Science Direct | August 2026
Original article can be viewed HERE
During the past twenty years, the prevailing clinical approach to child and adolescent gender dysphoria changed dramatically. Before then, most clinicians considered youth gender dysphoria a mental health problem best addressed through psychological management. Typically, childhood gender dysphoria resolved prior to adulthood. Recently, however, the gender-affirming approach has prioritized facilitating social and medical gender transition of dysphoric youth. The ascendancy of gender-affirming care did not arise because of empirical advances. Rather, gender-affirming care triumphed because of the unquestioned ideological beliefs that treating gender dysphoria as a psychological problem is unenlightened, unethical, and akin to conversion therapy for sexual orientation. Clinical referrals for youth gender dysphoria skyrocketed. Adolescent-onset dysphoria among natal females, previously unknown, became the most common subtype, and there are indications it is socially transmitted. Concerns about these developments led to systematic research on the claims that gender affirmation is necessary for improvement and to prevent suicide. Comprehensive reviews failed to support these claims, and gender transition has serious social and medical complications. Thus, gender-affirming care is increasingly seen as a dubious approach. Psychotherapy, including cognitive-behavioral therapy, holds promise as a tool to manage gender dysphoria, ideally until it desists. Gender transition should be considered only after alternatives have been explored. Three distinct pathways are discussed: childhood-onset, autogynephilic, and rapid-onset gender dysphoria. Their optimal treatment may differ.
For twenty years a single therapeutic approach has predominated in the treatment of gender dysphoric children and adolescents: gender-affirming care [1,2]. This approach is based on several propositions, listed in Table 1, and the most important are as follows: Children and adolescents who feel they may be transgender should not be questioned or doubted. The goal of mental health professionals, doctors, and parents should be to facilitate social and medical gender transition as soon as possible. Delaying, or worse, opposing gender transition is courting suicide. Recently, systematic research has examined these propositions and found them either lacking evidence or false (see Table 1).
Table 1. Central propositions of gender-affirming care.
| Proposition | Current Status of Proposition |
|---|---|
| Transgender self-identification is trustworthy among youth and unlikely to change. | Careful follow-up of gender dysphoric children has found frequent desistance for childhood-onset cases [11,12,32]. For adolescent-onset cases, there is insufficient evidence. |
| The wishes of gender dysphoric youth should direct therapy. | Recent gender dysphoric youth have a high rate of other psychopathology, which is unlikely to improve their judgment [4,6]. |
| The optimal outcome is social and medical transition so that a transgender youth can be a member of the other sex, the sooner the better. | No reliable evidence shows an advantage of youth transition [4,6]. |
| Focusing on managing gender dysphoria rather than transition is conversion therapy | The analogy from sexual orientation conversion therapy is inapt [4,14,15]. Conversion therapy for sexual orientation is based on moral/religious disapproval. Managing gender dysphoria to prevent gender transition is motivated by the desire to reduce suffering and medical complications of transition, not by religious or moral objections to transgender. Non-heterosexual orientation tends to be stable, especially for males [36] but gender dysphoria is much less so [11,12,32,33]. |
| Psychological problems of gender dysphoric youth are caused by minority stress, reflecting societal intolerance [37,38], and by delay of gender affirming care. | In recent studies, psychological problems often predate gender dysphoria and are not alleviated by gender transition [28,39, 40, 41]. |
| Gender-affirmative care helps prevent suicide [38,41]. | Although gender dysphoric youth have elevated rates of suicidality, completed suicides are rare. No good evidence supports gender transition as effective suicide prevention [4,6,41] |
Gender-affirming care: ideology challenged by science
Gender-affirming care is on its way out in the U.S., at least for now. The Trump administration’s Executive Order 14,187, “Protecting Children from Chemical and Surgical Mutilation,” proclaimed: “Across the country today, medical professionals are maiming and sterilizing a growing number of impressionable children under the radical and false claim that adults can change a child’s sex through a series of irreversible medical interventions. This dangerous trend will be a stain on our Nation’s history, and it must end.” The order included several provisions that made “gender affirming care” more difficult. It also directed the Secretary of Health and Human Services to “publish a review of the existing literature on best practices for promoting the health of children who assert gender dysphoria, rapid-onset gender dysphoria, or other identity-based confusion” [3]. The final version of this review [4] reported the lack of international consensus on best practices for treating gender dysphoria in youth, in part because available evidence is of “very low quality,” summarized likely risks of medical gender transition, and concluded that currently risks of transition were not justified by demonstrated benefits. The Executive Summary of the report concluded with a section on psychotherapy, calling the equation of “psychotherapeutic approaches to managing gender dysphoria” with “conversion therapy” a “mischaracterization.” Furthermore, it expressed a clear preference for psychotherapy over gender transition.
