“Over Advocacy”: Fighting for Trans Rights in the Face of Erasure

Historically, transgender nonconforming  (TGNC) people were subjected to psychoanalysis, pathologizing, and various conversion therapy strategies. As a result, internalized trans negativity/transphobia became prevalent in our current healthcare system. So, where does that leave us as clinicians? We live in a country where cis and heteronormativity (the assumption that everyone identifies with the sex assigned at birth and is heterosexual) is the “norm.” Our current president is stating that no other gender identity exists besides the one assigned at birth. No one knows why certain people are transgender or gender nonconforming, but we know that they have existed pre-colonization for millennia. Many TGNC folks are concerned that these executive orders/actions are the beginning of the end of gender-affirming care as we know it.

What is gender-affirming care?

In his first week in office, President Trump signed several executive orders. Their main focus: banning gender-affirming care for those who are incarcerated, those who receive federal funding, and trans youth. He attempted to ban all gender-affirming care for anyone under nineteen. Some children’s hospitals preemptively stopped care after this order was passed. At the time of this writing, a judge has since overturned the order. But the message is clear: Transness is being erased.

Gender-affirming care is a supportive form of healthcare that may include medical, surgical, and non-medical care for transgender and non-binary people. It is patient-centered and assists patients in matching gender identities with physical traits (Colt Keo-Meier & Ehrensaft, 2018). Essentially, it is about believing that our clients know who they say they are. Gender is a deeply personal experience for most of humanity. It helps us feel connected, authentic, and real. However, historically, it has been restrictive. We are often put into categories and adhere to certain stereotypes and expectations of how to look, feel, and act (Chang et al., 2019). These restrictions can often impede our self-actualization. I have had the pleasure and privilege of working with trans and gender non-conforming individuals over the past decade. It has been some of the most rewarding experiences of my life. It has also been some of the most challenging. After my initial article on gender-affirming care in 2022 in The Therapist, I was hit with hate mail from clinicians across the state, encouraging me to practice conversion therapy instead. They insisted I remain “quiet” overall. My family and friends who know me also know that telling me to be quiet does the opposite.

Case conceptualization

I recently went head-to-head with someone high up in a medical organization regarding a client. Last year, I was referred to a patient (a transgender teenager who I will not provide additional information for as to remain confidential) after they had been told they could not move forward with hormone replacement therapy (HRT) interventions until their other mental health concerns were “addressed.” After two meetings, I was able to assess that this young person was of sound mind, judgment, and experiencing extreme gender dysphoria. They had been living in their affirmed gender for two years. On top of that, they were feeling hopeless that they would never obtain the care they needed to affirm their identity. According to a Stanford Medicine study, transgender adults who started HRT as teenagers have overall better mental health outcomes into adulthood compared to those who waited until adulthood for treatment (2022). This study analyzed data from over 27,715 participants who were at least 18 at the time. This client told me that their clinicians frequently misgendered and dead-named them (using the wrong name and pronouns), and in general, they felt no support from the medical team.

The goal of these assessments in youth is to define whether the child is a “persister or a desister.”

As a result of the hesitation to provide HRT to patients with mental illness, they are frequently denied life-saving care, and over a quarter of transgender people have reported avoiding healthcare providers (Redcay et al., 2021). Without hesitation, I wrote a letter of concern to the clinician who conducted the gender assessment that determined they should wait to move forward with HRT. A gender assessment is a tool used with people under 18 who are of trans experience. This resource frequently includes specific questionnaires, physical examinations, and other evaluations to determine if the child is ready and/or appropriate to move forward with medical interventions (National Institute of Health, 2025). Overall, gender assessments are positive and align with the World Professional Organization on Transgender Health (WPATH) recommendations. Essentially, this tool is meant to benefit a client and their family in making informed decisions. Assessment is meant to reduce the likelihood of regret later in life. WPATH is essentially a standardized rule book that many medical professionals utilize as a guide for best clinical practice. They publish these standards in various versions, creating a framework that agencies adhere to. The goal of these assessments in youth is to define whether the child is a “persister or a desister.” They are looking to see if the person demonstrates consistent, persistent, and insistence of their gender identity over a prolonged period of time (Colt Keo-Meier & Ehrensaft, 2018).

