Advocating for transgender and nonbinary youths

The United States is seeing an unprecedented rise in anti-trans legislation. In 2021, more than 100 bills across 33 states aimed to prohibit gender-affirming care or restrict access to sports for transgender youth, according to the ACLUopens in new window. Numerous other legislative efforts attempted to ban trans people from using the bathroom that corresponds with their gender; others aimed to restrict them from changing their sex on their birth certificate.

More than 17 of these bills were enacted, surpassing 2015 as the worst year for anti-trans legislation in historyopens in new window.

Unfortunately, 2022 is yet another shocking year for sexual and gender minorities. The first week of January saw state lawmakers in at least seven statesopens in new window propose laws that further hinder the rights of transgender and nonbinary children and adolescents. This was followed swiftly by Texas Governor Greg Abbott directing state officials (PDF, 696KB)opens in new window to investigate health care providers or parents who help trans youth receive gender-affirming care, labeling it as “child abuse.” In March, a statewide injunction blocked the state from conducting these investigations, however, two months later, the Texas Supreme Court issued a ruling striking down this injunction.

“Trans people and nonbinary people for a long time have been used as political footballs,” said Anneliese Singh, PhD, a professor of social work at Tulane University who studies racial justice and the resilience of sexual and gender minorities and trans people of color.

Trans and nonbinary people already suffer disproportionately from suicidality and other mental health issues. According to a survey by the Trevor Project of over 40,000 LGBTQ+ youth ages 13 to 24, over 60% of trans and nonbinary youth reported engaging in self-harm and 52% had seriously considered suicideopens in new window in the past year. This is compared with 48% of cisgender lesbian, gay, and bisexual youth who reported engaging in self-harm, and 34% who have considered suicide—all of which are far above national averages.

As the stakes for the well-being of transgender and nonbinary kids continue to rise, Singh and other psychologists are pushing for more public education on gender-affirming care, including the use of puberty blockers, which delay on the onset of puberty, and hormones such as estrogen or testosterone that help trans individuals acquire the secondary sex characteristics more aligned with their gender identity. Psychologists must also continue to advocate for this community and combat the fearmongering used by anti-trans groups and lawmakers that aim to strip sexual and gender minorities of their rights and safety, Singh noted.

“I think for psychologists and other mental health professionals, it is imperative for us to prioritize advocacy in our work,” she said. “Now is the time we need all hands on deck.”

Some topics surrounding trans and nonbinary youth, particularly the assessments and treatments involved in gender-affirming care, still cause a lot of controversy among psychologists.

When treating a child who identifies as trans or nonbinary, some psychologists push for thorough mental health assessments that investigate how other issues or changes in the child’s life may contribute to their feelings surrounding their gender identity prior to any medical treatments.

“Anyone who comes to see me with an identity of any sort, it’s my job as a psychologist to say, ‘Wow, that’s interesting, tell me more about that,’” said Antonia Caretto, PhD, a clinical psychologist in Farmington Hills, Michigan, who works with trans and gender-diverse kids. “The process may go very quickly, or it may not.”

In November 2021, two clinical psychologists who work with trans and gender-diverse patients wrote an opinion essay for The Washington Postopens in new window asserting that many medical providers are giving “sloppy, dangerous care” to trans youth that lacks proper psychological assessments. They noted that the standards of care provided by the World Professional Association for Transgender Health (WPATH) recommends a comprehensive, typically months-long evaluation for all kids suffering from gender dysphoria (feelings of discomfort or distress when one’s gender identity differs from their sex assigned at birth) before starting puberty blockers or hormones.

Without this, the authors wrote, there is a fear of some youth detransitioning, or no longer identifying as transgender. In a survey of 100 individuals who detransitioned, 55% felt they did not receive an adequate evaluation from a doctor or mental health professional before starting their transition (Littman, L., Archives of Sexual Behavioropens in new window, Vol. 50, 2021).

“There are more and more people who are detransitioning, which I think is often happening because clinics are cutting corners with assessment and mental health involvement,” said Laura Edwards-Leeper, PhD, who helped found the first pediatric gender clinic in the United States in 2007 and coauthored the article in The Washington Post with her colleague, Erica Anderson, PhD—herself a transgender woman and expert in the field.

For Caretto, the big question is how psychologists can help individuals discover whether their gender dysphoria will persist or desist. “I don’t think the desistance rate is 100%, and I don’t think it’s 0%,” she said. “It’s foolish of us in the community to be reactionary and say that it doesn’t exist at all.”

