HHS/SAMHSA Press Release on Sexual Minority Youth Affirmation is a Model of Ideology Over Evidence
April 7, 2023
by Andrè Van Mol, MD
The U.S. Department of Health and Human Services (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA) issued a March 31, 2023 press release titled, “New HHS Report Released on Transgender Day of Visibility Offers Updated, Evidence-Based Roadmap for Supporting and Affirming LGBTQI+ Youth.” Even overlooking the fact that visibility for sexual minority youth is at an all-time high on a daily basis in every sector of society, the release was bracing in its lack of viewpoint diversity and how replete it was with erroneous ideological group think.
The opening paragraph asserts that “…LGBTQI+ youth are resilient and can thrive when they are supported and affirmed, but that pervasive discrimination, rejection, and bullying of LGBTQI+ youth has led to a nationwide mental health crisis.” There is much to contest here, and the components are repeated often in the document.
Thriving and resilience are born from and manifest through challenge. Indoctrinating youth, sexual minority or otherwise, that their problems are all or mostly due to externals set upon them may foster many responses and traits, but thriving and resilience are unlikely to be among them.
Affirming the individual is foundational and good, very much so! What about environments and groups that do not affirm the alternative sexuality? A 2017 study of sexual minorities (“Happily Religious”) found that “Surprisingly, no significant differences are found between mainline Protestants (whose church doctrine often accepts same-sex relations) and evangelical Protestants (whose church doctrine often condemns same-sex relations).” A 2013 study of black GLB-identified young adults asserted, “… those reporting higher religious faith scores and higher internalized homonegativity reported the highest resiliency scores.” “Highest resiliency,” not suicidality. A 2019 paper, “Same-Sex Attracted, Not LGBQ,” by a team of progressive (GLBT-affirming) and conservative (change allowing) researchers examining Mormon sexual minorities found both those coming out and rejecting their faith and those rejecting gay identification and embracing their faith experienced equal health benefits regarding depression, anxiety, flourishing and life satisfaction. The GLSEN 2017 National School Climate Survey found that religious schools without LGBTQ-affirming programs were among the safest for sexual minority students, had fewer anti-LGBTQ student comments and had the least victimization and bullying of any schools—even less than in private secular schools using the recommended affirmation methods. These findings contradict minority-stress expectations and HHS.
Bullying is nearly universal. We all have likely found ourselves bullied at some point in our youth. However, bullying can be a two-way street. A 2021 study with a large (139,000+) nationally representative sample in Finland declared, “…we found that transgender identity was generally associated with perpetrating bullying and that the association was stronger than that of transgender identity and being bullied.”
The press release continues, “this crisis is most acute for transgender youth, whose mental health and wellbeing is put at risk by policies that seek to restrict their access to appropriate health care and inclusion at school.”
What constituted appropriate healthcare is what is in question, and inclusion in schools is not the issue, but rather the invasion of spaces set aside for girls and women when alternative arrangements can usually be reasonably accommodated on campus.
Comprehensive literature reviews in the United Kingdom (located here and here, with NICE downloads available here), Sweden, Finland (located here and here) and Florida have found the strength of evidence of pro-transition studies to be low to very low. This has resulted in said nations rejecting their prior leadership in gender transition medical interventions in favor of strong emphasis on comprehensive and continuing mental health evaluation and support for the minor and family.[i],[ii],[iii],[iv] Norway has very recently done the same. The French Académie Nationale de Médecine’s 2022 press release similarly lauds this approach.
The report “Moving Beyond Change Efforts: Evidence and Action to Support and Affirm LGBTQI+ Youth” is also referenced in the HHS/SAMHSA press release. Several quotes are listed, such as “it is normal and healthy for children to identify as LGBTQI+ and that all children should have their sexual orientation or gender identity affirmed and supported.” For sake of protecting and helping these minors, one must protest that if these were “normal and healthy,” we wouldn’t be having this discussion about how poor their mental health statistics are, let alone blame shifting the cause onto externals that fail to hold up under inspection.
