Mental Health and Care Denial in Transgender Youth

The role of psychiatrists in caring for transgender youth typically includes assessment of general and gender-related mental health, as well as interventions to support mental health on an individualized patient basis. Depending on age and developmental appropriateness, psychiatrists may also refer transgender adolescents to clinicians qualified to provide medical treatment for gender dysphoria. For such referrals, psychiatrists play an interdisciplinary role by providing comprehensive assessments of gender identity, decision-making capacity, and general mental health before medical treatment begins. As with other medical care for youth, the consent of parents or legal guardians is required. Research evaluating this approach to managing gender dysphoria in youth shows effectiveness in reducing gender-related distress, improving mental health and psychosocialwell-being.¹ However, recent policy shifts in the US raise escalating concerns that transgender adolescents are facing involuntary discontinuation of medical treatment for gender dysphoria.

As of 2025, bans enacted in 27 states prohibiting treatment for transgender youth² remain legal after the US v Skrmetti Supreme Court ruling. The medical and surgical care that remains legal in some states is now facing significant restrictive action at the federal level. After a January 2025 presidential executive order, “Protecting Children From Chemical and Surgical Mutilation,”³ the US Department of Justice issued a memorandum directing criminal prosecution of health care professionals and investigation of practitioners, hospitals, and pharmaceutical companies involved in the care of transgender youth younger than age 19 years,⁴ the Centers for Medicare and Medicaid Services threatened to pull Medicaid funding from select hospitals if they did not comply, and the US Department of Health and Human Services issued a report challenging current care standards and promulgated numerous policy statements directing recipients of federal funding to cease providing treatment for gender dysphoria to transgender youth.⁵ Prior state rulings allowed for grandfathering of youth undergoing treatment, but no such clause exists under federal restrictions. Although the legality of efforts to federally ban this care remains contested, the legal environment for transgender youth, their families, and the health care professionals who care for them is increasingly hostile and fraught with civil, criminal, and financial risks. As a result, hospital systems across the country have moved to limit medical treatment for transgender youth, even in states where no bans on treatment exist.

Care denial—the involuntary cessation, by law, of medical treatment for gender dysphoria, which is internationally recognized as a medical condition—raises profound psychiatric and ethical concerns. Although a small number of individuals may voluntarily stop treatment for personal reasons, mandating care discontinuation against the will of patients and their legal guardians poses severe risk of harm and presents psychiatrists with a stark medical and ethical dilemma. Given the well-documented link between treatment for gender dysphoria and improved mental health, it is imperative that psychiatrists understand the mental health risks and ethical challenges associated with care denial and strategies to manage the mental health harms.

Psychiatric Risks

Psychiatrists treating transgender youth must be aware of the mental health consequences that may arise when medical treatment is forcibly stopped. These risks stem from multiple mechanisms, including biological, psychological, and social factors.

1. Emergence of serious distress related to gender incongruence (International Classification of Diseases, 11th Revision) or gender dysphoria (DSM-5). Before treatment, many transgender youth experience significant distress or impairment in social, occupational, or other important areas of functioning due to incongruence between their gender identity, characteristics associated with sex assigned at birth, and/or how others perceive their gender. Increasing gender congruence reduces gender distress; ameliorates associated symptoms of depression, suicidality, and anxiety^1,6; and improves social functioning and life satisfaction. Care denial removes the protective benefits of gender congruence, thereby becoming an iatrogenic risk factor for deteriorating anxiety, depression, suicidality, gender dysphoria, quality of life, and social and occupational functioning.

2. Psychological factors. The sudden nature of care denial in the absence of patient-practitioner decision-making creates exposure to an unwanted and uncontrollable situation. These characteristics may result in care denial being separately experienced as a serious injury that is stressful or traumatic. Combined with gender-related distress, the exposure to sudden care denial may create additive impact on depression, suicidality, and posttraumatic stress disorder.

3. Biological factors. Although there are no direct studies on the acute cessation of treatment for transgender youth, parallels can be drawn from endocrinology and reproductive psychiatry. Rapid changes in sex steroid levels (eg, postpartum period) can influence immune function and mood,^7,8 with symptoms persisting for 6 months after sex steroid changes. Acute cessation of hormone therapy may create a high-risk window for emergence or exacerbation of mental health concerns due to hormonal and immunologic changes. Abrupt changes in hormones may also impact drug-drug interactions with psychiatric medications. For example, as estradiol increases the clearance of lamotrigine,⁹ an abrupt discontinuation of estradiol could raise lamotrigine levels due to clearance changes, which could place a patient at risk for lamotrigine toxicity.

Ethical Risks

Psychiatric risks of care denial can be understood in the context of bioethical concerns, all of which psychiatrists must be prepared to address.

1. Obligations to promote good and prevent harm. The foundations of ethical medical practice are duties to promote good (beneficence) and prevent harm (nonmaleficence). Care denial withdraws effective treatment, thereby eliminating good and causing harm, placing both patients and parents at significant risk for moral distress.

2. Overriding autonomy. Midtreatment denial of care, initiated after informed consent, overrides patient autonomy and parental ability to function as a surrogate decision-maker via substituted judgment. Psychiatrists recognize only exceptionally rare circumstances where practitioners may override patient and parent autonomy (eg, imminent threat of harm to self or others), and treatment of gender dysphoria does not meet any threshold for overriding patient/parent autonomy. Care denial thus violates health professionals’ obligation to preserve patient/parent autonomy, placing practitioners at risk for moral injury.

3. Threats to confidentiality. Enforcement of care denial through criminal or fraud investigations may result in the unauthorized and dangerous disclosure of personal health information that is protected by state and federal laws such as the Health Insurance Portability and Accountability Act.¹⁰ Forced disclosure of information about patients who are part of a stigmatized population can create moral distress by violating longstanding tenets of ethical care.

Psychiatric Preparedness

In the setting of care denial forced by law, health systems will need to invest resources to adjust to the expected emergence of mental health concerns. Psychiatrists can play a key role in developing and implementing such programs locally. Such programs should enhance monitoring of psychiatric symptoms, including suicidality, through electronic health records and phone services, ensure expedited access to crisis services and intensive outpatient programs, provide support services for transgender youth and their families, and ensure support for providers of medical treatment for dysphoria who are forced to terminate services with patients.

Conclusions

Care denial resulting from federal directives and state bans targeting transgender youth will have wide-ranging and profoundly troubling psychiatric consequences. As a field, psychiatrists must understand the risks of care denial, advocate against policies that worsen the mental health of transgender youth, and prepare the field to care for transgender youth and their families in the face of escalating care denials. The ethical and scientific principles of psychiatry—and the well-being of the patients and families that we serve—depend on it.