The mental health establishment is failing trans kids

Gender-exploratory therapy is a key step. Why aren’t therapists providing it?

Daryn Ray for The Washington Post

A previous version of this essay said that a quarter of study subjects who reversed their gender transitions did not report this change to their doctors. In fact, three-quarters did not share the information.

At 13, Patricia told her parents she was a transgender boy. She had never experienced any gender dysphoria — distress at a disconnect between gender identity and the sex assigned at birth — she said. But a year earlier, she’d been sexually assaulted by an older girl. Soon after this trauma, she met another older girl who used they/them pronouns and introduced her to drugs, violent pornography and the notion of dissociation from her body. Her lingering psychic wounds, coinciding with a raft of new and unsettling ideas, plunged her into depression and anxiety. Patricia’s parents took her to a therapist so she could talk through her shifting identity and acute mood swings.

The job of a mental health provider here should have been clear: Perform an assessment, ask how long she’d experienced dysphoria and investigate how mental health issues and any other changes in her life might be contributing to it. Instead, on first meeting, the therapist simply affirmed her new identity, a step that can lead to hormonal and eventually surgical treatments. Was Patricia ready for these next steps — or, her parents wondered, was this a normal bout of teenage confusion stemming from a recent trauma? The therapist instructed them to “support” their child’s trans self-diagnosis and to socially transition her. If they didn’t, Patricia might end her own life: 41 percent of unsupported children commit suicide, they were told. Would Patricia’s parents rather have a dead child or a trans one?

They sought another therapist, one who was more curious and less certain, one who listened closely. After a year of exploring who she was, Patricia no longer felt she was a boy. She decided to stop binding her breasts and wearing boys’ clothes.

We are both psychologists who have dedicated our careers to serving transgender patients with ethical, evidence-based treatment. But we see a surge of gender dysphoria cases like Patricia’s — cases that are handled poorly. One of us was the founding psychologist in 2007 of the first pediatric gender clinic in the United States; the other is a transgender woman. We’ve held recent leadership positions in the World Professional Association for Transgender Health (WPATH), which writes the standards of care for transgender people worldwide. Together, across decades of doing this work, we’ve helped hundreds of people transition their genders. This is an era of ugly moral panic about bathrooms, woke indoctrination and identity politics in general. In response, we enthusiastically support the appropriate gender-affirming medical care for trans youth, and we are disgusted by the legislation trying to ban it.

Seeking a scientific explanation for trans identity could do more harm than good

But the number of adolescents requesting medical care is skyrocketing: Now 1.8 percent of people under 18 identify as transgender, double the figure from five years earlier, according to the Trevor Project. A flood of referrals to mental health providers and gender medical clinics, combined with a political climate that sees the treatment of each individual patient as a litmus test of social tolerance, is spurring many providers into sloppy, dangerous care. Often from a place of genuine concern, they are hastily dispensing medicine or recommending medical doctors prescribe it — without following the strict guidelines that govern this treatment. Canada, too, is following our lead: A study of 10 pediatric gender clinics there found that half do not require psychological assessment before initiating puberty blockers or hormones.

The standards of care recommend mental health support and comprehensive assessment for all dysphoric youth before starting medical interventions. The process, done conscientiously, can take a few months (when a young person’s gender has been persistent and there are no simultaneous mental health issues) or up to several years in complicated cases. But few are trained to do it properly, and some clinicians don’t even believe in it, contending without evidence that treating dysphoria medically will resolve other mental health issues. Providers and their behavior haven’t been closely studied, but we find evidence every single day, from our peers across the country and concerned parents who reach out, that the field has moved from a more nuanced, individualized and developmentally appropriate assessment process to one where every problem looks like a medical one that can be solved quickly with medication or, ultimately, surgery. As a result, we may be harming some of the young people we strive to support — people who may not be prepared for the gender transitions they are being rushed into.