>>Transgender Resources for MFTs

Despite my expertise, my letter of concern was taken as an attack. I was contacted by a member of the care team questioning my ability to not only provide adequate treatment, but also informing me that I had no right to advocate with the client in the first place. They declared that my assessment of the situation was premature. After being linked to a gender specialist supervisor, my concerns were heard and a new gender assessment was conducted. I worked collaboratively with the team, creating a treatment plan that addressed the client’s mental health issues. It was an apparent success. My client was scheduled for their initial endocrinology appointment for two months. Unfortunately, that gender specialist left this particular organization, and as a result, a grave miscommunication occurred. My treatment plan was lost, and the team’s previous decision was reversed.

Gender-affirming care is a supportive form of healthcare that may include medical, surgical, and non-medical care for transgender and non-binary people. 

The “over advocate”

At my client’s first HRT appointment, the endocrinologist told them that they had “behavioral health concerns” they wanted to address first and would not be administering their hormones that day. These concerns amounted to the doctor noticing scars on my client’s legs from old self-injurious behavior. They never addressed this with my client or parent directly; however, the endocrinologist based their decision to withhold hormones on this observation. My client and mother shared with me that while my client cried, this doctor stated numerous dismissive and damaging comments that lacked an affirmative lens. Overall, inadequate training in transgender health within the medical community leads to healthcare professionals lacking essential knowledge. This results in inadequate care, discrimination, and increased health disparities for TGNC individuals (Redcay et al., 2021).

At this meeting, I was told, “Your over-advocacy is out of line.”

My client became suicidal. After a suicide assessment, I sent them to the emergency room with their mother. I contacted this organization again, and I expressed concern for my client’s well-being and explained they were hospitalized as a direct result of their experience with the endocrinologist. I was contacted the following morning by the social worker and their supervisor to schedule a meeting. At this meeting, I was told, “Your over-advocacy is out of line.” I explained that my client had previously been approved for HRT and gender-affirming care, that the past year has become exceedingly stressful for them to wait, and the delay has worsened their mental health. I discussed that statistically, people have improved mental health outcomes when they are provided affirming medical interventions. Unfortunately, I was met with laughter, belittlement, and told I was not adequately addressing their mental health concerns. I reviewed the multiple goals on their treatment plan—which discussed each concern the supervisor brought up. I inquired why no one contacted me to obtain my view about these concerns or reviewed my treatment plan that had been submitted months before. They had no record of it. I was told that I was not a member of their team and that they did not need to contact me. I asked how I could collaborate with them to help my client move forward with obtaining HRT. Whenever I used the words “delay” or “move forward” I was gaslighted. I was told that the entire staff was gender affirming. When I explained what was said by the endocrinologist and encouraged additional staff training, I was again dismissed. I was told that my client’s suicidal hospitalization may further delay the process of approval, showing they lacked “mental stability.” I explained that their reaction was a result of the denial, to which I was mocked further.

According to an article in Psychiatric Services TGNC people with serious mental illness frequently experience challenges in obtaining HRT. This group of individuals are rare, vulnerable, and due to limited research treating them can be challenging. Some examples of these disorders could include schizophrenia, PTSD, and bipolar—all heavily impairing one’s functionality. The study asserted that gender dysphoria symptoms will improve or resolve among patients who receive gender-affirming medical care. The reason for hesitation to prescribe HRT is to rule out that the patient is experiencing gender dysphoria or some sort of gender related delusion. The study’s overall recommendations are that patients who have a diagnosis of gender dysphoria and a severe mental illness be assessed for their ability to make informed decisions.  Although I do agree that there are certain mental health outcomes that need to be addressed prior to starting HRT, these are in extreme cases. The WPATH guidelines suggest co-current treatment and abstinence from care only if absolutely necessary (WPATH V8). It is equally important to review the WPATH standards and seek consultation on why the patient cannot have these addressed while concurrently taking hormonal intervention. Knowing this, and knowing this patient had no such severe mental health diagnosis, I knew advocacy was needed to save their life.

Over advocacy. These words burned in my brain. I hung up the phone feeling defeated. My hands trembled, I felt sweaty and overall sick to my stomach. Was I really being inappropriate? Was I “too much” as they said I was? Was my advocacy harming my client in some way? My client’s mother is an amazing advocate; they filed a complaint, per my direction, and they were able to schedule a new HRT appointment in three months. The team heard my concerns and decided to make the appointment. My client still struggles with dysphoria, but we are hopeful that this does not happen again. In the interim, I sent them to the Trans Wellness Center/Planned Parenthood.

