Supreme Court to Hear Challenge to State Conversion Therapy Ban
Within the pediatric gender medicine field, there have been conflicts over whether such state bans compromise mental health care for minors with gender-related distress.
The Supreme Court announced on Monday that it would hear a case challenging a Colorado law barring counselors from practicing conversion therapy—meaning efforts to change an individual’s sexual orientation or gender identity—on minors.
The case was brought by Alliance Defending Freedom, a conservative legal powerhouse that has sought to undo laws protecting abortion, insurance coverage for contraception, gay rights and pediatric access to gender-transition treatment.
The Supreme Court case concerns whether conversion therapy bans violate the free-speech rights of counselors.
“The government has no business censoring private conversations between clients and counselors, nor should a counselor be used as a tool to impose the government’s biased views on her clients,” said ADF CEO Counsel Kristen Waggoner in a press release.
Not all leaders in pediatric gender medicine are necessarily in support of conversion therapy bans in the pediatric context, however—at least as they are currently written. Some argue that when it comes to gender identity, these laws are overly broad. They say that, even with language allowing for exploration of a child’s gender identity, these statutes erect barriers around counselors’ ability to freely treat gender-related distress in minors. They argue that the laws essentially put the finger on the scale in preference of what’s known as the affirmation model, in which a counselor is expected to show strict deference to the child’s perception of their gender.
The Supreme Court is set to settle these disputes, either during the current term or the next one.
Internal tensions over best practices for caring for gender-distressed youths
Amid the battle in the courts over state bans of pediatric gender-transition treatment, a quieter yet crucial dispute has long been burgeoning among gender-medicine and mental-health experts over psychotherapeutic best practices for treating children and adolescents who are distressed over their gender identity.
Firstly, there is ongoing debate over whether gender-dysphoric adolescents should be required to receive psychological counseling before they can access puberty blockers and cross-sex hormones in the states where pediatric gender-transition treatment remains legal. (Gender dysphoria involves significant distress related to having a gender identity that doesn’t align with an individual’s sex.)
Leaders in pediatric medicine, such as Dr. Jack Turban of University of California, San Francisco, have advocated for doing away with psychosocial assessments prior to prescribing gender-transition treatment to minors, saying these barriers to care are counterproductive.
Dr. Jack Turban's Quietly Radical Bible On Pediatric Gender Medicine: a Primer
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Among the most provocative figures pushing the needle in favor of free and open access to gender-transition treatment for minors is transfeminine jurist Florence Ashley, an assistant professor in the faculty of law at the University of Alberta. Ashely wrote in a paper published in 2024 in Psychology of Sexual Orientation and Gender Diversity: “In addition to the harm that may be caused by delaying care, some studies suggest that gender assessments are experienced as distressing, invasive, degrading, and unjust by trans individuals.”
As for any psychotherapy that gender dysphoric youth do receive, considerable contention remains within the field of pediatric gender medicine about where to draw the line dividing appropriate counseling from conversion therapy.
Conversion therapy in the transgender context is counseling, often conducted by force or coercion, that holds a rigid goal of re-aligning a person’s gender identity with their sex.
Ashley is among the most vocal trans advocates who argue for an particularly expansive definition of conversion therapy—essentially any counseling that does not follow what’s known as the “gender-affirmative” model of care.
Laura Edwards-Leeper is a psychologist in Ohio and a leading voice among mental health professionals who care for gender dysphoric children. She holds sharply differing views from Ashley and said therapists should be allowed broad latitude to explore children’s gender identities with them.
“Conflating conversion therapy and identity exploration is perhaps the largest threat to both gender-distressed cisgender youth and transgender youth, alike,” said Edwards-Leeper.
Caring for kids while minding the law
Conversion therapy has a long and notorious history in the homosexuality context. Throughout the 20th century, psychotherapists commonly promised to “cure” gay people of same-sex attraction. Research into this practice’s myriad harms began to emerge in the mid-1990s and ultimately led academics to conclude that it was actually impossible to change a person’s sexual orientation. Conversion therapy has since become anathema among mainstream mental-health experts. Since 2012, the practice has been banned for minors in 21 states, including Colorado, and Washington, DC.
All of these bans apply to both sexual orientation and gender identity. Such laws were drafted and passed over the concerns of some mental-health professionals who have noted that research into gender identity–focused conversion therapy remains in its infancy. These skeptics have further argued that defining conversion therapy in the transgender context is challenging, in part because compared with sexual orientation, gender identity is much more, subjective, complex, multifaceted, fluid and difficult to characterize.