Their insistence “that all children should have their sexual orientation or gender identity affirmed and supported” is both contradicted later in the document and runs afoul of professional literature caution against premature affirmation. The contradiction states, “According to the report, effective therapeutic approaches support youth without seeking predetermined outcomes related to their sexual orientation, gender identity, or gender expression.” Yet the press release repeatedly says we must affirm, which sounds quite solidly predetermined. The rush to affirm is not indicated. The 2014 APA Handbook on Sexuality and Psychology cautions, “Premature labeling of gender identity should be avoided,” and that “This approach runs the risk of neglecting individual problems the child might be experiencing and may involve an early gender role transition that might be challenging to reverse if cross-gender feelings do not persist…” The APA Handbook further warns, “it is critically important for clinicians not to assume that any experience of same-sex desire or behavior is a sign of latent homosexuality…” (v.1, p. 257). A 2020 article by Finland’s Kaltiala asserts “An adolescent’s gender identity concerns must not become a reason for failure to address all her/his other relevant problems in the usual way.”
HHS/SAMHSA continues, “sexual orientation and gender identity (SOGI) change efforts, commonly known as so-called ‘conversion therapy,’ are never appropriate for youth, are ineffective, and can cause significant harm.”
I can think of few things more “conversionary” than the chemical sterilization and surgical mutilation of healthy young bodies for sake of mental health issues that overwhelmingly desist by adulthood, as gender dysphoria usually does. Desistance is the norm,[v],[vi],[vii] so gender transition interventions should not be. Prioritizing mental health evaluation and support assisting the youth to be comfortable with their own body is anything but conversion, and it is precisely what the previously stated European nations that were formerly leaders in gender transition interventions have moved to based on evidence.
“Conversion therapy” is a pejorative, misrepresentative, provocative, and vague phrase spawned by opponents in 1991 and used as a jamming tactic. Change-allowing counseling is voluntary, patient-initiated and patient-directed conversation—just talk—with licensed therapists working with willing and motivated people. Several recent landmark studies show it is beneficial and non-harmful, even if it fails.
A 2021 prospective study (Pela & Sutton) showed “…that exploring sexual attraction fluidity in therapy can be effective, beneficial, and not harmful,” and that “It is no longer true that there is no scientific evidence concerning whether SAFE-T is helpful or harmful.”
A 2022 reanalysis of their findings by Schumm confirmed, “Harms from SOCE seem to be minimal compared to the positives reported for young adults.” Additionally, even for study subjects whose same-sex identification and behavior became stronger, they “nevertheless reported high levels of helpfulness for SOCE.” A 2022 study of the Generations Study data base by Prof. Paul Sullins revealed that change-allowing counseling strongly reduced suicidality. He concluded its restriction was “putting them [sexual minorities] at substantially increased suicide risk.” Sullins did a companion study constituting a “stress test” of the counseling “harm” hypothesis found that even people who failed change-allowing counseling for undesired same-sex desires “did not suffer higher psychological or social harm” and that “Concerns to restrict or ban SOCE due to elevated harm are unfounded.”
The press release asserts that “Everyone should be able to be who they are and access the care they need – but, too often, that is sadly and shamefully not the case for transgender people, including transgender youth.” This reminds me of Ken Zucker’s comment, “The term ‘transgender identity’ is hardly an objective label for a child’s gendered subjectivity.” Language is weaponized. And, yes, everyone should be able to be who they are, but gender transition procedures won’t get them there. They need good mental health evaluation and intervention, which is in short supply.
They continue, “we have helped to stand up the 988 Suicide & Crisis Lifeline and have staffed the lifeline with counselors trained to support LGBTQ youth and young adults, invested in crisis health centers, and worked to get mental health support into schools.” It would be most helpful if the counselors were trained in suicide prevention and intervention rather than a vague “support.”
HHS/SAMHSA adds, “Just as evidence shows that SOGI change efforts are harmful, the report includes evidence that withholding timely gender-affirming care can also be harmful and can exacerbate distress and suicidality among transgender youth.” And here we have a violation of 30 years of CDC instruction on reducing suicide contagion found in a 1994 MMWR warning against, “Presenting simplistic representations of suicide. Suicide is never the result of a single factor or event, but rather results from a complex interaction of many factors and usually involves a history of psychosocial problems.”
