers and cross-sex hormones—whereas psychotherapy has a much more favorable risk profile. There is no evidence that ethical, non-pathologizing psychotherapy harms trans-identified youth. As D’Angelo points out, psychotherapy has been shown to help alleviate suffering for various kinds of psychic distress, including distress over the body and identity concerns, which bodes well for its application to gender dysphoria. Medical ethics, especially involving the care of minors, privileges interventions that “do no harm” and preserves a child’s “right to an open future.” Even the World Health Organization allows treatments to be recommended based on low-quality evidence when risks are low and alternative interventions present higher risks—exactly the circumstances pediatric gender medicine finds itself in.
Comparing the efficacy and risks of the two treatment paradigms also raises the issue of clinical neutrality, which therapeutic ethics demands. Clinical neutrality in this context refers to remaining unbiased and nonjudgmental while guiding a patient’s exploration rather than steering him or her in a particular direction. But Winn says that remaining clinically neutral here would suggest that “all treatment paths are the same,” preventing the field from identifying the risks of the affirming care model.
“A mental health service must be able to define what ‘health’ is, and in a meaningful sense, outcomes that promote patient health are preferable to outcomes that promote patient harm,” Winn said. “In the case of medical affirmation, these practices are known to culminate in both reduced relationship satisfaction and life expectancy.”
Conversion laws like Kentucky’s are built on a misunderstanding—or willful misreading—of the clinical research. They treat the entire “LGBTQ+” community as a monolith, ignoring the myriad ways in which children, in particular, might come to a cross-sex identity. While practitioners of exploratory psychotherapy are unlikely to face real professional consequences, the effect of these laws is to reduce the pool of open-minded therapists willing to work with sex-distressed kids outside of the affirmative paradigm. Those same kids are thus denied the treatment that they need.
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