Ending

Conversion Therapy:

Supporting and Affirming

LGBTQ Youth

October 2015
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Ending Conversion Therapy: 

Supporting and Affirming 

LGBTQ Youth 

October 2015 
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Acknowledgements 

This report was prepared for the Substance Abuse and Mental Health Services Administration 

(SAMHSA) by Abt Associates under contract number HHSS283200700008I/HHSS28342001T 

with SAMHSA, U.S. Department of Health and Human Services (HHS). David Lamont Wilson 

served as the Government Project Officer. Elliot Kennedy served as the Task Lead. 

Disclaimer 

The views, opinions, and content of this publication are those of the author and do not 

necessarily reflect the views, opinions, or policies of SAMHSA or HHS. Listings of any nonFederal resources are not all-inclusive and inclusion of a listing does not constitute endorsement 

by SAMHSA or HHS. 

Public Domain Notice 

All material appearing in this report is in the public domain and may be reproduced or 

copied without permission from SAMHSA. Citation of the source is appreciated. However, 

this publication may not be reproduced or distributed for a fee without the specific, written 

authorization of the Office of Communications, SAMHSA, HHS. 

Electronic Access and Printed Copies 

This publication may be downloaded or ordered at http://store.samhsa.gov. Or call SAMHSA at 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

Recommended Citation 

Substance Abuse and Mental Health Services Administration, Ending Conversion Therapy: 

Supporting and Affirming LGBTQ Youth. HHS Publication No. (SMA) 15-4928. Rockville, 

MD: Substance Abuse and Mental Health Services Administration, 2015. 

Originating Office 

Division of Systems Development, Center for Substance Abuse Prevention, Substance Abuse 

and Mental Health Services. 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ i 
ii ▬ 
 

Contents 

Executive Summary .................................................................................................................................................1 

Introduction..............................................................................................................................................................7 

Professional Consensus Process .............................................................................................................................9 

Statements of Professional Consensus................................................................................................................ 11 

Research Overview................................................................................................................................................ 15 

Approaches to Ending the Use of Conversion Therapy ................................................................................... 37 

Guidance for Families, Providers, and Educators............................................................................................. 41 

Summary and Conclusion.................................................................................................................................... 51 

References............................................................................................................................................................... 52 

Appendix A: Glossary of Terms .......................................................................................................................... 64 

Appendix B: Acknowledgments ......................................................................................................................... 64 

Endnotes................................................................................................................................................................. 66 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ iii 
iv ▬ 
Executive Summary 

Lesbian, gay, bisexual, and transgender youth, and 

those who are questioning their sexual orientation 

or gender identity (LGBTQ youth) experience 

significant health and behavioral health disparities. 

Negative social attitudes and discrimination 

related to an individual’s LGBTQ identity can 

contribute to these disparities, and may result 

in institutional, interpersonal, and individual 

stressors that affect mental health and well-being. 

(Bockting, Miner, Swinburne Romine, Hamilton, 

& Coleman, 2013; Meyer, 2003). This stress, 

as well as limited opportunities for support, are 

encountered by sexual and gender minority1

youth 

in their families, communities, and school settings. 

Additionally, some transgender youth experience 

gender dysphoria – psychological distress due to 

the incongruence between one’s body and gender 

identity (Coleman et al., 2012). 

SAMHSA is committed to eliminating health 

disparities facing vulnerable communities, including 

sexual and gender minority communities. One 

key factor to preventing these adverse outcomes is 

positive family (including guardians and caregivers) 

and community engagement and appropriate 

interventions by medical and behavioral health 

care providers. Supporting optimal development 

of children and adolescents with regard to sexual 

orientation, gender identity, and gender expression 

is vital to ensuring their health and well-being. 

The purpose of this report, Ending Conversion 

Therapy: Supporting and Affirming LGBTQ outh, 

is to provide mental health professionals and 

families with accurate information about effective 

and ineffective therapeutic practices related to 

children’s and adolescent’s sexual orientation and 

gender identity. Specifically, this report addresses 

the issue of conversion therapy for minors. The 

conclusions in this report are based on professional 

consensus statements arrived at by experts in the 

field. Specifically, conversion therapy—efforts to 

change an individual’s sexual orientation, gender 

identity, or gender expression2

—is a practice 

that is not supported by credible evidence and 

has been disavowed by behavioral health experts 

and associations. Conversion therapy perpetuates 

outdated views of gender roles and identities as 

well as the negative stereotype that being a sexual 

or gender minority or identifying as LGBTQ is 

an abnormal aspect of human development. Most 

importantly, it may put young people at risk of 

serious harm. 

Key Findings 

This report and its recommendations are based 

on consensus statements developed by experts 

in the field after a careful review of existing 

research, professional health association reports 

and summaries, and expert clinical guidance. The 

consensus statements highlight areas of the ethical 

and scientific foundations most relevant to the practice 

of conversion therapy with minors. A full list of the 

consensus statements is found in the body of this 

report; key statements that form the underpinnings of 

the guidance in this report are provided here. 

• Same-gender3

sexual orientation (including

identity, behavior, and attraction) and variations

in gender identity and gender expression are a

part of the normal spectrum of human diversity

and do not constitute a mental disorder.

• There is limited research on conversion therapy

efforts among children and adolescents;

however, none of the existing research supports

the premise that mental or behavioral health

interventions can alter gender identity or sexual

orientation.

• Interventions aimed at a fixed outcome,

such as gender conformity or heterosexual

orientation, including those aimed at changing

gender identity, gender expression, and sexual

orientation are coercive, can be harmful,

and should not be part of behavioral health

treatment. (American Psychiatric Association,

2013b; American Psychological Association,

2010; National Association of Social Workers,

2008). 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 1 
Understanding Sexual Orientation 

and Gender Identity in Children 

and Youth 

Behavioral health providers, parents, schools, and 

communities can best provide support to children, 

adolescents, and their families when they have 

access to the most current information about sexual 

orientation, gender identity, and gender expression 

in youth. The following overview presents the best 

current evidence regarding understandings of child 

and adolescent sexual orientation, gender identity, 

and gender expression. 

Sexuality occurs across a continuum; same-gender 

attraction and relationships are normal variations of 

human sexuality (Diamond, 2015; Vrangalova & 

Savin-Williams, 2012). Similarly, a gender identity 

that is incongruent with assigned sex at birth, as 

well as a gender expression that diverges from 

stereotypical cultural norms for a particular gender, 

are normal variations of human gender (American 

Psychological Association, 2015a; Knudson, De 

Cuypere, & Bockting, 2010). Being a sexual or 

gender minority, or identifying as LGBTQ, is not 

pathological (American Psychological Association, 

2015a; APA Task Force on Gender Identity and 

Gender Variance, 2009; Coleman et al., 2012). 

There is not a single developmental trajectory 

for either sexual minority or gender minority 

youth. Compared to the 20th century, in the 21st 

century, youth started realizing and disclosing a 

minority sexual orientation and/or identifying as 

lesbian, gay, or bisexual at younger ages than in 

previous generations (Diamond & Savin-Williams, 

2000; Floyd & Bakeman, 2006; Grov, Bimbi, 

Nanín, & Parsons, 2006; R. C. Savin-Williams, 

2001). Though aspects of sexuality are displayed 

beginning in infancy, little is known about 

sexual orientation among pre-pubertal children 

(Adelson & American Academy of Child and 

Adolescent Psychiatry (AACAP) Committee on 

Quality Issues (CQI), 2012). Children are rarely 

if ever distressed about their current or future 

sexual orientation; more commonly, parents and 

guardians are distressed about a child’s perceived 

current or future sexual orientation and seek the 

assistance of behavioral health providers (American 

Psychological Association, 2009). Sexual minority 

adolescents face the same developmental tasks that 

accompany adolescence for all youth, including 

sexual orientation identity development. Unlike 

those with a heterosexual orientation, however, 

adolescents with a minority sexual orientation 

must navigate awareness and acceptance of a 

socially marginalized sexual identity; potentially 

without family, community, or societal support. In 

comparison with their heterosexual counterparts, 

sexual minority adolescents are at increased risk for 

psychological distress and substance use behaviors, 

including depressive symptoms, increased rates 

of substance use and abuse, suicidal ideation 

and attempts, as well as increased likelihood 

of experiencing victimization, violence, and 

homelessness (Corliss et al., 2010; Friedman et al., 

2011; Goldbach, Tanner-Smith, Bagwell, & Dunlap, 

2014; Hatzenbuehler, 2011; Institute of Medicine, 

2011; Kann et al., 2011; Marshal et al., 2011; 

Russell, 2003). Supportive families, peers, and 

school and community environments are associated 

with improved psychosocial outcomes for sexual 

minority youth (Bouris et al., 2010; Kosciw, 

Greytak, Palmer, & Boesen, 2014; Lease, Horne, & 

Noffsinger-Frazier, 2005). 