Acknowledging concerns that conversion therapy bans could impose undue constraints on well-meaning psychotherapists, most conversion-therapy bans include carve-outs that provide flexibility for counseling that provides general exploration of gender identity.
Such exceptions notwithstanding, some pediatric mental health professionals still report that they remain wary about accepting as patients children with gender dysphoria. They express fear that they will be accused of practicing conversion therapy if they provide counseling that strays from what they characterized as the rigid principles of “affirmative care.”
The affirmative care model, which has become the predominant practice in U.S. gender clinics over the past 15 years, generally prioritizes allowing the child to lead in defining their gender identity and gender-expression preferences.
A history of fast-evolving best practices
Prevailing attitudes among experts about what constitutes standard practice for treating gender dysphoria in children have shifted dramatically in the United States in recent years.
During the 2000s, many mental health professionals looked to methods pioneered by American-Canadian psychologist Dr. Kenneth Zucker at his youth gender clinic at the Centre for Addiction and Mental Health in Toronto.
Zucker explicitly sought to discourage gender nonconformity in dysphoric children and to favor gender-neutral interests and play. This was based on research, now controversial and disputed by many trans advocates, finding that most prepubescent children with distress over their gender grow out it during adolescence. In particular, most of those born male, this research found, grew up to be gay men rather than trans women.
But during the 2010s, uproar began to mount among activists and among some psychotherapists over Zucker’s methods, which detractors characterized as conversion therapy. This culminated in 2015 with the academic administration overseeing Zucker firing him and shutting down the clinic. Zucker sued for wrongful termination and defamation. He ultimately settled with the center’s administration for $586,000, and the clinic administrators were compelled to apologize and retract various critical claims they made about his practices.
While trans activists as well as many experts in the care of gender dysphoric children remain adamant that Zucker’s approach is indeed conversion therapy, he does maintain strong support among a faction of other mental health professionals. He now works in private practice and edits the academic journal the Archives of Sexual Behavior, which frequently publishes heterodox papers about pediatric gender medicine that top medical journals such as the New England Journal of Medicine apparently refuse to touch.
The establishment of Zucker’s ignominy represented a watershed moment for the swift rise of tranformative new practices in pediatric gender medicine.
In 2007, Laura Edwards-Leeper was among those who first imported to the U.S. the so-called “Dutch protocol,” cultivated by researchers in the Netherlands, of treating gender dysphoria in select children with puberty blockers and cross-sex hormones. This move would transform the care of gender-distressed youths, giving rise to over 100 pediatric gender clinics throughout the U.S.
The Dutch protocol promoted a so-called “watchful waiting” premise that discouraged social transitioning—changing clothing, haircut, name and pronouns—among prepubescent children. The method favored assessing whether their gender dysphoria was “consistent, persistent and insistent” through puberty’s onset. Only then would gender-transition medication be considered.
In recent years, this more cautious approach has been supplanted in the United States by the much more liberal gender-affirmative model, which is now backed by most of the nation’s major medical societies. Many experts in treating gender dysphoria now support social transitions among prepubescent children. The criteria for permitting treatment with gender-transition medications have become less rigid.
In 2018, the American Academy of Pediatrics (AAP) endorsed the affirmative model in a position statement written by Brown University child psychiatrist Dr. Jason Rafferty. Rafferty dismissed “watchful waiting” as an “outdated approach” and stated that conversion therapy has “been proven to be not only unsuccessful but also deleterious.”
The following year, Canadian sex researcher James Cantor published a scathing critique of the AAP position statement. Cantor noted that the studies Rafferty cited to characterize conversion therapy were only focused on sexual orientation, and that there was no research on the practice in the context of gender identity. (At least two such studies have since been published.) Many of the paper’s citations, Cantor further noted, actually supported watchful waiting as the standard of care.
Neither Rafferty nor the AAP has ever publicly responded to Cantor’s criticisms. In August 2023, the organization renewed its endorsement of Rafferty’s paper, making no changes. However, in the wake of a pressure campaign from a small but vocal group of its members, the AAP also pledged to commission a systematic review of the evidence regarding pediatric gender-transition treatment.
And yet, to date, there is no evidence that such a review has begun, as I reported in my investigation about internal turmoil among AAP members regarding its most recent conference being held in Florida—home of Ron DeSantis’ attacks on pediatric gender medicine and other transgender rights.