WPATH, advocacy, and our role

When is advocacy too much? I called CAMFT to ask a lawyer. They told me that there are no minimum time frames or limitations in advocacy as long as it is within our scope of competence/practice. According to AAMFT, advocacy is an essential role for an MFT. MFTs can and should advocate for their clients, communities, and the field of mental health by speaking out against stigma, misinformation, and oppression. They can also advocate for policy changes that improve access to care. Some common places where advocacy is required are emergency rooms and psychiatric units (both of these often misgender and misname patients and sometimes stop HRT). If our clients are on hold, we can educate the staff by calling the lead clinician evaluating them, encouraging them to focus on the problem that brought the patient in, instead of focusing on their identity. Fifty percent of TGNC people have had to teach their clinicians about their own care (Colt Keo-Meier & Ehrensaft, 2018). If we can continue educating ourselves by joining professional organizations, attending conferences, and talking to fellow professionals, I believe we can help this population.

When working with adolescents who identify as TGNC, WPATH states that “Emotional and cognitive maturity is required to provide informed consent/assent for the treatment.” Under the gender-affirming model, it is our job to help clients and guardians understand the risks/benefits and make an informed decision with their medical professionals. We do not give recommendations on what they should or should not do. We guide them in making informed decisions.

According to A Clinician’s Guide to Gender-Affirming Care, “Demonstrating true allyship means being a consistent, trusted, and accountable presence in trans clients’ lives, educating colleagues and interrupting transphobia” (Singh, 2018). I take this to heart, and despite others telling me to be quiet, I became louder.

Harm reduction

TGNC youth are more susceptible to developing mental health struggles. Many co-occurring ones include: anxiety, depression, behavioral problems, eating disorders, substance abuse, ASD/ADHD, self-harm, and social isolation (Colt Keo-Meier & Ehrensaft, 2018). As a result, many TGNC youth may present with mental health conditions secondary to their experience of dysphoria. As clinicians, providing pathways that support our clients’ gender identity will likely alleviate much of their symptomatology. According to the largest U.S. transgender survey of over 27,000 people, 9 percent were using nonprescription hormones (Stroumsa, 2020) and 70% of trans women are obtaining their hormones from a non-medical source. This is frequently due to economic and social barriers that make gender-affirming medical care nearly impossible to obtain. With an uncertain future in this avenue of healthcare, I fear that this may become the new norm. So, where does that leave us as clinicians? If children fear a future where trans healthcare is banned, they begin to lose hope.

What if our clients go online to buy HRT or source it from other means? Buying things without medical professionals has a set of risks: lack of regulation, unknown ingredients, and dangers of overdosing. According to Transharmreduction.org, a grassroots organization run by queer individuals assisting trans folks in minimizing harm when acquiring HRT without the help of medical professionals, there are a few ways to decrease these risks. One area is clean needles and regular blood work. Self-pay testing labs like QuestHealth.com are confidential and do not require insurance. It is important to note that it is considered negligent and within our reporting mandate if a parent obtains hormones for a minor without a script. This is particularly challenging in states where this healthcare is banned for minors. However, I spoke to a lawyer at CAMFT, and even if that child is at increased suicide risk for not being able to obtain hormones, it is still considered negligent for a parent to obtain them without a doctor/prescriber operating in their medical capacity. So, where harm reduction strategies work with adults, our reporting mandate is often triggered with minors if parents are aware.

Conclusion

My client was finally prescribed HRT after the “team” agreed with my opinions. They have had improved mental health outcomes since starting their prescribed medication. Advocacy for the transgender/nonconforming community is crucial now. I encourage clinicians to advocate for their clients when facing insurance companies that consistently deny or delay starting care.

In this current climate, there is a lot of uncertainty. The one certainty I know is that advocacy has always been and will continue to be of utmost importance. It is our job to stay informed, link our clients to advocacy groups/lawyers, and provide resources for them to obtain the life-saving information and care they deserve. At the time of this writing, minors in California still have access to gender-affirming care. But the future is unpredictable. I will always assist my clients in obtaining the healthcare to which they are entitled. The general fear in our community now is not knowing what is next. If the worst happens, it is even more imperative to instill hope that things will improve again. It may not always be easy to be undermined, insulted, and belittled, but it’s necessary to keep our patients alive and thriving. In the words of Frederick Douglas, “If there is no struggle, there is no progress.”

What can I do in my practice?

• Provide harm reduction material/education
• Link clients to support groups/resources
• Use inclusive signage in the office
• List in your online profiles how you are competent in this community
• Provide appropriate options on intake forms for sex/gender
• Assist clients with social transition
• Advocate for community engagement workshops with tailored training for providers
• Have a list of resources: gynecologists, surgeons, legal services, shelters