Gender development begins in infancy and 

continues progressively throughout childhood. 

Gender diversity or signs of gender dysphoria may 

emerge as early as a child’s preschool years, or as 

late as adolescence (Cohen-Kettenis, 2005). For 

many gender minority children, gender dysphoria 

will not persist, and they will develop a cisgender 

identity in adolescence or adulthood; a majority 

of these children will identify as lesbian, gay, or 

bisexual in adulthood (Bailey & Zucker, 1995; 

Drescher, 2014; Leibowitz & Spack, 2011; Wallien 

& Cohen-Kettenis, 2008). Whether or not these 

individuals continue to have a diverse gender 

expression is unknown. For other gender minority 

children, gender dysphoria will persist and usually 

worsen with the physical changes of adolescence; 

these youth generally identify as transgender (or 

another gender identity that differs from their 

assigned sex at birth) in adolescence and adulthood 

2 ▬
	
(Byne et al., 2012; Coleman, et al., 2012). For still 

another group, gender dysphoria emerges in postpuberty without any childhood history of gender 

dysphoria gender diversity (Edwards-Leeper & 

Spack, 2012). Gender dysphoria that worsens with 

the onset of puberty is unlikely to remit later in 

adolescence or adulthood, especially among youth 

with a childhood onset, and long-term identification 

as transgender is likely (American Psychological 

Association, 2015a; American Psychological 

Association, 2008; Byne, et al., 2012). 

While most adolescents with gender dysphoria 

score within normal ranges on psychological tests 

(Cohen-Kettenis & van Goozen, 1997; de Vries, 

Doreleijers, Steensma, & Cohen-Kettenis, 2011; 

Smith, van Goozen, & Cohen-Kettenis, 2001), some 

gender minority children and adolescents have 

elevated risk of depression, anxiety, and behavioral 

issues. These psychosocial issues are likely related 

to if not caused by negative social attitudes or 

rejection (Vance, Ehrensaft, & Rosenthal, 2014). 

As with sexual minority adolescents, other 

issues of clinical relevance for gender minority 

adolescents include increased risk of experiencing 

victimization and violence, suicidal ideation and 

attempts, and homelessness (Coleman, et al., 2012; 

Garofalo, Deleon, Osmer, Doll, & Harper, 2006; 

Institute of Medicine, 2011; Mustanski, Garofalo, 

& Emerson, 2010; Simons, Leibowitz, & Hidalgo, 

2014). Improved psychosocial outcomes are seen 

among youth when social supports are put in place 

to recognize and affirm gender minority youth’s 

gender identities (Vance, et al., 2014). 

Therapeutic Efforts with Sexual 

and Gender Minority Youth4

Given the professional consensus that conversion 

therapy efforts are inappropriate, the following 

behavioral health approaches are consistent with the 

expert consensus statements and current research, 

and are recommended by professional associations 

(American Psychological Association, 2015a; APA 

Task Force on Appropriate Therapeutic Responses 

to Sexual Orientation, 2009; Byne, et al., 2012). 

When providing services to children, adolescents, 

and families, appropriate therapeutic approaches 

include: providing accurate information on the 

development of sexual orientation and gender 

identity and expression; increasing family and 

school support; and reducing family, community, 

and social rejection of sexual and gender minority 

children and adolescents. Approaches should be 

client-centered and developmentally-appropriate 

with the goal of treatment being the best possible 

level of psychological functioning, rather than 

any specific gender identity, gender expression, 

or sexual orientation. Appropriate therapeutic 

approaches with sexual and gender minority youth 

should include a comprehensive evaluation and 

focus on identity development and exploration 

that allows the child or adolescent the freedom of 

self-discovery within a context of acceptance and 

support. It is important to identify the sources of any 

distress experienced by sexual and gender minority 

youth and their families, and work to reduce this 

distress. Working with parents and guardians is 

important as parental behaviors and attitudes have 

a significant effect on the mental health and wellbeing of sexual and gender minority children and 

adolescents. School and community interventions 

may also be necessary and appropriate. 

In addition to the appropriate therapeutic 

approaches described above – comprehensive 

evaluation, support in identity exploration and 

development without an a priori goal of any 

particular gender identity or expression, and 

facilitation of family and community support 

– social transition and medical intervention are

therapeutic approaches that are appropriate for

some gender minority youth. Careful evaluation

and developmentally-appropriate informed consent

of youth and their families, including a weighing

of potential risks and benefits are vital when

considering medical intervention with gender

minority youth.

Eliminating the practice of conversion therapy 

with sexual and gender minority minors is 

an important step, but it will not alleviate the 

myriad of stressors they experience as a result of 

interpersonal, institutional, and societal bias and 

discrimination against sexual and gender minorities. 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 3 
LGBTQ youth still need additional support to 

promote positive development in the face of such 

stressors. Supportive family, community, school, 

and health care environments have been shown to 

have great positive impacts on both the short- and 

long-term health and well-being of LGBTQ youth. 

Families and others working with LGBTQ children 

and adolescents can benefit from guidance and 

resources to increase support for sexual and gender 

minority minors and to help facilitate the best 

possible outcomes for these youth. 

Ending the Use of Conversion 

Therapy for Minors 

Given that conversion therapy is not an appropriate 

therapeutic intervention; efforts should be taken 

to end the practice of conversion therapy. Efforts 

to end the practice have included policy efforts to 

reduce the negative attitudes and discrimination 

directed at LGBTQ individuals and families; 

affirmative public information about LGBTQ 

individuals, particularly directed at families and 

youth; resolutions and guidelines by professional 

associations to inform providers that conversion 

efforts are inappropriate and to provide guidance 

on appropriate interventions; and, state and federal 

legislation and legal action to end the practice of 

conversion therapy. Future efforts may include 

improved provider training, federal regulatory 

action, advancement of legislation at the state 

and federal level, and additional activities by the 

Administration, which issued a public statement 

supporting efforts to ban the use of conversion 

therapy for minors in the spring of 2015. 

4 ▬
	
Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 5 

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6 ▬
	
Introduction 

This report, Ending Conversion Therapy: 

Supporting and Affirming LGBTQ outh, provides 

an overview of the current state of scientific 

understanding of the development of sexual 

orientation and gender identity in children and 

adolescents as well as the professional consensus 

on clinical best practices with these populations. 

Specifically, this report addresses the issue of 

conversion therapy for minors. Conversion 

therapy—efforts to change an individual’s sexual 

orientation, gender identity, or gender expression5

— 

is a practice that is not supported by credible 

evidence, and has been disavowed by behavioral 

health experts and associations. Importantly, 

this report also provides a nuanced overview of 

appropriate supportive interventions to assist 

families in exploring the sometimes difficult issues 

associated with sexual orientation, gender identity, 

and gender expression. 

This work is the result of a collaboration between 

the Substance Abuse and Mental Health Services 

Administration (SAMHSA) and the American 

Psychological Association (APA), which convened 

a panel of behavioral health professionals (e.g., 

psychologists, researchers and clinicians from 

psychology, social work, and psychiatry) with 

expertise in the fields of gender development, 

gender identity, and sexual orientation in children 

and adolescents in July 2015. That convening, 

which is discussed in greater depth below, aimed 

to establish consensus with respect to conversion 

therapy for minors, based on the best available 

research and scholarly material available, as well as 

the clinical experience of experts in the field. The 

resultant statements of professional consensus are 

printed in their entirety in the following section. 

In addition, this report highlights areas of 

opportunity for future research, and provides an 

overview of mechanisms to eliminate the use of 

harmful therapies. In an effort to provide useful 

tools for families, practitioners, and educators, the 

report also provides resources on several topics, 

including: Family and Community Acceptance, 

“ Being gay is not a 

disorder. Being transgender
	

is not a malady that 

requires a cure.

—Vice Admiral Vivek H. Murthy, 

19th U.S. Surgeon General 

”

School-Based Issues, Pediatric Considerations, 

and Affirmative Exploratory Therap . In addressing 

these four topics, SAMHSA aims to enable families, 

providers, educators, and community members to 

take actions that will reduce the health risks and 

disparities facing this vulnerable population. 