American opinions about transgender youth have shifted dramatically in the past 15 years. The pendulum has swung from a vile fear and skepticism around ever treating adolescents medically to what must be described, in some quarters, as an overcorrection. Now the treatment pushed by activists, recommended by some providers and taught in many training workshops is to affirm without question. “We don’t actually have data on whether psychological assessments lower regret rates,” Johanna Olson-Kennedy, a pediatrician at Children’s Hospital in Los Angeles who is skeptical of therapy requirements and gives hormones to children as young as 12 (despite a lack of science supporting this practice, as well), told the Atlantic. “I don’t send someone to a therapist when I’m going to start them on insulin.” This perspective writes off questions about behavioral and mental health, seeing them as a delaying tactic or a dodge, a way of depriving desperate people of the urgent care they clearly need.

But comprehensive assessment and gender-exploratory therapy is the most critical part of the transition process. It helps a young person peel back the layers of their developing adolescent identity and examine the factors that contribute to their dysphoria. In this stage, patients reflect on the duration of the dysphoria they feel; the continuum of gender; the intersection with sexual orientation; what medical interventions might realistically entail; social media, Internet and peer influences; how other factors (e.g., autism, trauma, eating disorders/body image concerns, self-esteem, depression, anxiety) may help drive dysphoria, rather than assuming that they are always a result of dysphoria; family dynamics and social/peer relationships; and school/academic challenges. The messages that teens get from TikTok and other sources may not be very productive for understanding this constellation of issues.

The latest form of transphobia: Saying lesbians are going extinct

There are several reasons the process can move too quickly and hurtle toward medical treatment. For one, the stigma around mental health in general, along with the trauma caused to transgender adults by the health-care field in the past (yes, including conversion therapy), has made our peers extremely skeptical of becoming “gatekeepers” — experts who deny the needed help because they supposedly know best. Slowing down the process and encouraging deeper, thoughtful exploration is considered, many tell us, unnecessary and unaffirming. Providers may also be afraid of being cast as transphobic bigots by their local colleagues and referral sources if they engage in gender exploring therapy with patients, as some have equated this with conversion therapy. We’ve personally experienced this backlash at professional conferences.

All this means only that the purpose of assessment is improperly understood. The approach WPATH recommends is collaborative and aims to provide a developmentally appropriate process that involves the parents and takes the complexities of adolescence into consideration. (The constituency of agitated parents who feel excluded is also growing rapidly. These are not conservative evangelicals who don’t believe trans people exist or deserve treatment. They’re usually progressive, educated, loving people who all say, If our kid is really trans, we’ll fully support them. We just want to be as sure as possible, and we can’t find a provider who will actually engage in gender exploring therapy. Instead, doctors and psychologists and social workers are ready to start hormones after one short visit.)

Another reason that teens can receive substandard mental health care is that gender clinics are disastrously overwhelmed. Most have a single social worker who completes a brief “intake,” relying instead on other mental health clinicians in the community to assess patients and offer their conclusions. Frequently, those community clinicians, just like the parents, assume that a more comprehensive assessment will occur in the gender specialty clinic. But in our experience, and based on what our colleagues share, this is rarely the case. Most clinics appear to assume that a referral means a mental health provider in the community has diagnosed gender dysphoria and thereby given the green light for medical intervention.

When working in gender clinics, we’ve also both received letters from therapists who had “assessed” patients they were referring to us. An astonishing number of these were nothing but a paragraph that stated the youth identified as trans, had dysphoria and wanted hormones, so that course was recommended. There are nearly 200,000 members of the American Psychological Association and the American Psychiatric Association. Add to that the clinical social workers, marriage counselors and family therapists. The overwhelming majority of those well-intentioned professionals receive limited or no training in the assessment of gender-diverse youth. (We receive requests frequently from people eager for more comprehensive, nuanced trainings, which we both deliver.) In simple terms, the demand for competent care has outstripped the supply of competent providers.

