What is Gender-Affirming Mental Health Care?

It seems like our culture cannot stop talking about gender-affirming care these days. From conservative commentators decrying it in the media to the hundreds of proposed bills banning access for patients under 18, gender-affirming care is a hot topic.³



Most of these laws restrict access to medical transition, including hormone treatment and surgery. But some, including Ohio’s HB68, passed in April 2024, limit access to gender-affirming mental health care, too.⁴ For therapists, who are taught from their first ethics courses to treat all clients, regardless of gender identity or other demographics, this presents a dilemma. Do we uphold our ethical obligation and continue to serve transgender and non-binary clients? Does this open us up to new liability as the state and federal government applies enhanced scrutiny to licensed professionals?



And, um, what exactly is gender-affirming mental health care, anyways? This term is not well-defined either in the legislation or in the news. Before we can wade into the ethics of providing gender-affirming care, we have to understand what it is and where it falls within our scope of practice.



What is gender-affirming care?



According to the World Health Organization, gender-affirming care refers to any “social, behavioural, or medical (including hormones or surgery) interventions” taken to affirm a patient’s gender identity.^1,2 When a person’s gender identity conflicts with their sex assigned at birth, they may desire changes to reflect how they identify.¹ They may or may not identify as transgender or non-binary.



In the context of healthcare, gender-affirming care often includes the use of hormone treatment to promote the development of secondary sex characteristics.³ For youth, it may also include the use of medication to prevent the onset of puberty. And in some cases, a patient might pursue surgery to alter their body in a way that reflects their gender identity.³



Gender-affirming care is not exclusive to non-cisgender people. In fact, some have cleverly noted that cisgender people benefit from gender-affirming interventions, and have done so safely for many years.³ Erectile dysfunction drugs, hair follicle transplants, and hormone replacement therapy after menopause – all of these interventions are considered gender-affirming care.



What is the role of mental health providers in gender-affirming care?



Mental health clinicians provide gender-affirming care in a number of ways. If you have a client who is exploring their gender identity in therapy, your support, affirmation, and aid in that process is providing gender-affirming care.



Therapists also often serve as part of a multidisciplinary care team when a client pursues medical transition. This is recommended by the World Professional Association for Transgender Health (WPATH) in many cases, to ensure that the client has mental health support as they pursue this journey.⁶



While this recommendation may be altruistic in nature, it also puts therapists in a gatekeeping role in some cases. Many laws restricting access to gender-affirming care now require meeting with a mental health provider before certain interventions are permitted, like starting hormones. This presents trans clients with new barriers to treatment, as an LGBTQ+ affirming provider may not be accessible geographically, financially, or otherwise.



Why is it controversial?



It’s not just about our societal discomfort or misunderstanding of transgender people. Some people believe that therapists are pressuring their clients to transition. Their argument is that talking about gender identity is a “slippery slope,” much like concerns about sex education. They fear that if we talk about gender or sexuality, we are giving our clients the go-ahead.



It is not inherently bad to give clients permission. Sometimes clients come to us knowing what changes they want in their life, but needing skills or a push in the right direction to take action.



On the other hand, the therapist holds power in their relationship with clients. And throughout the history of our profession, there have been plenty of times that relationship was exploited. One notable example is the 1980s satanic panic, in which therapists use hypnosis and other now-disgraced modalities to either “recover” or “fabricate” false memories of ritual abuse, depending on who you ask.⁵



A combination of factors make gender-affirming care a hot topic in 2025. Concerns about exploitation and the influence of therapists on their clients are, in many ways, valid. It is the responsibility of the therapist to monitor their own countertransference and how it may show up in session. This is where our professional codes of ethics come in, encouraging us to promote the client’s autonomy, dignity, and self-determination.



What does it look like in practice?



Gender-affirming mental healthcare looks different depending on the client’s stage of identity development. For clients who are questioning their gender identity, therapy can function as a container for ambiguity, confusion, and mixed emotions. It can be a safe place to explore and try new things. The therapist can introduce clients to “possibility models” – people who show them a way to live that they had not previously considered.⁷



If a client is pursuing transition, the therapist’s role shifts. It is well-documented that trans and gender non-conforming people are at an increased risk of mental health concerns like depression, anxiety, and PTSD.⁶ Gender-affirming care combines an understanding of how the biopsychosocial factors of being TGNC can impact mental health. This includes influences at the societal and cultural level, such as the impact of living in a hostile political climate, or with limited access to healthcare.



Lastly, for clients pursuing medical transition, the therapist becomes a member of their care team in this process as well. While mental health clinicians do not prescribe medication, we need to be informed enough to counsel clients on risks, benefits, alternatives, and potential side effects. We need to be capable of discerning when a client needs a referral back to their prescriber to rule out organic causes of symptomology. And of course, we need to know the limitations of our scope of practice, and to be humble enough to admit when we simply don’t know the answer.



How can I get involved?



Speaking of your scope of practice, it is important to practice gender-affirming care with competence. Allyship and support for the LGBTQ+ community are great, but clinically speaking, they are not enough to provide culturally responsive care.¹



Luckily, there are a number of ways to educate yourself about providing therapy to trans and gender non-conforming clients. Many continuing education programs through AASECT, the American Association of Sexuality Educators, Counselors, and Therapists, can offer insight into how gender and sexuality can show up in the therapy room. Books like “Am I Trans Enough?” by Alo Johnston and “Raising Trans Kids” by Rebecca Minor are aimed at trans people and their families, offering perspective on what your clients might be thinking.



Most importantly, gender-affirming therapists should be consuming media that is created by trans and gender non-conforming people, especially cis folks. Not only does this allow us to self-reflect and challenge our own biases, but it also gives us a deeper understanding of our clients’ experiences. So many LGBTQ+ clients come to affirming therapy and breathe a sigh of relief that they don’t have to explain themselves here. We want to treat our clients as the experts on their own experiences, but also know enough that we don’t ask them to give us a lecture on queer theory in their first session.



For fiction, I’d recommend works by trans authors including “Felix Ever After” by Kacen Callendar, a YA novel about a trans high schooler navigating first love and friendship, and “Detransition, Baby” by Torrey Peters, about three people whose lives intersect after a breakup and unplanned pregnancy. If you’re more of a first-person narrative fan, “Sissy” by Jacob Tobia and “She’s Not There” by Jennifer Finney Boylan are fantastic. And lastly, I think every clinician needs a copy of “Trans Bodies, Trans Selves,” an expansive resource guide for TGNC people.