SAMHSA is committed to eliminating health 

disparities facing vulnerable communities, including 

sexual and gender minority communities. In 

addressing the issues included in this report that 

have a significant impact on the lives and well-being 

of sexual and gender minority youth, SAMHSA 

aims to enable families, providers, and educators 

to take actions that will reduce the health risks and 

disparities facing this vulnerable population 

SAMHSA’s mission is to improve the behavioral 

health of the nation. As such, SAMHSA endeavors 

to improve public health and eliminate health 

disparities facing all vulnerable communities, 

including sexual and gender minority 

populations.6

As will be addressed in detail below, 

conversion therapy perpetuates outdated gender 

roles and negative stereotypes that being a sexual 

or gender minority or identifying as LGBTQ is 

an abnormal aspect of human development. Most 

importantly, it may put young people at risk of 

serious harm. This report is one of many steps 

SAMHSA is taking to improve the health and wellbeing of sexual and gender minority children and 

youth. 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 7 
8 ▬
	
Professional Consensus Process
 

In early April 2015, representatives from 

SAMHSA and APA agreed to collaborate to 

address the concerns of professional associations, 

policy makers, and the public regarding efforts 

to change gender identity and sexual orientation 

in children and adolescents (also referred to as 

conversion therapy). Through the support of the 

Federal Agencies Project, APA hosted an expert 

consensus convening on this topic in July 2015, 

which significantly informed this report. The 

research overview and clinical expertise highlighted 

throughout serve as the foundation from which the 

consensus statements were developed. Both the 

process of achieving consensus and the results of 

the meeting are published below. 

APA initially developed a list of the areas of 

expertise to be used in identifying potential experts 

to participate in the consensus panel based on 

existing professional guidelines and resolutions 

related to sexual orientation, gender identity, and 

gender expression, as well as published research. 

APA solicited nominations from specialists in the 

field with expertise in gender, sexuality and sexual 

orientation, child and adolescent development 

and mental health, and the psychology of religion. 

Additionally, APA solicited nominations from 

professional associations representing the major 

mental health and health professions. Using the 

input received from these sources, APA extended 

invitations to a short list of highly recommended 

group of experts. This initial expert pool nominated 

additional experts based on their assessment of 

the expertise needed to achieve the goals of the 

meeting. The final panel of 13 experts consisted 

of ten psychologists, two social workers, and 

one psychiatrist. These individuals included 

researchers and practitioners in child and adolescent 

mental health with a strong background in gender 

development, gender identity, and sexual orientation 

in children and adolescents. The panel also included 

experts with a background in family therapy, ethics, 

and the psychology of religion. Among others, the 

panel included: Sheri Berenbaum, PhD; Celia B. 

Fisher, PhD; Laura Edwards-Leeper, PhD; Marco 

A. Hidalgo, PhD; David Huebner, PhD; Colton L.

Keo-Meier, PhD; Scott Leibowitz, MD; Robin Lin

Miller, PhD; Caitlin Ryan, PhD, ACSW; Josh Wolff,

PhD; and Mark Yarhouse, PsyD. APA activities

were coordinated by Clinton W. Anderson, PhD and

Judith Glassgold, PsyD.

Based on published literature on consensus 

methods, APA developed an iterative process that 

culminated in a two-day meeting in Washington, 

DC on July 7 and 8, 2015. During the meeting, 

panelist-led discussions considered the relevant 

research, professional guidelines and clinical 

knowledge-base for each of the topics. The 

panel developed consensus statements on sexual 

orientation change efforts as well as gender identity 

change efforts in children and adolescents for each 

of the relevant developmental stages: pre-pubertal 

children, peri-pubertal adolescents, and pubertal and 

post-pubertal adolescents. 

Panelists agreed that unanimous consensus was 

a strong priority, but that if unanimity could not 

be reached, 80 percent support would consitute 

consensus. The panelists also agreed that minority 

opinions should be reflected in the record if any 

dissenting expert wished to issue such an opinion. 

Unanimous consensus was reached in nearly all 

instances. No dissenting opinions were formally 

registered. The statements of professional consensus 

are printed in Section 3 of this report. 

Observers from interested federal agencies, health 

and human services professional organizations, 

foundations, and LGBTQ human rights 

organizations also attended the meeting. These 

observers were offered an opportunity to submit 

written questions, which the panel addressed 

throughout the course of the meeting. 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 9 
“PFR “created something that was 

groundbreaking. It was the best piece of work 

ever created by the federal government.” Sue Thau 

10 ▬
	
Statements of Professional Consensus
 

The following are the statements of professional consensus regarding sexual orientation 

and gender identity and expression that were developed during the July 2015 APA 

consensus convening. After initially developing separate statements regarding issues 

relating to the development of sexual orientation and gender identity and gender 

expression, the panel developed a set of three key summary statements. The panel also 

developed a statement regarding the guiding human rights and scientific principles that

provide a foundation for behavioral health professionals’ work in this area. 

Guiding Principles 

Behavioral health professionals respect human dignity and rights. The foundational ethical principle of 

“self-determination” requires that children and adolescents be supported in their right to explore, define, 

and articulate their own identity. The principles of “justice” and “beneficence and nonmaleficence” require 

that all children and adolescents have access to behavioral health treatments that will promote their health 

and welfare. Children and adolescents have the right to participate in decisions that affect their treatment 

and future. Behavioral health professionals respect human diversity and strive to incorporate multicultural 

awareness into their work. 

These guiding principles are based upon the codes of ethics for the professional fields of Psychology, 

Psychiatry, and Social Work (American Psychiatric Association, 2013b; American Psychological 

Association, 2010; National Association of Social Workers, 2008). 

Professional Consensus on Conversion Therapy 

with Minors 

1. Same-gender7sexual orientation (including identity, behavior, and/or attraction) and variations in

gender identity and gender expression are a part of the normal spectrum of human diversity and

do not constitute a mental disorder.

2. There is limited research on conversion therapy efforts among children and adolescents; however,

none of the existing research supports the premise that mental or behavioral health interventions

can alter gender identity or sexual orientation.

3. Interventions aimed at a fixed outcome, such as gender conformity or heterosexual orientation,

including those aimed at changing gender identity, gender expression, and sexual orientation are

coercive, can be harmful, and should not be part of behavioral health treatments. Directing the

child to be conforming to any gender expression or sexual orientation, or directing the parents

to place pressure for specific gender expressions, gender identities, and sexual orientations are

inappropriate and reinforce harmful gender and sexual orientation stereotypes.

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 11
 
Professional Consensus on Sexual Orientation 

in Youth 

1. Same-gender sexual identity, behavior, and attraction are not mental disorders. Same-gender

sexual attractions are part of the normal spectrum of sexual orientation. Sexual orientation

change in children and adolescents should not be a goal of mental health and behavioral

interventions.

2. Sexual minority children and adolescents are especially vulnerable populations with unique

developmental tasks who lack protections from involuntary or coercive treatment, and whose

parents and guardians need accurate information to make informed decisions about behavioral

health treatment.

3. There is a lack of published research on efforts to change sexual orientation among children and

adolescents; no existing research supports that mental health and behavioral interventions with

children and adolescents alter sexual orientation. Given the research on the secondary outcomes

of such efforts, the potential for risk of harm suggests the need for other models of behavioral

health treatment.

4. Behavioral health professionals provide accurate information on sexual orientation, gender

identity, and expression; increase family and school support; and, reduce rejection of sexual

minority youth. Behavioral health practitioners identify sources of distress and work to reduce

distress experienced by children and adolescents. Behavioral health professionals provide efforts

to encourage identity exploration and integration, adaptive coping, and family acceptance to

improve psychological well-being.

Professional Consensus on Gender Identity 

and Gender Expression in Youth 

Consensus on the Overall Phenomena of Gender Identity and Gender 

Expression 

1. Variations in gender identity and expression are normal aspects of human diversity and do

not constitute a mental disorder. Binary definitions of gender may not reflect emerging gender

identities.

2. Pre-pubertal children and peri-pubertal adolescents who present with diverse gender expressions

or gender dysphoria may or may not develop a transgender identity in adolescence or adulthood.

In pubertal and post-pubertal adolescents, diverse gender expressions and transgender identity

usually continue into adulthood.

12 ▬
	
Consensus on Efforts to Change Gender Identity 

3. There is a lack of published research on efforts to change gender identity among children and

adolescents; no existing research supports that mental health and behavioral interventions with

children and adolescents alter gender identity.