Those wanting the best for gender dysphoric youth should resist dismissing the HHS report because of its political origin. Opposition to medicalized gender transition in the U.S. has obtained a strong majority among registered voters [5]. Furthermore, the general findings and recommendations of the HHS report are similar to those from an earlier, even more thorough, review conducted in the United Kingdom by an independent commission of experts [6] as well as reviews from several other European countries. Yet, during its reign–and even since it has become less popular with respect to both public opinion and policy–gender-affirming care has been endorsed by an impressive array of respectable professional organizations, including the American Public Health Association, American Medical Association, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, Endocrine Society, Pediatric Endocrine Society, American College of Physicians, and the American Psychological Association [7]. Revelations about another influential if highly controversial organization, the World Professional Association for Transgender Health, provided fuel for the fire set to pre-HHS U.S. clinical guidelines [8].
Could so many professional organizations support irrational and destructive clinical guidelines? Unfortunately, the answer is “yes.” This has happened in various fields of medicine, more often than we would like to believe. A common reason for these mistakes is reliance on medical dogma based on “gut feelings” and clinical experience rather than objective, systematic, scientific data, which are invariably better [9].
In the case of gender-affirming care, however, the culprit has been ideological bias. For poorly understood reasons during the past 20 years, elite institutions adopted a variety of politically progressive positions, with one primary motivation being the protection of favored minority groups [10]. Transgender persons comprise one of the main favored minority groups, along with non-white persons (“BIPOCs”), women, and immigrants. Leftward shifting institutions included the professional organizations mentioned above, as well as academia, mainstream media, and even many corporations.
Gender-affirming care was not the culmination of careful scientific study or extensive clinical experience. Before the mid-2000s, most gender clinicians’ priority was to manage youth gender dysphoria to prevent transsexual outcomes (the term used then for gender transition, which was only offered to adults). Only when gender dysphoria persisted did clinicians favor social and medical gender transition, typically after dysphoric youths reached legal adulthood. Research supported this preference, because most gender dysphoric children’s gender dysphoria did not persist long enough for them to seek sex reassignment (the former terminology for medical gender transition) [11, 12, 13].
Evidence that gender-affirming care became popular for ideological reasons includes the common but incorrect [14,15] assertion that psychotherapy to resolve gender dysphoria constituted “conversion therapy,” originally referring to coercive attempts to change sexual orientation for religious reasons. It also includes the ignoring or denying of obvious and concerning facts related to gender-affirming care, such as the unprecedented, extreme increase in clinical referrals for such care and the lax gatekeeping for adolescents seeking serious medical interventions such as cross-sex hormones [4,6]. Those expressing ideas inconsistent with preferred ideology were met not with intellectual disagreement but with cancellation attempts [16, 17, 18, 19, 20]. Finally, there has been a prominent role for transgender activists in limiting acceptable medical and academic discourse [21,22].
As a blanket approach to treating gender dysphoric youth, gender-affirming care has been increasingly challenged, scientifically, culturally, and politically. We are not asserting that gender transition is always harmful or even that it is always inferior to alternatives. Thoughtful and knowledgeable clinicians sometimes help transition gender dysphoric youth. (The second author has done so.) But they also consider costs and benefits of transition, acknowledging nontrivial costs and risks. Furthermore, they agree that clinical decisions should be based on good scientific evidence. Even these cautions have been unacceptable to most transgender activists and gender-affirming clinicians, who are justifiably losing their influence.
Opportunities and responsibilities for cognitive-behavioral therapy
During the past five years, the authors have received numerous inquiries from parents concerned about their gender dysphoric children. These parents wanted names of therapists near them who are not gender-affirming and consider gender transition a last resort, if at all. Invariably, the first author couldn’t help them, even after consulting knowledgeable experts. (He was usually able to connect them with a therapist willing to see them over the Internet, but there were not many of these.) The second author is one of the few clinical psychology specialists not using a gender affirming approach.
There is every reason to expect that Executive Order 14,187 will accelerate demand for therapy aiming to alleviate gender dysphoria via psychotherapy rather than via gender transition. Meeting this demand is both an opportunity for cognitive-behavioral therapists and a service–arguably a duty–to gender dysphoric youths and their families, who have been poorly served by the mental health profession during the past twenty years. Furthermore, improving upon the recent past will not be difficult. Merely admitting that the evidence does not show an advantage of social or medical gender transition and exploring the costs and benefits of different possible decisions would be a welcome advance.
Some advice
Here, we offer advice for therapists working with gender dysphoric youth. (Issues most relevant to gender dysphoric adults often differ.) Our advice is based on available research, especially that conducted in a scientific rather than an activist spirit. It is also based on the clinical experience of the second author, who has worked with gender dysphoric youth for more than 50 years.