Marci Bowers, MD, a trans woman and celebrated pelvic and gynecologic surgeon who has performed 2,000 vaginoplasties—a procedure to construct a vagina—has also expressed concern with the current state of conversation surrounding gender-affirming care. “There are definitely people who are trying to keep out anyone who doesn’t absolutely buy the party line that everything should be affirming and that there’s no room for dissent,” Bowers said for Common Sense, a newsletter by former New York Times writer Bari Weiss. “I think that’s a mistake.”

Other professionals in the field see the concerns about detransitioning as unfounded, as many studies have shown that the majority of trans individuals do not go on to detransition (Dhejne C., et al., Archives of Sexual Behavioropens in new window, Vol. 43, 2014; James, S. E., et al., The Report of the 2015 U.S. Transgender Survey (PDF, 2.22MB)opens in new window, National Center for Transgender Equity, 2016; Wiepjes C. M., et al., The Journal of Sexual Medicineopens in new window, Vol. 15, No. 4, 2018). A 2021 study, for example, showed that 13.1% of people who identify as transgender have detransitioned at some point in their lives. However, 82.5% of those who did so attribute their decision to at least one external factor, such as pressure from family, nonaffirming school environments, and increased vulnerability to violence, including sexual assault (Turban, J. L., et al., LGBT Healthopens in new window, Vol. 8, No. 4, 2021).

In a Facebook discussion on Edwards-Leeper and Anderson’s article, Colt St. Amand, PhD, MD, a licensed psychologist and physician in Houston, Texas, who is transgender and works with trans patients, wrote that psychologists should affirm a patient’s gender identity. “My approach with anyone who tells me that they are trans is to accept that at face value,” he wrote. “After all, it is an identity, and identities develop over time.”

People outside of the field of psychology have also raised issues about the article. “They pointed to a single study of an extremely small number of people who have detransitioned to support their argument in favor of delaying or even denying gender-affirming medical care to gender-diverse youths,” two parents of transgender kids wroteopens in new window.

Regardless of the controversy on how and when to administer treatments to trans and nonbinary kids, psychological science is very clear that gender-affirming care helps trans kids, said Singh. “It is unconscionable that politicians would label it as child abuse,” said Edwards-Leeper.

A study out of the University of Washington discovered that among 104 trans and nonbinary youths ages 13 to 20, gender-affirming care lowered the odds of moderate to severe depression by 60% and suicidality by 73% (Tordoff, D. M., et al., JAMA Network Openopens in new window, Vol. 5, No. 2, 2022).

Another study, which used data from more than 27,000 people collected by the National Center for Transgender Equality’s 2015 U.S. Transgender Survey (PDF, 2.22MB)opens in new window, showed that transgender youth who began hormone treatment in adolescence had fewer thoughts of suicide, were less likely to experience major mental health disorders, and had fewer problems with substance misuse than those who started hormones in adulthood (Turban, J. L., et al., PLOS ONEopens in new window, Vol. 17, No. 1., 2022).

“One of my guiding principles is it doesn’t hurt any of us to treat and honor people with respect as they see and experience themselves,” said clinical psychologist Winley K, PsyD, who is genderqueer and founded the WaterYourFire Wellness Collective, which provides psychotherapy to people of color and queer people.

Society sees transgender individuals as people who are breaking a societal norm, said Winley. However, transgender folks “exist all throughout history. It’s just someone decided, mostly through colonization, that this is how things are supposed to be and anything outside of [cisgender people] is not normal.”

Furthermore, the fact that transgender people make up a minority of the U.S. population doesn’t take away from their humanity, said Winley. “Transgender folks may not be what you deem the norm, but they are still valuable, they still matter, they still exist.”

In response to the recent onslaught of anti-LGBTQ+ legislation, APA President Frank C. Worrell, PhD, released a statement condemning the directive by Abbott to report parents and transgender minors. Worrell also published a response against Florida’s “Don’t Say Gay” bill.

APA’s Division 54 (Society of Pediatric Psychology) also made known their support of access to gender-affirming care. “The proposed bills do not align with international standards of care, research, or clinical expertise. Thus, we strongly oppose these bills and call upon lawmakers to introduce legislation to promote the health, well-being, and safety of transgender and gender-diverse youth,” the society wrote.

Four more APA divisions, including Division 44 (Society for the Psychology of Sexual Orientation and Gender Diversity), also plan to issue a statement this year. “The working group hopes to summarize relevant evidence and empirical literature and then make recommendations based upon that,” said Richard Sprott, PhD, a developmental psychologist at California State University, East Bay and president of Division 44 . “They’ll focus on evidence-based medicine and mental health care, along with the ethical issues of gatekeeping care.”