4. It is clinically inappropriate for behavioral health professionals to have a prescriptive goal related

to gender identity, gender expression, or sexual orientation for the ultimate developmental

outcome of a child’s or adolescent’s gender identity or gender expression.

5. Mental health and behavioral interventions aimed at achieving a fixed outcome, such as gender

conformity, including those aimed at changing gender identity or gender expression, are coercive,

can be harmful, and should not be part of treatment. Directing the child or adolescent to conform

to any particular gender expression or identity, or directing parents and guardians to place

pressure on the child or adolescent to conform to specific gender expressions and/or identities, is

inappropriate and reinforces harmful gender stereotypes.

Consensus on Appropriate Therapeutic Intervention for Youth with 

Gender-Related Concerns 

6. Children and adolescents experiencing gender-related concerns are an especially vulnerable

population with unique developmental tasks. Parents and guardians need accurate scientific

information to make informed decisions about appropriate mental health and behavioral

interventions, including whether or not to initiate a social gender transition or, in the case of peripubertal, pubertal, and post-pubertal adolescents, medical intervention. Treatment discussions

should respect the child’s and adolescent’s developing autonomy, recognizing that adolescents are

still transitioning into adult decision-making capacities.

7. Approaches that focus on developmentally-appropriate identity exploration, integration, the

reduction of distress, adaptive coping, and family acceptance to improve psychological wellbeing are recommended for children and adolescents of all ages experiencing gender-related

concerns.

Pre-Pubertal Children 

8. Gender expression and gender identity are interrelated and difficult to differentiate in prepubertal children, and are aspects of identity that develop throughout childhood. Therefore, a

detailed psychological assessment should be offered to children and families to better understand

the present status of a child’s gender identity and gender expression, as well as any associated

distress.

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 13
 
Peri-Pubertal Adolescents 

9. For peri-pubertal adolescents, the purpose of pubertal suppression is to provide time to support

identity exploration, to alleviate or avoid potential distress associated with physical maturation

and secondary sex characteristics8

, and to improve future healthy adjustment. If pubertal

suppression is being considered, it is strongly recommended that parents or guardians and

medical providers obtain an assessment by a licensed behavioral health provider to understand

the present status of a peri-pubertal adolescent’s gender identity or gender expression and

associated distress, as well as to provide developmentally-appropriate information to the peripubertal adolescent, parents or guardians, and other health care professionals involved in the

peri-pubertal adolescent’s care. The purpose of the assessment is to advise and inform treatment

decisions regarding pubertal suppression after sharing details of the potential risks, benefits, and

implications of pubertal suppression, including the effects of pubertal suppression on behavioral

health disorders, cognitive and emotional development, and future physical and sexual health.

Pubertal and Post-Pubertal Adolescents 

10. Decision-making regarding one’s developing gender identity is a highly individualized process

and takes many forms. For pubertal and post-pubertal adolescents, if physical gender transition

(such as hormone therapy or gender affirming surgeries) is being considered, it is strongly

recommended that adolescents, parents, and providers obtain an assessment by a licensed

behavioral health provider to understand the present status of an adolescent’s gender identity

and gender expression and associated distress, as well as to provide developmentally-appropriate

information to adolescents, parents or guardians, and other health care professionals involved in

the pubertal or post-pubertal adolescent’s care. If physical transition is indicated, the potential

risks, benefits, and implications of the transition-related procedures being considered – including

the effects on behavioral health disorders, cognitive and emotional development, and potentially

irreversible effects on physical health, fertility, and sexual health – are presented to the adolescent

and parents or guardians.

Withholding timely physical gender transition interventions for pubertal and post-pubertal

adolescents, when such interventions are clinically indicated, prolongs gender dysphoria and

exacerbates emotional distress.

14 ▬
	
Research Overview 

Sexual Orientation 

Sexual orientation is a multidimensional construct 

that consists of sexual identity, sexual and romantic 

attraction, and sexual behavior. Great shifts in the 

understanding of sexual orientation have occurred 

over the past century (Herek, 2010). Though a 

minority sexual orientation was once considered 

abnormal or a medical problem, scientists now 

understand that sexuality occurs on a continuum 

and variations in sexual orientation are part of 

the normal range of human sexuality (American 

Psychological Association, 2009; Diamond, 2015; 

Vrangalova & Savin-Williams, 2012). In 1973, 

homosexuality was removed as a diagnostic 

category in the Diagnostic and Statistical Manual 

of Mental Disorders with a declaration of support 

for the civil rights of lesbian, gay, and bisexual 

people from the American Psychiatric Association. 

Many health organizations followed suit in passing 

resolutions that affirmed their support for the 

civil rights of lesbian, gay, and bisexual people, 

including the American Psychological Association, 

the National Association for Social Workers, the 

American Counseling Association, the American 

Medical Association, the American Psychoanalystic 

Association, and the American Academy of 

Pediatrics. In 1992, the World Health Organization 

removed homosexuality from the International 

Classification of Diseases (Nakajima, 2003; World 

Health Organization, 1992)9

. 

Gender 

Gender is a ubiquitous and multi-faceted social 

category. When discussing the concept of gender, 

scientists distinguish between biological sex, gender 

identity, and gender expression. Biological sex 

refers to one’s physical sex characteristics (Hughes, 

Houk, Ahmed, & Lee, 2006). Infants’ biological 

sex is labeled at birth, almost always based solely 

on external genital appearance; this is referred to 

as one’s assigned sex at birth10. Gender identity 

refers to a person’s deeply felt, inherent sense of 

being a girl, woman or female; a boy, a man or 

male; a blend of male or female; or an alternative 

gender (Bethea, 2013; Institute of Medicine, 2011). 

Gender expression refers to the ways a person 

communicates their gender within a given culture, 

including clothing, communication patterns, and 

interests; a person’s gender expression may or may 

not be consistent with socially prescribed gender 

roles or assigned sex at birth, and may or may 

not reflect his or her gender identity (American 

Psychological Association, 2008). 

Similar to sexual orientation, significant changes 

have occurred over time in the scientific 

understanding of gender. Though one’s biological 

sex, gender identity, and gender expression are 

distinct constructs, society expects that they will 

align, and for most individuals this is true – that is, 

most individuals who are assigned female at birth 

identify as girls or women and adopt a feminine 

gender expression, while most individuals who are 

assigned male at birth identify as boys or men and 

adopt a masculine gender expression11(American 

Psychological Association, 2015a). However, for 

some individuals, these constructs do not align. The 

term transgender refers to individuals whose gender 

identity is not consistent with their sex assigned 

at birth. The term gender diverse (or gender 

nonconforming) refers to individuals whose gender 

expression does not conform to the stereotypical 

norms in their culture for their assigned sex at birth. 

Research in recent decades has also challenged 

the perception of gender as a binary construct 

with mutually exclusive categories of male or 

female, boy or girl, man or woman (American 

Psychological Association, 2015a; Steensma, 

Kreukels, de Vries, & Cohen-Kettenis, 2013). It 

has also often been assumed that one’s gender 

identity – that is, the deeply felt, inherent sense of 

one’s gender – always aligns with sex assigned as 

birth (American Psychological Association, 2015a). 

Scientists now recognize that a wide spectrum of 

gender identities and gender expressions exist (and 

have always existed), including people who identify 

as either man or woman, neither man nor woman, 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 15
 
a blend of man and woman, or a unique gender 

identity (Harrison, Grant, & Herman, 2012; Kuper, 

Nussbaum, & Mustanski, 2012). 

Furthermore, scientists and clinicians now 

understand that identifying with a gender that does 

not align with sex assigned at birth, as well as a 

gender expression that varies from that which is 

stereotypical for one’s gender or sex assigned at 

birth, is not inherently pathological (American 

Psychological Association, 2015a; Coleman, et al., 

2012; Knudson, De Cuypere, & Bockting, 2010) 

and does not always require clinical attention 

(Steensma, Kreukels, et al., 2013). However, people 

may experience distress associated with discordance 

between their gender identity and their body or sex 

assigned at birth (i.e., gender dysphoria) as well 

distress associated with negative social attitudes 

and discrimination (Coleman, et al., 2012). This 

paradigmatic shift in the understanding of diverse 

gender identities and expressions was reflected 

in the replacement of Gender Identity Disorder 

with Gender Dysphoria in the 2013 edition of 

the Diagnostic and Statistical Manual of Mental 

Disorders (American Psychiatric Association, 

2013a). The diagnosis of Gender Dysphoria, 

which is marked in children and adolescents by 

clinically significant distress encountered by the 

discordance between biological sex and gender 

identity that disrupts school or social functioning, 

depathologizes diverse gender identities and 

expressions, instead focusing on the potential 

psychosocial challenges associated with gender 

diversity (American Psychiatric Association, 2013a; 

Simons, et al., 2014; Vance, et al., 2014). 

