The Trump administration is pushing therapy for transgender youth. What does that look like?

Miami Herald

2 days ago

Since President Donald Trump returned to office in January, federal policy has shifted to promote psychological therapy as the only treatment for transgender youth in distress.
A report issued last month by the Trump administration's Department of Health and Human Services on care for transgender and nonbinary people analyzed 17 studies out of more than 3,400 looking into gender-affirming care - an umbrella term that can include talk therapy, puberty blockers, hormone treatments and surgeries.
They included only analyses of other studies that didn't include any patients older than 26. Those that examined mental health generally found improvements from gender-affirming care, though with low certainty, because they didn't include a large enough group, the effects were small, or other factors.
The report had more sweeping conclusions, however, stating that people under 19 with gender dysphoria should receive only psychological therapy, rather than being able to choose puberty blockers or hormone therapy. Gender dysphoria refers to distress when someone's gender identity and their sex, or the way others see them, don't match.
Major medical groups, such as the American Academy of Pediatrics, have endorsed offering the full range of affirming care to appropriate patients, and experts interviewed by The Denver Post agreed that while some patients only need therapy, others benefit from gender-affirming medical care.
The new report comes as the administration ordered providers to stop offering puberty blockers and hormone therapy to anyone under 19, threatening to take away federal funding from hospitals that didn't comply. A federal judge blocked Trump's executive order while a legal challenge plays out from four states, including Colorado.
The Trump administration also forbade transgender people from serving in the military, threatened federal funding for schools if they promote "gender ideology," removed references to LGBTQ health disparities from health websites, ordered the Justice Department to take action to stop trans girls from playing on sports teams with cisgender girls, forbade the issuing of passports displaying the gender trans people identify with, and moved inmates who are trans women into men's prisons.
Dr. Rae Narr, a nonbinary psychologist in Denver, said the administration's actions targeting transgender people suggest the government is going to push therapy that attempts to change someone's sexual orientation or gender identity. But, done right, therapy can also be affirming, they said.
"On their face, what they are suggesting is therapy and support for these youth," Narr said. "When you really look at what they're suggesting, it's conversion therapy."
Conversion therapy, as typically practiced today, looks for a pathological root for someone's sexual orientation or gender identity, Narr said. For example, the practitioner might argue that another condition, such as autism, caused someone to think that they were transgender, or that they wanted to change their gender because of shame about being gay or a history of sexual trauma, they said.
Mainstream medical groups condemn the practice and Colorado banned conversion therapy for minors, though the law faces a challenge at the Supreme Court.
Affirming therapy, in contrast, starts from the position that no identity is right or wrong, Narr said. The goal isn't to encourage young people to transition, but to help them sort through what would make them comfortable in their bodies and lives, they said.
That can involve talking about how they imagine their adult lives and practical exercises, such as trying on different clothes, Narr said. They also discuss where the young person would feel physically and emotionally safe exploring. For example, someone might go to the next town over to try out going to a store dressed differently, they said.
"I talk to kids a lot about what does it mean to you when you imagine being a boy, or a girl, or something else," they said.
'We listen to them'
In 2024, 46% of transgender or nonbinary young people reported seriously considering suicide, and 14% attempted it, according to the LGBTQ nonprofit The Trevor Project.
Those who reported they'd experienced bullying or physical harm because of their gender identity were more likely to report thoughts of suicide, as were those who said their schools didn't support them.
But the odds of suicide drop when youth report that people in their lives accept them, such as by calling them by their chosen name and pronouns, Narr said.
Dr. Casey Wolf, a child and adolescent psychiatrist at WellPower in Denver, said the field hasn't agreed to a protocol for treating gender dysphoria, but does have evidence-based therapies for the depression, anxiety or trauma that typically push people to seek help.
Sometimes, those symptoms stem from gender dysphoria or from mistreatment based on someone's gender identity, but not always, she said.
"We listen to them. We try to understand what their symptoms are," Wolf said.
While the public is talking about gender identity more than in the past, Wolf said she hasn't seen an increase in young people experiencing gender dysphoria. Despite the perception that being transgender is trendy, people don't take on marginalized identities like they change their hairstyles, she said.
Not all trans people experience gender dysphoria, and not everyone who has gender dysphoria decides to transition, said John Mikovits, an assistant professor of nursing who studies care for LGBTQ people at Moravian University in Pennsylvania. Some people may only need emotional support at some points in their life, but may decide to socially or medically transition later, he said.
What the therapist helps the patient work on may also change, Mikovits said. For example, a person who opts to transition may feel relief from gender dysphoria, but needs to learn skills to cope with increased discrimination, he said.
"The treatment is not about curing someone's transgender or misaligned identity, it's about affirming that identity and improving their quality of life," he said.
'The most basic and easiest thing to do'
Acting as a liaison between kids and parents can also be part of the job.
Young people often struggle to tell their parents what they're feeling, so the news they're questioning their gender can feel like it comes out of nowhere, Narr said. Parents also don't always do the best job explaining their feelings, so confusion or fear for their child's future can come off as rejection, they said.
"Even if the parents are supportive, it's reasonable to have some fear and grief" for the life they imagined for their child, they said.
While discussion about affirming care focuses on puberty blockers, hormones and surgeries, just using the right pronouns for someone can be important affirmation, Mikovits said.
"It's the most basic and easiest thing to do, to refer to people the way they want to be referred to," he said.
Everyone wants others to see them the way they see themselves, and if that isn't happening, it can bring shame and hopelessness, Wolf said. When someone says they aren't wrong or sick because of how they see themselves, that can bring back some hope that the problem is their environment, and they may be able to change it, she said.
"That's the beginning," she said.
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