Learn about three types of gender dysphoria
Three distinct kinds of gender dysphoria regularly occur among children and adolescents [23]: childhood onset [24], autogynephilic [25, 26, 27], and rapid-onset gender dysphoria (ROGD) [28]. They differ in their risk factors, correlates, and presentation, among other aspects summarized in Table 2. We suspect that optimal therapeutic approaches also differ among them, though this has not been studied. Unfortunately, neither the Cass Review nor the HHS report addressed gender dysphoria typology, likely to avoid controversy. Transgender activists and their allies have attempted to suppress discussion of both autogynephilic gender dysphoria [29] and ROGD [16,30], preferring the incorrect account that all gender dysphoria is fundamentally similar and begins during childhood. This represents an important limitation of both reports.
Table 2. Three types of gender dysphoria among children and adolescents.
| Empty Cell | Subtype | ||
|---|---|---|---|
| Childhood-Onset Gender Dysphoria |
Autogynephilic Gender Dysphoria |
Rapid-Onset Gender Dysphoria |
|
| Typical onset | Childhood (by age 6) | Adolescence through late adulthood | Adolescence into young adulthood (by age 25) |
| Sex affected | Both male and female | Male only | Predominately female |
| Underlying vulnerabilities | Extreme childhood gender nonconformity | Autogynephilia: Sexual arousal by the idea or fantasy of being a woman | Preexisting emotional and social problems |
| Associated with sexuality? | Strongly associated with later same-sex orientation | Autogynephilia. Presenting sexual orientation may be heterosexual, bisexual, or asexual. | Sexual identity is variable |
| Provisional explanation | Discomfort with birth sex; preference for activities, dress, playmates of other sex | Erotic arousal by fantasy of being a woman progresses to dysphoria | Culturally/Socially acquired commitment to transgender identity due to maladaptive coping or avoidance of underlying conditions |
| Recent increase in incidence? | Yes | Yes | Did not exist 20 years ago and is now the most common subtype |
| Amount of available research on syndrome | Extensive | Less extensive but significant | Sparse so far due to its newness and ideological resistance |
| Parents’ response | Most parents feel turmoil over the suffering of these children. Some allow/encourage social transition as a “solution.” parents are not surprised by transgender announcement. | Parents rarely are aware of their sons’ autogynephilia and are surprised by transgender announcement. | Parents are typically surprised by (and often skeptical of) transgender announcement. |
| Gender dysphoric youth’s attitudes toward understanding themselves this way | Accepting, with members of the other types often incorrectly claiming they are of this type | Varied from enthusiastic acceptance to hostile rejection | Skeptical/dismissive, hostile |
| Activists’ (and most professionals’) attitudes toward existence of syndrome | Accepting, with many insisting that all gender dysphoria is this type | Hostile | Hostile |
| Outcome desired by gender dysphoric person | Social and medical transition | Social and medical transition or in some cases, reduction of gender dysphoria | Social and medical transition |
| Evidence regarding persistence versus desistance | Studies of children first seen by 2008 find most desisted by early adulthood; a recent study of families supporting social transition find high rates of persistence across 6 years average follow-up. | Sparse, partly due to failure of researchers to clearly distinguish such cases from childhood-onset cases | Non-existent |
| Evidence regarding benefit of transition | Adult studies, with most transitioners expressing more satisfaction than regret; short-term follow-ups of youth transitioners with unclear benefit | Adult studies, with most transitioners expressing more satisfaction than regret | Very short-term prospective studies with no control group, with most finding no benefit, on average |
| Evidence about transition regret and detransition, for youth who transitioned since 2010 | Non-existent | None from prospective studies. Studies of male detransitioners suggest a preponderance of this type. | Sparse |
| Potential CBT focus | Expand schemas related to gender (e.g., one can be a boy without liking sports). Address other mental health issues. |
Explore different ways of living with autogynephilia. Reduce time on internet. Address other mental health issues. |
Address identity disturbance. Reduce time on internet. Address other mental health issues. |
Practice CBT, not gender medicine
With its emphasis on identifying negative and irrational thought patterns and behaviors and learning better ways of coping, cognitive-behavioral therapy is a promising treatment for gender dysphoria. Furthermore, CBT is effective at treating depression and anxiety, both of which are common among gender dysphoric youth [4,6].
Relief of psychological symptoms associated with gender dysphoria should be the central goal of the cognitive-behavioral therapist; medical transition should not be. Recently, a formerly dysphoric young woman successfully sued her ex-therapist (a clinical psychologist who claimed that his approach was cognitive-behavioral). Instead of focusing on his patient’s many psychological problems, the therapist encouraged her gender transition. He pressured the patient’s mother to support her daughter’s medical transition, admonishing that otherwise, the patient was at high risk for suicide. At age 16, the patient had her breasts surgically removed, regretting the decision almost immediately. Now 22 years old, she won a $2 million settlement [31].