Sexual Orientation and Gender in 

Childhood 

Sexual Orientation in Childhood 

Sexual orientation, as usually conceptualized, 

begins at or near adolescence with the development 

of sexual feelings (APA Task Force on Appropriate 

Therapeutic Responses to Sexual Orientation, 

2009). While children display aspects of sexuality 

from infancy, and almost universally develop sexual 

feelings by adolescence or earlier, the limited 

research focused on children’s sexuality generally 

does not assess sexual orientation (Adelson & 

AACAP CQI, 2012). Therefore, little is known 

about sexual orientation in pre-pubertal children, 

and no direct research on sexual orientation in 

pre-pubertal children has been conducted. Studies 

that have retrospectively asked lesbian, gay, and 

bisexual adults about their childhood experiences 

have reported that LGB adults often describe having 

had same-gender emotional and sexual feelings and 

attractions from childhood or early adolescence; 

many recall a sense of being different even earlier 

in childhood (APA Task Force on Appropriate 

Therapeutic Responses to Sexual Orientation, 

2009). 

Gender Identity and Gender Expression in 

Childhood 

Gender-related development begins in infancy and 

continues progressively throughout childhood. 

Research has focused on three key concepts: gender 

constancy, gender consistency, and gender identity. 

On average, children develop gender constancy – 

stability across time in identification of their gender 

– between ages 3 to 4 (Kohlberg, 1966) and gender

consistency – recognition that gender remains

the same across situations – between ages 4 to 7

(Siegal & Robinson, 1987). The development of

gender identity appears to be the result of a complex

interplay between biological, environmental, and

psychological factors (Steensma, Kreukels, et al.,

2013). For most people, gender identity develops

in alignment with one’s sex assigned at birth.

However, for some individuals, gender identity

may not align with one’s assigned sex at birth, and

the period during which gender identity is clarified

and solidified is unclear (Diamond & Butterworth,

2008; Steensma, Kreukels, et al., 2013). There is no

single trajectory of gender identity development for

gender minority children.

It is important to note that research on gender 

identity issues among children is largely clinical in 

nature and focuses on the treatment and intervention 

of Gender Dysphoria and, previously, Gender 

Identity Disorder12(APA Task Force on Gender 

Identity and Gender Variance, 2009). Though there 

16 ▬
	
have been no epidemiological studies to determine 

the prevalence of gender diverse and transgender 

children or adolescents, there has been a notable 

increase in the number of gender minority youth 

presenting to specialty gender clinics in the past 

decade (Vance, et al., 2014). Recent evidence 

indicates that as a culture becomes more supportive 

of gender diversity, more children are affirming a 

transgender identity or diverse gender expressions 

(Vance, et al., 2014). 

Some gender non-conforming children experience 

significant distress, currently termed gender 

dysphoria. Signs of gender dysphoria may emerge 

as early as the preschool years; children as young 

as two years may indicate that they want to be 

another gender, express dislike for the gender 

associated with their sex assigned at birth, express 

anatomic dysphoria, and state that they want to 

be another gender as soon as they can express 

language (Cohen-Kettenis, 2005). For most gender 

minority children, gender dysphoria does not 

persist through adolescence. Existing research 

suggests that between 12 percent and 50 percent 

of children attending a specialty clinic for gender 

dysphoria may persist in their identification 

with a gender different than sex assigned at 

birth into late adolescence and young adulthood 

(Drummond, Bradley, Peterson-Badali, & Zucker, 

2008; Steensma, McGuire, Kreukels, Beekman, & 

Cohen-Kettenis, 2013; Wallien & Cohen-Kettenis, 

2008). These studies were based on clinical 

samples of youth and many of the researchers 

categorized youth no longer attending the clinics 

(whose gender identity may be unknown) as no 

longer gender dysphoric, and so this research 

likely underestimates the percentage of youth who 

persist with a cross-gender or transgender identity 

(American Psychological Association, 2015a). 

The fact that a large proportion of gender minority 

children do eventually develop a gender identity 

consistent with their sex assigned at birth has been 

viewed as evidence of the malleability of gender 

identity (Zucker, 2004; Zucker & Bradley, 1995). 

However, this conclusion has been challenged in 

recent years by some scholars. These researchers 

and clinicians have pointed out that the diagnostic 

criteria for Gender Dysphoria (and, previously, 

Gender Identity Disorder) in Childhood includes 

indicators that might denote gender dysphoria or 

gender identity, but might also simply be markers of 

diverse gender expression (for example, children’s 

play preferences; Steensma, Biemond, de Boer, 

& Cohen-Kettenis, 2011; Steensma, McGuire, et 

al., 2013). These scholars have suggested that the 

inclusion in study samples of many children with 

diverse gender expressions who may not have 

gender dysphoria could explain the large proportion 

of gender minority children who eventually do not 

meet the diagnostic criteria in adolescence (Hidalgo 

et al., 2013; Wallien & Cohen-Kettenis, 2008). 

One of gender’s greatest complexities is that 

some people never identify with the sex they 

were assigned at birth, some people consistently 

identify with the sex they were assigned at birth, 

and still others vary over time. Gender minority 

children follow two trajectories13: On the first, 

children will experience gender dysphoria through 

adolescence and adulthood (unless dysphoria is 

mitigated through social or medical transition) 

and will identify as transgender or as a gender 

different from that assigned at birth. On the other 

trajectory, gender minority children will develop to 

be cisgender individuals, i.e., they will eventually 

identify with a gender consistent with their sex 

assigned at birth (Simons, et al., 2014). Gender 

minority children who eventually develop a 

cisgender identity are more likely to identify as 

lesbian, gay, or bisexual in adolescence and young 

adulthood (Bailey & Zucker, 1995; Drescher, 

2014; Leibowitz & Spack, 2011; Wallien & CohenKettenis, 2008). It is unknown whether gender 

minority children who develop a cisgender identity 

continue to express their gender in ways that do 

not conform to stereotypical gender norms, as this 

has not been studied. No prospective data exist on 

factors that might predict for any particular child 

which trajectory they will follow. There is, however, 

recent retrospective evidence identifying factors that 

are more common among children who eventually 

identify as transgender: early cognitive (“I am 

a girl”) rather than affective (“I feel like a girl”) 

assertion of gender; consistent and firm genderEnding Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 17
 
fluid or gender-crossing expressions and identity; 

and distress about the incongruence between their 

physical sex characteristics and affirmed gender 

(Steensma, Biemond, de Boer, & Cohen-Kettenis, 

2011; Steensma, McGuire, et al., 2013; Vance, et 

al., 2014). 

Clinical Issues in Childhood 

Researchers have not systematically investigated 

whether children experience distress related to their 

sexual orientation. No published research suggests 

that children are distressed about their sexual 

orientation. When pre-pubertal children are referred 

to behavioral health professionals for concerns 

related to sexual orientation, such referrals are 

often precipitated by a parent or guardian’s concern 

or distress about a child’s behavior – generally, 

a failure to conform to stereotypical gender role 

behaviors – and possible future sexual orientation 

(APA Task Force on Appropriate Therapeutic 

Responses to Sexual Orientation, 2009). Research 

has shown that gender diverse children who develop 

a cisgender identity do have a higher likelihood of 

identifying as a sexual minority in adulthood, and 

that some (but not all) sexual minority adults recall 

gender nonconforming behaviors in childhood 

(APA Task Force on Appropriate Therapeutic 

Responses to Sexual Orientation, 2009). It is 

unknown whether cisgender lesbian, gay, and 

bisexual adults who were treated by behavioral 

health providers as youth experienced distress 

related to their gender nonconformity (APA Task 

Force on Appropriate Therapeutic Responses to 

Sexual Orientation, 2009). 

Gender minority children are not a monolithic 

group: some gender diverse children are distressed; 

while others are not distressed, but may be referred 

for mental health care because of parental concerns 

related to their gender or perceived future sexual 

orientation. Among those who are distressed, the 

source of distress varies. Some gender diverse 

children are distressed by their primary sex 

characteristics or by the anticipation of future sex 

characteristics, while others are not (Coleman, 

et al., 2012; Vance, et al., 2014). In addition to 

anatomical dysphoria, children’s feelings of gender 

typicality, gender contentedness, and pressure to 

conform to stereotypical gender norms also appear 

related to children’s psychosocial adjustment. 