Secondly, SOGI change efforts are not shown to be harmful, and the studies claiming harm habitually have the same fatal flaws. Pediatric endocrinologist and academic Dr. Paul Hruz explains, “Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on “expert” opinion.” Common failings of anti-counseling studies for undesired same-sex attracted include: ill or undefined use of the pejorative term “conversion therapy;” routinely conflating and combining simple pastoral or vague spiritual counseling with professional counseling by licensed clinicians; employing a simplistic “affirmation” versus “conversion” false dichotomy; using survey designs (notably convenience sampling—from which statistical projections cannot be drawn—of exclusively LGBTQ+ organizations, clubs and venues) that assure the exclusion of those who benefitted from therapy; and committing the “correlation as causation” fallacy by failing to assess pre-and post-counseling mental health even when the data exists.[viii],[ix]
The press release claimed, “Gender-affirming care is a highly specialized model of care that uses evidence-based practices to address distress arising from gender dysphoria. It is highly individualized and focuses on the needs of each person, appropriate to age and developmental level. Any decisions about providing gender-affirming care are reached with the involvement of an adolescent’s parent or legal guardian.” I don’t think so. So-called gender affirming care guidelines ultimately derive from non-scientific, non-medical activist groups like WPATH (World Professional Association for Transgender Health) whose SOC 7 was rated by a 2021 BMJ first of its kind review with a quality score of zero out of six. There is no comprehensive literature review behind it. Just calling them “Standards of Care” does not make them so. The latest SOC 8 version removes age restrictions[x] for medical and surgical interventions, so “appropriate to age” is manifestly false. The previously cited comprehensive literature reviews found pro-transition data to be of low to very low quality. The “highly individualized” care is a sales pitch I personally have seen refuted by parents and patients in several states in legislative hearings. Whistle blowers contest it as well (which you can find here and here). It’s impossible to deliver in a 30-minute visit to the gender clinic or Planned Parenthood. And how can it be highly individualized with affirmation on demand? Parental involvement is very often reported by the parents to include emotional blackmail and gaslighting such as “Do you want a live son or a dead daughter?” or “Would you rather be planning a funeral or a transition?” An article claimed that more than 6,000 “US public schools conceal child’s gender status from parents.” And here is a related case from California. California passed SB-107 making itself a so-called sanctuary state for minors seeking transition procedures with or without a parent or parents. HHS is advancing slogans, not reality.
The press release affirms, “The increased risks to LGBTQI+ youth are not a function of their identity — but are related to the stress of stigma and discrimination.” But sexuality and feelings are not identity—this is the ideology of orientation essentialism. Historically, sexuality was a verb and not a noun—what you do and perhaps how you are, but not who you are—thus, behavior and not identity. The homosexual-heterosexual category error was an ideological product of the 1800s, and the gay-straight category error was one of the 20th century. But we are all more than our desires. As believers, we maintain that people are a special creation of God made in His image and profoundly loved by Him. Per Jurgen Habermas, this theological/philosophical premise is the source of universal human equality and rights. As for risks to gender dysphoric youth, decades of medical literature confirm the very high probability of underlying mental health issues, adverse childhood experiences, poor family dynamics and high rates of autism spectrum disorder that predate gender dysphoria.[xi],[xii],[xiii],[xiv],[xv],[xvi] Furthermore, the literature demonstrates that stigma does not explain for poor LGBT behavior statistics. A 2015 study found the high rate of attempted suicide in sexual minorities was not explained for by either discrimination or psychological disorders. Stigma wasn’t it. A 2016 Canadian study examined 40 years of data in children referred for gender dysphoria and found “once we controlled for general behavior problems, poor peer relations [ostracism/stigma] was no longer a signiﬁcant predictor of suicidal ideation and behavior.” Three meta-analytic studies indicate the strength of this relationship of stigma to mental health is significant but small, with minority stresses directly explaining less than 9 percent of the relationship.[xvii],[xviii],[xix] Michael Bailey commented, …“The minority stress model has been prematurely accepted as the default explanation for sexual orientation-associated differences in mental health.” “And at least one obvious rival hypothesis exists: That the increased prevalence of mental health problems in homosexual persons is, at least in part, the cause, rather than the effect, of increased self-reported experiences of stigmatization, prejudice, and discrimination.”
