A 400-page report from the Department of Health and Human Services released on May 1 regarding gender-affirming care for transgender youth is drawing backlash from medical and mental health professionals, parents, and LGBTQ+ organizations.
The report comes three months after Donald Trump’s executive order outlining his plans to eliminate gender-affirming medical treatments for transgender children, which called on Secretary of Health and Human Services Robert F. Kennedy Jr. to publish a “review of the existing literature on best practices” on the subject within 90 days. Although the report doesn’t have the force of law, it does provide what’s likely a preview of policy proposals to come.
While decades of evidence–based research have established guidelines within the medical community, the authors of the report opted to rely on a small number of hand-picked studies that align with the administration’s agenda, and contradict the current standard of care for gender dysphoria. Instead, they recommend courses of action that experts say are akin to conversion therapy, a discredited practice that attempts to change an individual’s sexual orientation or gender identity.
Major mainstream medical associations — including the American Academy of Pediatrics, the American Medical Association, the American Psychiatric Association, the American Psychological Association, the Endocrine Society, and the American Academy of Child & Adolescent Psychiatry — support the use of gender-affirming care in both children and adults.
“These decades of established research standards of care that have been empirically validated are now relegated to junk science, and the legitimate science is whatever they want to make up — but that’s the Trump administration for you,” Douglas C. Haldeman, PhD, a clinical psychologist who began working with survivors of conversion therapy in 1983, tells Rolling Stone.
Or, as Casey Pick, director of law and policy at The Trevor Project, puts it, the report “ignores and distorts science to try and take away essential care from young people who simply want to live healthy, happy lives like anyone else.”
The HHS report was released without the names of the contributing authors, prior to peer review. “For folks in the scientific and medical communities, this drastically diminishes the credibility of information contained within it,” says Morissa Ladinsky, MD, a pediatrician providing gender-affirming care and clinical professor at Stanford Medicine. “This is extremely unorthodox, disappointing, and concerning.” In a statement emailed to Rolling Stone, a spokesperson for HHS said that the department “has not released contributor names in order to preserve the integrity of the review process and prevent undue pressure or politicization of evidence-based research.”
Some of the most concerning parts of the report have to do with mental health, including the proposal to treat gender dysphoria with “exploratory therapy” — which experts are calling out as a rebanding of conversion therapy — and false claims that mental health assessments play little or no role in current gender-affirming care. Rolling Stone spoke with a range of experts to learn about what gender-affirming care actually involves, and why “exploratory therapy” could be harmful for transgender kids.
A rebranding of conversion therapy?
The bulk of the report is spent attempting to discredit gender-affirming care, and concludes by positioning psychotherapy as the best option for treating gender dysphoria in adolescents. Interestingly, the review found a “dearth of research on psychotherapeutic approaches to managing gender dysphoria in children and adolescents,” but the authors reason that because psychotherapy is effective for a wide range of mental health conditions “it may also be beneficial for gender dysphoria, specifically.”
But this isn’t just any kind of psychotherapy: HHS is recommending “exploratory therapy” for transgender kids. Though details of how it’s done and what it entails are scarce, the practice — also known as “gender exploratory therapy” — involves therapists casting doubt that their client’s “gender identity and experience of gender dysphoria are authentic and not pathological,” jurist and bioethicist Florence Ashley writes in a 2022 article published in Perspectives on Psychological Science.
The HHS report attempts to get ahead of the accusation that exploratory therapy is essentially conversion therapy in a section titled “The charge of ‘conversion therapy.’” In it, the authors argue that instead of looking at exploratory therapy as trying to “promote gender identities that are aligned with the person’s sex assigned at birth,” it should be viewed as therapists “trying to help children and adolescents come to terms with their bodies.” They also argue that “discomfort with the sexed body or with societal sex-based expectations is common during puberty and adolescence,” and “for this and other reasons, characterizing as ‘conversion therapy’ any approach focused on reducing a minor’s distress about their body or social role is a problematic and potentially harmful rhetorical device.”
But experts aren’t buying it.
“[Exploratory therapy] is well-known around LGBTQ health and wellness as literally a moniker for what we’ve known as conversion or reparative therapy — a long discredited, well-studied modality of behavioral therapy designed to get a patient to change either their gender identity or their romantic attractions,” Ladinsky tells Rolling Stone.
According to Haldeman, the clinical psychologist, the treatment described in the report “is a sort-of ‘conversion therapy lite,’ or a conversion therapy dressed up as something that is freely chosen.” In reality, though, he says that almost everyone who undergoes counseling with the goal of changing their identity or orientation isn’t doing so of their own free will, but because of pressure from society, family, church, or community.
According to a resolution from the American Psychological Association, conversion therapy is associated with an extensive list of long-lasting social and emotional consequences, including depression, anxiety, suicidality, substance abuse, a range of post-traumatic responses, feelings of anger and grief, loss of connection to community, damaged familial relationships, self-blame, guilt, and shame.
“Conversion therapy — no matter what you call it — isn’t actually therapy,” Pick tells Rolling Stone. “It’s a harmful practice that isolates and harms young people, scapegoats parents, and divides families through blame and rejection. When LGBTQ+ youth are pressured by conversion therapists to ‘change’ who they are, they are more than twice as likely to attempt suicide.”
Not only is exploratory therapy dangerous in itself, it’s also “an attempt to delay or discourage transition,” says therapist Casey Wiezman, founder of Gender Wellness Los Angeles, which provides mental health services — including gender-affirming care — for LGBTQ+ individuals and their families. “It’s not a neutral process. It could do a lot of damage.”