Researchers have reported on the relationships 

between these various components of gender 

identity and indicators of children’s psychosocial 

adjustment, such as self-esteem, internalizing and 

externalizing problems, and social competence 

with peers (Carver, Yunger, & Perry, 2003; Egan & 

Perry, 2001; Yunger, Carver, & Perry, 2004). 

Gender minority children, on average, have poorer 

relationships with parents (Adelson & AACAP 

CQI, 2012; Alanko et al., 2009) and peers (Smith 

& Leaper, 2006; Zucker, 2005), experience high 

rates of mistreatment from peers (D’Augelli, 

Grossman, & Starks, 2006), and are at increased 

risk of physical and sexual abuse in childhood, 

as compared to their gender conforming peers 

(Roberts, Rosario, Corliss, Koenen, & Austin, 

2012). Clinical samples of gender minority 

children with gender dysphoria have increased 

rates of internalizing disorders, such as depression 

and anxiety (de Vries, et al., 2011; Spack et al., 

2012) and behavioral problems (Simons, et al., 

2014; Zucker, 2004), as compared to the general 

population of children. Behavioral issues among 

those with gender dysphoria increase with age; 

poor peer relations explain most of the variance in 

behavioral problems among children with gender 

dysphoria (Zucker, 2004). Negative social attitudes 

or rejection are likely related if not the direct causes 

of these psychological difficulties (Vance, et al., 

2014). Additionally, autism spectrum disorders 

appear to occur more commonly among clinical 

samples of children with gender dysphoria than 

among children in the general population, though 

the reason for this increased co-occurrence, and 

whether this increased co-occurrence also occurs 

outside of clinic populations, is not fully understood 

(de Vries, et al., 2010; Edwards-Leeper & Spack, 

2012). 

18 ▬
	
Sexual Orientation and Gender in 

Adolescence 

Sexual Orientation in Adolescence 

Significant physical, cognitive, and social 

development occurs during adolescence. Sexual 

minority adolescents face the same developmental 

tasks that accompany adolescence for all youth, 

including sexual identity development. Unlike 

those with a heterosexual orientation, however, 

adolescents with a minority sexual orientation 

must navigate awareness and acceptance of a 

socially marginalized sexual identity; potentially 

without family, community, or societal support. 

Various factors affect the trajectory of development 

related to sexual orientation, and there is not a 

single or simple trajectory experienced by all 

individuals (Diamond, 2006, 2008; Diamond & 

Savin-Williams, 2000; Dube & Savin-Williams, 

1999; Horowitz & Newcomb, 2001). In a large 

prospective cohort study of adolescents living 

throughout the U.S., 12 percent of males and 22 

percent of females at one point indicated a minority 

sexual orientation identity (i.e., mostly heterosexual, 

bisexual, mostly homosexual, or completely 

homosexual; Ott, Corliss, Wypij, Rosario, & Austin, 

2010)14. Compared to earlier cohorts, today’s sexual 

minority adolescents are developing an awareness 

of their sexual orientation and disclosing their 

sexual orientation to others earlier than previous 

generations, frequently disclosing their sexual 

orientation or “coming out” as lesbian, gay, or 

bisexual in middle or high school (Diamond 

& Savin-Williams, 2000; Floyd & Bakeman, 

2006; Grov, et al., 2006; R. C. Savin-Williams, 

2001; R.C. Savin-Williams, 2005). This earlier 

disclosure means that adolescents are now often 

coming out while still dependent on their families 

and communities for emotional and instrumental 

support. 

Gender Identity in Adolescence 

Gender minority adolescents include both youth 

who realized a transgender identity or gender 

diverse presentation in childhood (i.e., early-onset 

individuals) and youth for whom gender dysphoria 

first emerges in adolescence (i.e., later-onset 

individuals). Adolescence is a crucial period for the 

consolidation of gender identity and persistence 

of gender dysphoria in early-onset individuals and 

for the initiation of gender dysphoria in later-onset 

individuals (Steensma, McGuire, et al., 2013). 

Youth for whom gender dysphoria first emerges 

in adolescence may have no history of a gender 

diverse expression or gender identity questioning 

in childhood (Edwards-Leeper & Spack, 2012; 

Wallien & Cohen-Kettenis, 2008). The onset of 

typical physical changes associated with puberty 

is often associated with worsening of anatomical 

dysphoria and distress in adolescents with gender 

dysphoria (Byne, et al., 2012; Coleman, et al., 

2012). Increasing numbers of adolescents have 

already starting living in their desired gender role 

upon entering high school (Cohen-Kettenis & 

Pfäfflin, 2003) and many (but not all) adolescents 

with gender dysphoria express a strong desire for 

hormone therapy and gender affirming surgeries 

(Coleman, et al., 2012). 

When gender dysphoria persists through childhood 

and intensifies into adolescence, the likelihood 

of long-term persistence of gender dysphoria and 

identification as transgender in adulthood increases. 

Two different follow up studies reported that 50-

67 percent of adolescents attending a specialty 

clinic for gender dysphoria went on to have gender 

affirming surgeries, suggesting high rates of 

persistence (Cohen-Kettenis & van Goozen, 1997; 

Smith, van Goozen, & Cohen-Kettenis, 2001). 

Since not all individuals with gender dysphoria 

have gender affirming surgeries, the percentage of 

adolescents in these study samples who continued 

to experience gender dysphoria is likely higher than 

50-67 percent; in fact, the Smith et al. (2001) study

suggested that a considerable number of the patients

who did not have gender affirming surgeries still

experienced gender dysphoria four years later.

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 19
 
Clinical Issues in Adolescence 

Although many sexual and gender minority youth 

successfully navigate the challenges of adolescence, 

others experience a variety of mental health and 

psychosocial concerns. In comparison with their 

heterosexual and cisgender counterparts, sexual 

and gender minority adolescents are at increased 

risk for psychological distress and substance 

use behaviors, including depressive symptoms, 

increased rates of substance use and abuse, 

suicidal ideation and attempts, as well as increased 

likelihood of experiencing victimization, violence, 

and homelessness (Coleman, et al., 2012; Corliss, 

et al., 2010; Friedman, et al., 2011; Garofalo, et 

al., 2006; Goldbach, et al., 2014; Hatzenbuehler, 

2011; Institute of Medicine, 2011; Kann, et al., 

2011; Liu & Mustanski, 2012; Marshal, et al., 2011; 

Mustanski, et al., 2010; S. T. Russell, 2003; Simons, 

et al., 2014). Sexual and gender minority youth 

who lack supportive environments are especially 

vulnerable to these negative outcomes (for example, 

research from Kosciw, et al., (2014), Ryan, 

Huebner, Diaz, & Sanchez, (2009), and Travers, et 

al. (2012)). 

Pubertal development can be especially 

distressing for transgender adolescents and can 

set off a cascade of mental health problems during 

adolescence (Byne, et al., 2012; Coleman, et al., 

2012). Mental health challenges are more common 

among adolescents with gender dysphoria than 

among children with gender dysphoria (Byne et 

al., 2012), which may be due to peer ostracism that 

increases with age (APA Task Force on Gender 

Identity and Gender Variance, 2009). Additionally, 

as with children, the prevalence of autism spectrum 

disorders appears to be higher among clinical 

samples of adolescents with gender dysphoria 

than among the general population of adolescents 

(de Vries, et al., 2010; Edwards-Leeper & Spack, 

2012). Adolescents with autism spectrum disorders 

(ASD) would benefit from careful assessment 

distinguishing between symptomatology related to 

gender dysphoria and symptoms related to ASD. 

de Vries, et al. (2010) reported a rate of autism 

spectrum disorders 10 times higher among children 

and adolescents referred to their gender clinic 

in Amsterdam, Netherlands as compared to the 

general population. This research only examined 

cases of severe autism and not milder versions 

such as Asperger’s disorder, which EdwardsLeeper and Spack (2012) reported being more 

commonly seen among patients in the GeMS clinic 

in Boston, especially among those with a late-onset 

of gender dysphoria. The question of whether 

gender dysphoria is simply a symptom of autism 

spectrum disorder among youth with ASD has been 

raised by behavioral health providers; EdwardsLeeper and Spack (2012) suggest that it is also 

worth questioning validity of the autism diagnosis 

among transgender youth, particularly those with 

Asperger’s disorder, as it is possible that social 

awkwardness and lack of peer relationships are the 

result of feeling isolated and rejected due to gender 

identity and expression (Edwards-Leeper & Spack, 

2012). More research is needed into appropriate 

treatment for sexual and gender minority children 

and adolescents with developmental disabilities 

as well; behavioral health providers should not 

presume that young people with developmental 

disabilities cannot also be sexual and gender 

minorities. 