In late 2023, Rafferty and the AAP were sued by a detransitioner—a former patient of his who received gender-transition treatment as a minor by him and his colleagues and later stopped treatment and reverted to presenting and identifying as a woman.
In recent years, England, Sweden and Finland have all conducted their own systematic reviews of the evidence behind pediatric gender medicine and concluded that it is weak and inconclusive. The first such review to include a meta-analysis, conducted by Canadian researchers, was published in January and reached the same conclusion. Those three nations, along with Denmark and Norway, have sharply dialed back the availability of gender-transition medication for children, reclassifying it as experimental.
All told, these five nations now favor psychological counseling for gender dysphoric children.
What is “gender exploratory therapy”?
During the years leading up to the second Trump administration, American leaders in pediatric gender medicine betrayed no signs of adopting the five European nations’ more measured response to the available science. Instead, the legal landscape sharply polarized, largely dividing into states that outright banned pediatric gender-transition treatment versus those that protected the gender-affirmative model zealously.
Since his inauguration, Trump has sought to eliminate the entire field of pediatric gender medicine. His executive order barring federal funding for health care providers that provide gender-transition treatment to minors was put under a preliminary injunction by a federal judge in Maryland last week.
Prior to the current period of all-out assault on this field by the Trump administration, some in the pediatric gender-care field advocated for what they characterized as a middle ground in the psychological care of gender dysphoric children. Such advocates included Erica Anderson, a clinical psychologist and a former head of the trans health care group USPATH, who along with Edwards-Leeper has advocated for so-called gender-exploratory therapy.
In an interview, Anderson, who is transgender, called this “a holistic form of psychological evaluation and counseling.”
Edwards-Leeper said that that many of the youth presenting with gender dysphoria have multiple psychological diagnoses that need parsing from gender distress. In some cases, she said, psychotherapy may indeed provide children the means to determine that other psychological factors, and not an intrinsic transgender identity, were driving the dysphoria.
She said that without such therapeutic exploration, mental health professionals are hamstrung in their effort to determine the children for whom the theoretical benefits of a medical transition, such as mitigated dysphoria and improved mental health, would likely outweigh the risks, including potential infertility.
Florence Ashley, however, is among those who have claimed that gender-exploratory therapy as conversion therapy by another name. She has further argued that there is no evidence backing claims that psychothreapy can help identify children who would later regret a medical transition.
Erin Reed, a prominent transgender activist, claimed on her popular Substack in December 2022 that the central purpose of gender-exploratory therapy is to stall until a patient has gone through puberty, and that the method excludes “being transgender as an end point.”
Anderson characterized this claim as scurriluous and fanciful.
“All psychotherapy is exploratory,” Anderson said. “The term ‘conversion therapy’ as applied to exploratory therapy with minors has been weaponized to try to discount anything other than simple acceptance of a child’s self-attestation of their gender.”
I am an independent journalist, specializing in science and health care coverage. I contribute to The New York Times, The Guardian, NBC Newsand The New York Sun. I have also written for the Washington Post, The Atlantic and The Nation. Follow me on Twitter: @benryanwriter and Bluesky: @benryanwriter.bsky.social. Visit my website: benryan.net
Benjamin, do you think it's possible that in some ways the discussion of what constitutes conversion therapy and whether "exploratory therapy" is a form of conversion therapy is a red herring, because what we really need to be talking about is whether doctors and therapist are being allowed to do proper evaluation and differential diagnosis? Dr. Anderson briefly uses the language of "assessment" in her critiques of how the term conversion therapy is applied, but then goes on to keep talking about therapy. I'm wondering if we need to shift the conversation to appropriate differential diagnostic procedures. There needs to be proof from people like Florence Ashley and Jack Turban that there is literally no other cause for gender distress except for gender dysphoria and a mismatched gender identity that must be affirmed and the body changed to align to it. For example, the unstable and shifting identity issues of borderline personality disorder or the obsessive thoughts that can come with OCD or autism? It seems to me the problem is not with whether or not something is conversion therapy, but whether trans activists have proof that there is always only one cause of gender related distress and whether doctors and therapists are being allowed to do proper differential diagnosis. It seems this needs to be resolved before we're even getting into the weeds of what is and isn't conversion therapy when it comes to gender dysphoria.
Andrew Sullivan, on the other hand, has repeatedly argued that the transitioning of gay kids is the "gay conversion therapy" of today... (Such as here: https://andrewsullivan.substack.com/p/will-big-trans-be-held-to-account-3ad)