People like Dylan Thomas Cotter — a publicist, author, and transgender rights activist — know what it’s like to grow up without gender-affirming care. For him, getting top surgery was a 14-year process. “Had I had access to the advanced gender-affirming care that now exists for transgender children, I would not have suffered so much in my life socially, physically, and mentally,” he tells Rolling Stone. “This is why transgender adults advocate so strongly for transgender children — because we know that they can and should have a better life experience than we have had.”
Mental health therapy is the “backbone of care”
The report also claims that in the current gender-affirming model of care “comprehensive mental health assessments are often minimized or omitted,” and that “in some of the nation’s leading pediatric gender clinics, assessments are conducted in a single session lasting two hours.”
Haldeman, Wiezman, Pick, and Ladinsky all stress that this assertion is unequivocally false. “Mental health therapy is a key element [in gender-affirming care], and the vast, vast, vast majority of young people are already receiving longitudinal mental health care [prior to any kind of medical transition],” Ladinsky explains. “That’s really one of the first and most important elements [of gender-affirming care]. It’s the backbone of care for young people contending with gender dysphoria.”
To be clear, gender-affirming therapy — which, according to the American Psychiatric Association, “focuses on affirming a patient’s gender identity and does not try to ‘repair’ it” — is different from the “exploratory therapy” that the HHS report is espousing.
The HHS report’s assertion that mental health therapy plays little or no role in gender-affirming care supports the Republican narrative that adults — including parents, school officials, and doctors — are pushing or rushing trans youth into medical transition, including treatments like puberty blockers, hormones, and surgeries. But that couldn’t be further from the truth, Ladinsky says. “There’s the continual contention that physicians are so eager to grab a prescription pad, but in reality, young people are under our care for a very long period of time before medicine is part of the care that they merit,” she explains.
Gender-affirming medical care typically takes place in specialized clinics in academic medical centers, after a referral from the patient’s pediatrician or mental health provider, Ladinsky says. “When young people enter into puberty and that gender dysphoria ramps up, that is where discussions around medication will begin,” she says, noting that these conversations involve the patient, their family, and typically an entire medical team, including their mental health provider.
That’s been the experience of parents like Mandy Giles, the mother of two transgender young adults and the founder of Parents of Trans Youth. One of her children received gender-affirming care before they were 18. “They had to go through varying levels of mental health assessments and therapy to receive that care, and it was taken very seriously by the providers,” she says. “There were many people on the team. It was a very long process.”
Beginning medical interventions isn’t something parents, healthcare professionals, or transgender adolescents take lightly. “There’s this myth out there that people can go get puberty blockers and hormones for minors at Walgreens, or over-the-counter, or from a gumball machine or something,” Giles tells Rolling Stone. “But there are so many steps that have to happen for the safety of the child.”
Gender-affirming care often starts in therapy, says Wiezman, who has been providing mental health counseling for transgender clients for 35 years. “Usually by the time someone comes to see me — either a parent or a young person or even an adult — they’ve tried every way possible to not be transgender,” she tells Rolling Stone. “Sometimes I’m the first person they’ve ever told in their entire life.”
Contrary to what it says in the HHS report, gender-affirming mental health care involves significantly more than a two-hour evaluation. “Coming to therapy is a process,” Wiezman says. “It’s not like you come see me and the next thing is you’re starting on hormones or blockers.”
Eventually, if the transgender young person and their family decide to look into a medical transition, Wiezman will refer them to a gender-affirming provider or clinic that has training and specializes in treating transgender youth. But that doesn’t mean that therapy stops. “I always think of myself as a cheerleader,” she says. “I start with the client, and a lot of times I’ll go all the way through any medical care [they receive] and even afterwards. It’s a long process.”
For Giles’s family, the process took more than a year. “My child was receiving mental health treatment before we made the decision together with their mental health provider, who agreed that [medical intervention] would be a good course of action,” she says. “It was a year from when we first contacted the medical provider to get the appointment to jump through administrative hoops and then all those assessments.”
Of course, the timeline looks different for everyone and “depends on the age and stage of the patient,” Ladinsky says. For example, because there’s no medication indicated or prescribed for prepubescent children, they may spend a longer time in therapy than older transgender youth, she explains.
Using data from the private insurance claims from 2018-2022 from more than five million adolescents, the authors of the first peer-reviewed study looking at the rate of hormone and puberty blocker use among youth in the U.S. — published in January in JAMA Pediatrics — found that fewer than 0.1 percent of transgender teenagers with private insurance in the U.S. received gender-related medicines. Fewer than 18,000 teenagers in the study were diagnosed with gender dysphoria. Of those, fewer than 1,000 took puberty blockers, and fewer than 2,000 accessed hormones.
Older teens with sustained gender dysphoria and transgender identity are “vetted by their mental health providers, as well as those on our teams in the academic centers,” Ladinsky says. “Their mental health providers are part of the team who decides when they begin hormones. [At that point,] they’ve been with us for a very long period of time. This is not a ‘one day, one visit one, here you go.’”
According to Ash Lazarus Orr, press relations manager at Advocates for Trans Equality, the report’s claim that transgender kids are being “rushed” into receiving gender-affirming medical care ignores reality entirely. “Trans people, including trans youth, know who they are,” he tells Rolling Stone.
The HHS report also falsely claims that “there is no evidence that pediatric medical transition reduces the incidence of suicide.” However, a 2022 peer-reviewed study published in The Journal of Adolescent Health by researchers at The Trevor Project demonstrated that there’s “a significant relationship” between access to gender-affirming hormone therapy and lower rates of depression and suicidality among transgender and nonbinary youth.
“No one would go through either social transition, medical transition, [or] legal transition unless that was something they truly needed to be themselves,” Giles says. “All of those steps are hard, mainly because of how society views transgender people. They are not easy hoops to jump through.”
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