Influences on Health and 

Well-Being 

The increased risks faced by sexual or gender 

minority youth are not a function of their identity. 

Rather, these risks stem from the stresses of 

prejudice, discrimination, rejection, harassment, 

and violence (Bockting et al., 2013; Harper & 

Schneider, 2003; Hendricks & Testa, 2012; Meyer, 

1995). The presence of sexual orientation- and 

gender-related stressors – and opportunities for 

support – encompasses multiple social systems, 

including family, school, and religious networks 

(U. Bronfenbrenner, 1979; U. Bronfenbrenner, 

2005; Harper, 2007); Mustanski, Birkett, Greene, 

Hatzenbuehler, & Newcomb, 2013)15. Therefore, 

when a distressed sexual and gender minority 

adolescent is evaluated by a behavioral health 

provider, it is imperative to assess the broader 

family and community systems in which the child 

lives, in addition to individual issues. Assessing 

20 ▬
	
not only the adolescent’s level of distress, but also 

identifying the source(s) of distress and support are 

vital components of a comprehensive assessment. 

Family 

Family response to an adolescent’s sexual 

orientation, gender identity, or gender expression 

has a significant impact on the adolescent’s 

wellbeing. Parents can serve as both a source 

of stress and a source of support for sexual and 

gender minority youth (Bouris, et al., 2010; Ryan, 

Russell, Huebner, Diaz, & Sanchez, 2010; Travers 

et al., 2012). Negative parental responses to sexual 

orientation or gender are associated with young 

people’s psychological distress; however, parentchild relationships characterized by closeness and 

support, however, are an important correlate of 

mental well-being. Research by Doty, Willoughby, 

Lindahl and Malik (2010) has emphasized the 

benefits of sexuality-specific family and peer 

support to sexual minority adolescents’ well-being. 

Sexual and gender minority adolescents are at 

increased risk for experiencing violence and 

victimization, including psychological, physical, 

and sexual abuse from those within their families 

compared to adolescents from the general 

population (Friedman, et al., 2011; Roberts, et al., 

2012). Past parental verbal and physical abuse has 

been associated with suicide attempts in transgender 

adolescents (Grossman & D’Augelli, 2007). These 

adolescents may also be ejected from their homes 

or run away, contributing to the overrepresentation 

of sexual and gender minority adolescents among 

the nation’s homeless youth; 20-40 percent of all 

homeless youth identify as lesbian, gay, bisexual, or 

transgender (Durso & Gates, 2012; Ray & National 

Gay and Lesbian Task Force, 2006). Some data 

suggest that, compared to cisgender youth who 

conform to stereotypical gender norms, transgender 

and other adolescents whose gender expressions do 

not conform to stereotypical norms have a higher 

risk of abuse from family members (Roberts, et al., 

2012; Roberts, Rosario, Slopen, Calzo, & Austin, 

2013). 

Furthermore, the level of family acceptance or 

rejection an adolescent experiences appears to have 

effects that extend into young adulthood. Data 

from the Family Acceptance Project have shown 

that sexual and gender minority young adults who 

experienced high levels of family rejection during 

adolescence fared significantly worse than those 

who experience low levels of family rejection in 

terms of depression, substance abuse, sexual risk 

behaviors, and suicide attempts (Ryan, Huebner, 

Diaz, & Sanchez, 2009); conversely, high levels of 

family acceptance in adolescence predicted greater 

self-esteem, social support, and general health 

status, and protected against depression, substance 

abuse, and suicidal ideation and behaviors in young 

adulthood as compared to those with low levels 

of family acceptance in adolescence (Ryan, et al., 

2010). 

Religion & Spirituality 

When considering family and community 

influences, an adolescent’s religious background 

is also an important factor. Religious beliefs 

and background are far-reaching influences that 

encompass multiple arenas of one’s life, including: 

personal and family religious identity, beliefs and 

coping; family attitudes, beliefs and relationships; 

and community character and support. Religious 

views of homosexuality in the United States vary 

widely (Moon, 2014), and religion can have a 

large influence on sexual minority adolescents’ 

mental health and wellbeing (cf. Ream & SavinWilliams, 2005; Page, Lindahl, & Malik, 2013). 

Though research on who seeks conversion therapy 

to change sexual orientation is lacking, it appears 

that such requests occur primarily among religious 

communities that view minority sexual orientations 

as undesirable or morally wrong (APA Task Force 

on Appropriate Therapeutic Responses to Sexual 

Orientation, 2009). 

Though religiosity is often associated with better 

psychosocial adjustment among young people in 

general, sexual minority youth may feel rejected 

by their religion or experience conflict between 

their sexual orientation and religious identities 

(Cotton, Zebracki, Rosenthal, Tsevat, & Drotar, 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 21
 
2006). However, various ways in which adolescents 

and young adults reconcile this conflict have been 

identified (Meanley, Pingel, & Bauermiester, 2015; 

Ream & Savin-Williams, 2005). Sexual minority 

youth growing up in more conservatively religious 

families are, on average, exposed to more messages 

that portray minority sexual orientations as 

undesirable or morally wrong (Schope & Eliason, 

2000), which are associated with shame, guilt, and 

internalized homophobia (Ream & Savin-Williams, 

2005). Sexual minority adolescents with religious 

parents may be less likely to disclose their sexual 

orientation to others (Schope, 2002; Stewart, Heck, 

& Cochran, 2015). Some research has indicated 

that involvement with religious or spiritual 

belief systems that cast rejecting or disapproving 

messages about sexual minorities is associated with 

greater psychosocial challenges, including increased 

internalized homophobia (Meanley, Pingel, & 

Bauermeister, 2015; Page, Lindahl, & Malik, 2013). 

Religiosity or spirituality can be a deeply affirming 

and supportive aspect of identity, including for 

sexual minorities from faith communities. Research 

with adults indicates that affirming religious 

environments – that is, those that are inclusive and 

supportive of sexual minorities –may be associated 

with improved psychological wellbeing and 

reduced internalized homophobia (e.g., research 

from Lease, et al. (2005) and Yakushko (2005). 

Research from Hatzenbuehler, Pachankis, and Wolff 

(2012) supports the benefit of affirming religious 

environments for youth as well; the researchers 

reported that lesbian, gay, and bisexual high school 

students who lived in Oregon counties with a 

supportive religious climate (i.e., counties where 

the majority of religious individuals adhered to 

a religious denomination supportive of minority 

sexual orientations) had significantly fewer alcohol 

abuse symptoms and fewer sexual risk behaviors 

than those living in counties with a less supportive 

religious climate. 

It is important not to reify categories within faiths 

such as “traditional”, “liberal”, “affirming” and 

“non-affirming”; religion and spirituality are 

complex, nuanced aspects of human diversity. 

Parents from faith backgrounds have reactions that 

are similar in essential ways to all parents (e.g., 

sense of loss, desire for information, coming to 

terms with difference between hopes and reality; 

Maslowe and Yarhouse, 2015). Research indicates 

that families who identify superordinate goals such 

as unconditional love, mercy, forgiveness, and 

respect for all human beings can remain connected 

to their children in positive ways (Ryan et al, 2009; 

Maslowe & Yarhouse, 2015). 

Given the great potential impact of religion on the 

lives of sexual and gender minority youth, little 

research has been done in this area with sexual 

minority adolescents and almost none has been 

completed with gender minority adolescents; 

further, almost no research has focused on sexual 

minority youth or adults in the United States from 

non-Christian religious backgrounds (cf. Harari, 

Glenwick, & Cecero, 2014; Siraj, 2012). It is 

unknown whether similar relationships between 

various aspects of religion and well-being would 

be seen among gender minority youth and among 

sexual and gender minority youth from nonChristian religious backgrounds. 

School 

Sexual and gender minority adolescents may also 

experience a myriad of sexual orientation and 

gender-related stressors in the school environment, 

where they spend a large portion of their time. 

