Out On The Couch
In recent years, both the ethics and efficacy of affirmative mental healthcare have been debated on a national stage. In 2022 alone, Florida state legislators have proposed a “Don’t Say Gay” bill, Alabama passed a law outlawing gender-affirming medical or mental healthcare for teens, and more than a dozen states like Ohio have followed in their wake. Conservative lawmakers feel that things have “gone too far” by allowing transgender and gender nonbinary (TGNB) people access to care that validates their identity, especially youth, and are using their power and influence to limit that access.
While these dog whistles may be daunting, it is important for mental health providers to have all the evidence when making decisions about clinical care. To be clear: the literature of the field strongly reflects that providing gender-affirming care is associated with positive outcomes for TGNB clients. In this article, we will address arguments against providing affirmative care and summarize recent evidentiary support and best practices.
Criticisms of gender-affirming care
A common criticism of gender-affirming care is that children and adolescents are not mature enough to self-identify their gender. Any psychotherapist with an understanding of human development can easily debunk this claim. According to the work of Lawrence Kohlberg, a foundational theorist in the field of psychology, children develop a sense of gender identity as early as preschool (Sravanti & Sagar K, 2019). Many gender-expansive youth opt to socially transition long before entering puberty, though the standard approach in our field is that of “watchful waiting,” in which the child’s medical team closely observe their exploration of gender until puberty (Ehrensaft et al., 2018). In contrast, a gender-affirmative approach stresses the importance of self-identification by allowing the child to socially transition at any age, access puberty blocking medication if desired, and pursue medical transition after the onset of puberty (Ehrensaft, 2017). Both of these approaches have been heavily researched in recent years, yet the public consensus remains that we don’t (or can’t) know enough to establish gender-affirming care as a best practice.
One reason is that concerns about regret and detransition abound — though there is a paucity of research to support this. One study of adults who identify as transgender in the United Kingdom found that out of 175 individuals, only 12 reported detransitioning in the 16 months after receiving cross-gender hormone treatment (Hall et al., 2021). Out of that already small sample, only two patients reported feeling regret (Hall et al., 2021, p. 7). However, many clinicians actually recommend against further research on detransition or “desistance” rates, stating that it contributes to public mistrust and skepticism without serving youth. Academics have raised concerns about the methodology of desistance studies, as well as the working definition of “gender identity” that is used by other researchers, as lacking consensus may muddy the waters (Brooks, 2018).
Research in support of gender-affirming care
So how do we reach this consensus? Emerging research strongly indicates that affirmative care improves the mental health of transgender and gender nonbinary clients. A 2021 study of 104 TGNB youth at Seattle Children’s Hospital found that receiving gender-affirming interventions such as puberty blockers or gender-affirming hormones was associated with 60 percent lower odds of moderate to severe depression and 73 percent lower odds of self-harm or suicidal thoughts during their first year of involvement in gender care (Tordoff et al., 2022). A recently published secondary analysis of the 2015 United States Transgender Survey found that out of over 3,500 respondents reporting gender-affirming surgeries in the prior two years, undergoing surgery was associated with lower past-month psychological distress and was not associated with greater lifetime risk of suicidality (Almazan & Keuroghlian, 2021). The authors of this analysis answer earlier concerns about the methodology of “desistance” studies by controlling for baseline mental health status in their work (Almazan & Keuroghlian, 2021).
Similarly, a 2018 study published in JAMA Pediatrics found that out of 68 trans masculine patients undergoing chest reconstruction (top surgery), only one reported experiencing regret “sometimes” (Olson-Kennedy et al.). This study found no statistically significant differences between participants who underwent top surgery before age 18 and those who had surgery as adults (Olson-Kennedy et al.). The inverse effect can be observed when taking the impact of the COVID-19 pandemic into consideration — an international survey of 964 TGNB people conducted between April and August 2020 found that 55 percent of respondents experienced reduced access to gender-affirming resources, and this was correlated with higher prevalence of depression, anxiety, and suicidal ideation (Jarrett et al., 2020).
The literature of the field reflects clear conclusions: increasing access to gender-affirming care improves mental health outcomes, and limiting access negatively impacts them. Our profession’s division over best practices for the mental healthcare of TGNB clients has laid the groundwork for public uncertainty, as well as legislative harm. It is crucial that we continue to pursue research into mental health outcomes for TGNB clients and publish these findings in ways that are accessible outside of academia — not hidden behind a paywall or requiring institutional access. For cisgender psychotherapists, we need leverage our privilege and be generous with our labor, sharing this information with friends, family, colleagues, and writing to our elected representatives. It is an issue worth the extra time and effort, and can have life-altering consequences.
Almazan, A. N., and Keroughlian, A. S. (2021, April 28). Association between gender-affirming surgeries and mental health outcomes. JAMA Surgery 156 (7), 611-618.
Brooks, J. (2018, May 23). The controversial research on ‘desistance’ in transgender youth.
Ehrensaft, D. (2017). Gender nonconforming youth: current perspectives. Adolescent Health, Medicine, and Therapeutics (8)1, 57-67.
Hall, R., Mitchell, L., and Sachdeva, J. (2021, October 1). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. British Journal of Psychiatry 7(6), 1-8.
Jarrett, B. A., Peitzmeier, S. M., Restar, A., Adamson, T., Howell, S., Baral, S., and Beckham, S. W. (2020, November 4). Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people. medRxiv: the preprint server for health sciences (2), 1-32.
Olson-Kennedy, J., Warus, J., Okonta, V., Belzer, M., and Clark, L. F. (2018, May). Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatrics 172(5), 431-436.
Sravanti, L., and Sagar K, J. V. (2019). Gender Identity: Emergence in Preschoolers. Journal of Psychosexual Health I(3-4), 286-287.
Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., and Ahrens, K. (2022, February 25). Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA Pediatrics (5)2, 1-13.