“Supportive families and caregivers, peers, schools, and community environments are all associated with improved mental health and well-being, according to the report.”
Yes, support the child but not the delusion or transition. A 2021 study from the Hamburg Gender Identity Service was tellingly titled, “Not social transition status, but peer relations and family functioning predict psychological functioning in a German clinical sample of children with gender dysphoria.” They clarified, “claims that gender affirmation through transitioning socially is beneficial for children with GD could not be supported from the present results.” And Walter Schumm’s 2019 reanalysis of two popular studies claiming the benefits of parental support for gender transitioning found higher levels of depression and significantly higher levels of anxiety and low self-worth in trans-identified children in such celebratory homes.
“Because of stigma and discrimination, LGBTQI+ teenagers continue to face extremely high levels of violence and mental health challenges, according to new data [erroneous link in press release] reported by the Centers for Disease Control and Prevention (CDC).”
We’ve already shown stigma is a small factor in mental health challenges, and solid evidence indicates much of the violence comes from within the community, not only outside of it. A 2014 Australian study found a leading reason for suicide among “LGBTI” individuals was stress from romantic partners rather than societal rejection. A 2013 prevention grant from this same U.S. Department of Health and Human Services prevention stated, “Domestic/intimate partner violence is a significant health problem among LGBTQ populations….”
There is always a more honest answer to the gender confusion than the chemical sterilization and surgical mutilation of otherwise healthy young bodies. The issue’s roots are psycho-social and should be addressed as such. The HHS/SAMHSA press release and report have it wrong to the detriment of sexual minority youth.
[v] Zucker, K. J. (2018). The myth of persistence: response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al. International Journal of Transgenderism, 19(2), 231–245. Published online May 29, 2018. http://doi.org/10.1080/15532739.2018.1468293
[vi] Singh D, Bradley SJ and Zucker KJ (2021) A Follow-Up Study of Boys With Gender Identity Disorder. Front. Psychiatry 12:632784. doi: 10.3389/fpsyt.2021.632784
[vii] Hembree, W., Cohen-Kettenis, et al., (2017) Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guildeline. J Clin Endocrinol Metab,102:1–35.
[x] (2022) Correction, International Journal of Transgender Health, 23:sup1, S259-S261, DOI: 10.1080/26895269.2022.2125695.
[xi] Heylens G, et al. “Psychiatric characteristics in transsexual individuals: multicentre study in four European countries,” The British Journal of Psychiatry Feb 2014, 204 (2) 151-156; DOI: 10.1192/bjp.bp.112.121954.
[xii] Kaltiala-Heino R, Sumia M, Työläjärvi M, Lindberg N. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health (2015) 9:9.
[xiii] Becerra-Culqui TA, Liu Y, Nash R, et al. Mental Health of Transgender and Gender Nonconforming Youth Compared with Their Peers. Pediatrics. 2018;141(5):e20173845.
[xiv] Kozlowska K, McClure G, Chudleigh C, et al. Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service. Human Systems. 2021;1(1):70-95. doi:10.1177/26344041211010777
[xv] Littman, L. “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports,” journals.plos.org, Aug. 16, 2018. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330
[xvi] Bechard M et al, Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: a “proof of Principle” Study, J Sex and Marital Therapy 2017;43:678-688.
[xvii] Jones KP, Peddie CI, Gilrane VL, King EB, Gray AL. Not so subtle: A meta-analysitc investigation of the correlates of subtle and overt discrimination. Journal of Management. 2016 June; 42(6): 1588-1613.
[xviii] Pascoe EA, Richman LS. Perceived discrimination and health: A meta-analytic review. Psychological Bulletin. 2009. 135(4): 531–554.
[xix] Schmitt MT, Branscombe NR, Postmes T, Garcia A. The consequences of perceived discrimination for psychological well-being: A meta-analytic review. Psychological Bulletin. 2014. 140(4); 921-948.