Additionally, APA has put together a task force of 12 psychologists—including Anderson—who will revise the organization’s Guidelines for Psychological Practice With Transgender and Gender Nonconforming People (PDF, 461KB)opens in new window. The group, which started meeting last September, has come up with 40 potential guidelines, which are now being reviewed and trimmed down, said Ron Schlittler, assistant director of APA’s Sexual Orientation and Gender Diversity Portfolio and the task force’s staff liaison.

The goal is to educate psychologists on how to provide sensitive and informed care for transgender and gender-nonconforming people, which is particularly relevant with the harmful anti-trans rhetoric that is circulating, said Schlittler.

Yet more immediate action is also required to help sexual and gender minority kids. For example, psychologists can create a safe office space where their patients feel welcomed, use inclusive intake paperwork (such as forms that recognize diverse gender identities), and educate themselves on gender identity and expression to affirm the experiences of trans and nonbinary folks, Singh noted.

“Outside of our offices, I think that legislative advocacy is always important, but especially crucial right now because we are starting to see the rollback of some of the gains of trans and nonbinary liberation movements,” Singh said. “One of the most helpful things we can do on a local, state, and national level is connect with other psychologists who are doing the work, with other community members who have already been doing this work and follow their lead.”

This includes youth activists who are taking charge in the fight against anti-trans billsopens in new window and people like Ricardo Martinez, CEO of Equality Texasopens in new window, a nonprofit dedicated to securing full equality for LGBTQ Texans.

Megan Mooney, PhD, a licensed psychologist in Texas who works with LGBTQ+ youth, is pushing for psychologists to provide coordinated legislative testimony, publish articles in peer-reviewed journals on the importance of gender-affirming care, give interviews to media outlets, and promote relevant information on social media.

“We have to recognize that the political is professional. Our jobs as psychologists can and should include more than just providing individual therapy, teaching in a lecture hall, or conducting research in a lab,” said Mooney. “We are part of a profession that is rooted in science, and we have a duty to share that science with others, not just inform our own work with it.”

Advocacy like this is particularly vital as the field of mental health has historically fallen short when it comes to helping the LGBTQ+ community. For more than 20 years, homosexuality was listed in the Diagnostic and Statistical Manual of Mental Disorders as a sexual deviation. It wasn’t until 1973 that the American Psychiatric Association board of trustees voted to declassify homosexuality as a mental disorder. The DSM also diagnosed transgender individuals with “gender identity disorder” for many years, thus increasing stigma against the population.

In addition, the increasing number of kids who are now comfortable enough to come out as gender diverse need psychologists to speak up. One study found that 9.2% of students from 13 public schools in Pittsburgh reported incongruities between their sex assigned at birth and their gender identity (Kidd, K. M., et al., Pediatricsopens in new window, Vol. 147, No. 6, 2021). Another study sampled 81,000 Minnesota high school students in grades 9 and 11 and discovered that nearly 3% identified as transgender or gender nonconforming (Rider, G. N., et al., Pediatricsopens in new window, Vol. 141, No. 3, 2018). Both numbers are significantly higher than the 1.8% commonly cited in scientific literature and the media.

“I’m seeing an increase in parents seeking out affirming spaces,” said Winley. For Black and brown trans kids, this is particularly important as there is a stigma in these communities against LGBTQ+ individuals, Winley noted. “I’ve seen a wave of Black and brown parents saying, ‘I support my kid, I’m proud of my kid, I just want to find some support for my kid.’”

Singh recognizes that this type of advocacy may feel daunting, as many psychologists are not taught how to engage with the public in this manner. “I think sometimes we lose sight of the fact that our very profession exists because of advocacy,” she said.

Even with the record-breaking number of anti-trans laws, many psychologists still have hope for the future of gender and sexual minority health.

“I’ve seen the strength of the response that has come from a number of different sectors of our society,” said Sprott. “It’s come from the health care side, the legal side, the statements made by the APA president, statements from other professional organizations.”

Winley is also optimistic about the conversations surrounding transgender individuals moving forward, stating that although the legislation is horrid, it’s forcing people to talk about these issues with friends and family more often.

For Singh, she sees this fight as benefiting all people—be they cisgender, transgender, or nonbinary. “I think gender liberation is really valuable to bring into psychology, and it would help us right the way our ship is going with trans and nonbinary mental health,” said Singh. “We should be fighting and working for freedom for all genders. At the end of the day, this helps all of us.”