The therapeutic goal should Be desistance, not transition
Desistance is the waning of gender dysphoria to a low enough intensity that gender transition is no longer desired. Follow-up studies of childhood-onset gender dysphoric children first assessed prior to 2010 have shown that most desisted [32,33]. Equivalent long-term follow-up data on adolescent-onset autogynephilic gender dysphoria and ROGD are unavailable, but there is no reason to believe that persistence is inevitably high for either type. For example, recent studies of detransitioners–formerly transitioned persons who have changed their minds–disproportionately contain adolescent-onset cases [34].
Recently, some parents have allowed gender dysphoric children to transition socially, and preliminary data suggest that desistance will be rare among them [35]. Social transition is a powerful intervention facilitating medical transition, with both certain and uncertain complications [4,6]. It is neither transphobic nor unrealistic to prefer desistance as an outcome.
Preferring that gender dysphoria desist rather than persist does not require dogmatism. Persistence happens. Gender dysphoric youth who decide to transition when they are legally able should not be considered treatment failures, and they should not lose access to psychotherapy.
Resist intimidation
The temporary ascension of gender-affirming care over other approaches was achieved, not with data and reason, but with suppression and intimidation. Scholars often had difficulty publishing well-reviewed findings that challenged gender-affirming tenets (e.g., Refs. [16,17]). The accusation that any goal other than transition is tantamount to conversion therapy is specious but has nevertheless been rhetorically effective. (Who wants to be associated with conversion therapy?) Some transgender activists have behaved especially outrageously. The trans woman, Andrea James, dedicates individual webpages to researchers, therapists, public intellectuals, and others whose opinions she dislikes, often including information about their family members. Those opposed to gender-affirming care have not resorted to such tactics, which have begun to fail.
Be scholarly, not tribal
Many important questions about youth gender dysphoria remain unanswered. Even scientifically informed and reasonable persons sometimes disagree about scientific priors and optimal therapeutic approaches. When possible, disagreements should be resolved empirically. Barriers to scientific progress include egregious behavior such as intimidation, but also premature acceptance of preferred narratives that have not been empirically established. This obviously occurred among those supporting gender-affirming care. We also see it on the opposite side, those whose approach is “gender-critical.” Examples include the assertions that a common current cause of adolescent gender dysphoria is discomfort about having a homosexual orientation and that few if any adolescent boys thought to have rapid-onset gender dysphoria are autogynephilic. We doubt both of these beliefs, neither of which has empirically support. Finding the truth is helped by acknowledging current ignorance and the willingness to question and criticize one’s own side. These are characteristics of scholars and not activists.
Conclusions
We expect that it will not be long before the recent gender-affirming era will be retrospectively viewed with disdain, if not with horror. We are less certain, but more hopeful, about the aftermath.
Credit author statement
Both authors, JMB and KJZ, made significant contributions to each stage of this aticle, including conceptualization, investigation, writing, reviewing, and editing. We determined authorship order by the somewhat larger contribution by JMB.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Data availability
No data was used for the research described in the article.
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Further information on references of particular interest
- ∗4
Lengthy report commissioned by the U.S. HHS subsequent to Executive Order 14,187 to evaluate the evidence for medical and social transition of gender dysphoric youth. Its conclusions about gender transition were even more negative regarding transition than the Cass Review’s. The report recommends psychotherapy (including CBT) rather than medical and surgical options.
- ∗6
Independent review (commissioned by NHS England) of the available evidence concerning the effectiveness of medical interventions for youth gender dysphoria. The review also examined changes in gender dysphoria in the recent cohort, such as the striking rise in referrals, demographics (large increase in adolescent female referrals), and associated characteristics (much worse mental health).
- ∗22
Provides a review of ideological attempts to discourage scientific investigation and reasoned debate about topics disliked by transgender activists and their allies. The author blames “an authoritarian strand of activism” along with the failure of higher education and other structures to address the issue.
- ∗23
Although this is technically a blog and not a technical article, it remains the best condensed explication of the three distinct kinds of gender dysphoria. This is partly because ROGD did not exist until recently, but also because autogynephilia and ROGD provoke sufficient ideological controversy that most scholars avoid addressing them. Both clinicians and families should start here.
- ∗28
This first study of ROGD relied on the reports of parents recruited because they observed ROGD phenomena in their gender dysphoric adolescent and young adult children. Those included a rapid onset from first consideration to announcement of a transgender identity, lack of evidence for childhood gender dysphoria in the youths, social influence (via both peers and Internet/social media), and maladjustment in social relationships and mental health preceding gender dysphoria. This article named “rapid-onset gender dysphoria”.