In professional circles, we hear from pediatric endocrinologists and others who prescribe hormones for trans youth. Many openly discuss how they use the adult informed-consent model of care with their teen patients, which almost always means no mental health involvement and sometimes no parent input, either. “If you are trans, I believe you,” says A.J. Eckert, the medical director of Anchor Health Initiative in Connecticut. Eckert is wary of psychologists who follow the guidelines by completing a comprehensive assessment before recommending medical intervention for youths. “Gender-affirming medicine,” Eckert holds, means that “you are best equipped to make decisions about your own body,” full stop. These providers do not always realize they’ve confessed to ignoring the standards of care. (Contacted by The Post for comment on this essay, Eckert said that “no medical or surgical interventions are provided to anyone who has not started puberty” but added that, as Anchor Health sees it, “Therapy is not a requirement in this approach because being trans is not a pathology.”)

The battle over trans rights is about power, not science

Some providers may move quickly because they believe that an adolescent's clarity around their gender identity is no different than that of transgender adults, whose care is now typically based on simple informed consent. Some assume that a person with gender dysphoria who declares they are transgender is transgender and needs medical interventions immediately. Yet we know this is not always true. In a recent study of 100 detransitioners, for instance, 38 percent reported that they believed their original dysphoria had been caused by “something specific, such as trauma, abuse, or a mental health condition.” Fifty-five percent said they “did not receive an adequate evaluation from a doctor or mental health professional before starting transition.”

A handful of studies supposedly showing the suicide risk of gender minority youth who are not supported are also not entirely conclusive. The term “support,” for instance, is defined differently across studies, and it is never defined as “starting medical interventions.” Supporting trans youth may include using the correct name/pronouns or allowing the young person to present in a way that aligns with their affirmed gender (e.g., clothing, hairstyle). These studies also show correlations between teen-transition hurdles and suicidality, but not causal relationships. Suicide is a horrifying outcome for too many gender-diverse youth, but its specter should not be used to push forward unrelated medical treatment without professional care or attention for each patient.

I was a straight woman whose spouse came out as trans. It didn’t change a thing.

Longer-term longitudinal studies are needed to better understand the role of medical interventions on lifetime psychological health, particularly with the newer subset of adolescents presenting with no childhood dysphoria and significant mental health concerns. Research is needed to help determine whether quick medical treatment or a more cautious approach is best in these cases. Based on our experience with patients, we suspect that there will be variability based on age, when gender identity questions first emerged and other factors — which is why an individualized approach with careful assessment is so critical.

Trans youth, more than most patients in the health-care system, require an interdisciplinary approach: Their doctors rely on mental health colleagues for direction, and it is crucial that those therapists take the reins. Without proper assessment, many youths are being rushed toward the medical model, and we don’t know if they will be liberated or restrained by it. National figures do not yet exist, but the rising number of detransitioners that clinicians report seeing (they are forming support groups online) indicates that this approach can backfire. This is not the most common outcome of a transition process, but it is hardly unheard of, either. These are typically youth who experienced gender dysphoria and other complex mental health issues, rushed to medicalize their bodies and regretted it later. Only a quarter of them told their doctors they had reversed their transitions, making this population especially hard to track.

Anti-trans legislation has never been about protecting children

Many trans activists want to silence detransitioners or deny their existence, because those cases do add fuel to the conservative agenda that is pushing to deny medical treatment to all transgender young people. (Those conservative views are unacceptable, and medically unsound.) Instead, we should be learning from them and returning to the empirically supported careful assessment model recommended by WPATH. And none of this means that we shouldn’t be listening to the views of gender-diverse teens; it only means that we should listen in the fullest and most probing way possible.

The pressure by activist medical and mental health providers, along with some national LGBT organizations to silence the voices of detransitioners and sabotage the discussion around what is occurring in the field is unconscionable. Not only is it harmful to detransitioned young people — to be made to feel as if their lived experiences are not valid, the very idea that the gender-transition treatment is meant to remedy — but it will undoubtedly raise questions regarding the objectivity of our field and our commitment to help trans people. The fact that some people detransition does not mean that transgender people should not receive the services they need.

The energy currently spent fighting this political battle would be much better directed toward improving care for all gender-diverse young people. They deserve nothing less.

False claims of protecting children are fueling anti-trans legislation