The climates of U.S. middle and high schools 

are generally unsupportive and unsafe for many 

sexual and gender minority youth, who experience 

high levels of verbal and physical harassment 

and assault, sexual harassment, social exclusion 

and isolation, and other interpersonal problems 

with peers (Kosciw, Greytak, & Diaz, 2009). In 

the most recent National School Climate Survey, 

the Gay, Lesbian & Straight Education Network 

(GLSEN) found that 55.5 percent of surveyed 

sexual and gender minority students felt unsafe 

at school because of their sexual orientation and 

37.8 percent felt unsafe because of their gender 

expression (Kosciw, et al., 2014). Most students 

reported hearing homophobic remarks and negative 

remarks about their gender expression at school 

22 ▬
	
from fellow students and teachers or other school 

staff; a third of students reported hearing negative 

remarks specifically about transgender people. Of 

the students surveyed, 74.1 percent of surveyed 

students were verbally harassed, 36.2 percent were 

physically harassed, 16.5 percent were physically 

assaulted, and 49.0 percent were cyberbullied in 

the past year because of their sexual orientation. 

On average, sexual minority students of color and 

students who did not conform to stereotypical 

gender roles experienced higher frequencies of 

victimization. Over half of the students surveyed 

experienced policies that were discriminatory 

based on sexual orientation, gender identity, or 

gender expression at school. Transgender students 

were particularly targeted by some discriminatory 

policies: 42.2 percent of transgender students had 

been prevented from using their preferred name; 

59.2 percent were required to use a bathroom or 

locker room of their legal sex; and 31.6 percent 

were not allowed to wear clothes consistent with 

their gender identity. 

This mistreatment has a significant effect on sexual 

and gender minority adolescents’ mental health and 

wellbeing. Those who experience victimization due 

to sexual orientation or gender expression are more 

likely to report depressive symptoms, suicidality, 

and low self-esteem (Burton, Marshal, Chisolm, 

Sucato, & Friedman, 2013; Kosciw, et al., 2014). 

Experiences of victimization and discrimination are 

linked to negative academic outcomes, including 

missing school, lower grades, and not planning 

to pursue post-secondary education (Kosciw, et 

al., 2014). Further, these effects may last into 

young adulthood (Russell, Ryan, Toomey, Diaz, 

& Sanchez, 2011). Victimization from peers and 

school staff, combined with discriminatory policies, 

likely contributes to the over-representation of 

sexual and gender minorities in the juvenile justice 

system: though sexual and gender minority youth 

comprise only five to seven percent of the nation’s 

youth, it is estimated that 13 to 15 percent of youth 

in the juvenile justice system are sexual and gender 

minority youth (Majd, Marksamer, & Reyes, 2009). 

School and peer networks can also be a place where 

sexual and gender minority youth find support. 

The presence of friends to whom youth can be out 

about their sexual orientation or gender identity has 

been linked to mental health and wellbeing (Doty & 

Brian, 2010; Elizur & Ziv, 2001). Sexual and gender 

minority friends may be of particular importance, 

as they are more likely than heterosexual and 

cisgender friends to provide support for sexualityrelated stress, which is associated with lower levels 

of both emotional distress and sexuality distress 

(Doty, et al., 2010; Snapp, Watson, Russell, Diaz, & 

Ryan, 2015). Additionally, both the presence of and 

participation in a Gay-Straight-Alliance (GSA) – a 

student-led, school-based club aiming to provide 

a safe place for LGBTQ students – has beneficial 

outcomes for sexual and gender minority students 

(for example, research from Goodenow, Szalacha, 

and Westheimer (2006), Kosciw, Greytak, Diaz, 

and Bartkiewicz (2010), Toomey, Ryan, Diaz, and 

Russell (2011), and Walls, Kane, and Wisneski 

(2010)). 

Identity Development 

Sexual and gender minority adolescents may 

experience identity conflict when reconciling a 

sexual minority identity that may conflict with the 

expectations of their family, peers, and community. 

Difficulty with the identity development process, 

such as difficulty accepting one’s sexual orientation 

and dissonance between one’s self-image and 

societal beliefs about sexual minorities, can increase 

internalized homophobia (Page et al., 2013). 

Sexual orientation conflict has been linked to 

negative psychosocial outcomes in adolescents and 

young adults (Willoughby, Doty, & Malik, 2010). 

Furthermore, a negative self-image as a sexual 

minority contributes to the relationship between 

sexuality-specific stressors, including family 

rejection and victimization, to poorer mental health 

outcomes (Page, et al., 2013; Willoughby, et al., 

2010). 

Though less research has been done with gender 

minority adolescents overall, and especially on 

topics related to identity, internalized transphobia 

is expected to have a deleterious effect on mental 

health (Hendricks & Testa, 2012). Therefore, 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 23
 
important areas of focus for behavioral health 

professionals who work with sexual and gender 

minority adolescents include internalized 

homophobia, transphobia, and clients’ minority 

identity. 

Intersecting Identities 

Finally, sexual and gender minority adolescents are 

not a single, homogenous population; individuals 

may hold multiple minority identities. Race, 

ethnicity, sex assigned at birth, social class, 

religion, disability, and immigration status may 

each confer their own unique minority identities, 

stressors, and strengths that interact with those 

related to sexual orientation and gender identity 

and expression. Sexual and gender minority youth 

have multiple, interlocking identities defined by 

relative sociocultural power and privilege that 

shape individual and collective identities and 

experiences (Crenshaw, 1991; Parent, DeBlaere, 

& Moradi, 2013; Shields, 2008; Yarhouse & Tan, 

2005). Though a full review is beyond the scope 

of this report, research has begun to identify 

some of the ways that sexual and gender minority 

adolescents’ experiences vary by race/ethnicity 

(Corby, Hodges, & Perry, 2007; Grov, et al., 2006; 

Kosciw, et al., 2014; Ryan, et al., 2009; Ryan, et 

al., 2010), immigration status (Daley, Solomon, 

Newman, & Mishna, 2008; Ryan, et al., 2009; 

Ryan, et al., 2010), gender (Bontempo & D’Augelli, 

2002; Ryan, et al., 2009), gender expression 

(Hidalgo, Kuhns, Kwon, Mustanski, & Garofalo, 

2015; Roberts, et al., 2012; Roberts, et al., 2013; 

Toomey, Ryan, Diaz, Card, & Russell, 2010), and 

socioeconomic status (Kosciw, et al., 2009; Ryan, 

et al., 2009; Ryan, et al., 2010). Behavioral health 

professionals working with sexual and gender 

minority youth should be aware of and responsive 

to the intersecting identities held by young people 

when considering the effects of minority stress on 

mental health and wellbeing. Given the gaps in our 

understanding, more research on the experiences 

of adolescents who hold multiple marginalized 

identities is needed in order to understand both 

the unique strengths and sources resilience, as 

well as the stressors youth and their families may 

experience. 

Therapeutic Efforts with Sexual 

and Gender Minority Youth 

Introduction16 

Despite dramatic social changes in the recognition 

of same-gender relationships and families and 

transgender identities, sexual and gender minority 

children and adolescents and their families face 

misinformation, negative social attitudes and 

discrimination that can pose challenges for child 

development and family acceptance. Behavioral 

health providers may receive referrals for 

treatment that include requests to change a child 

or adolescent’s actual, perceived, or future sexual 

orientation or same-gender sexual behaviors, 

gender identity, or gender expression. Requests for 

conversion therapy most often come from a parent 

or guardian, or more rarely, a child or adolescent. 

In providing services to children, adolescents, and 

families experiencing distress related to sexual 

orientation or gender, behavioral health providers 

should consider the following as the scientific basis 

of treatment17: 

• Same-gender sexual identity, behavior, and

attraction do not constitute a mental disorder;

• Transgender identities and diverse gender

expressions do not constitute a mental disorder;

• Same-gender sexual attractions are part of

the normal spectrum of sexual orientation

and occur in the context of a variety of sexual

orientations and gender identities;

• Variations in gender identity and expression are

normal aspects of human diversity, and binary

definitions of gender may not reflect emerging

gender identities;

• Gay men, lesbians, bisexual and transgender

individuals can lead satisfying lives as well

as form stable, committed relationships and

families.

Conversion Therapy 

Lesbian, gay, and bisexual orientations are normal 

variations of human sexuality and are not mental 

health disorders; therefore, treatment seeking to 

24 ▬
	
change an individual’s sexual orientation is not 

indicated. Thus, behavioral health efforts that 

attempt to change an individual’s sexual orientation 

are inappropriate. In 2009, the APA Taskforce on 

Appropriate Therapeutic Responses to Sexual 

Orientation Change Efforts conducted a thorough 

review of peer-reviewed literature published on 

conversion therapy. The APA Taskforce concluded 

that no methodologically-sound research on adults 

undergoing conversion therapy has demonstrated its 

effectiveness in changing sexual orientation. There 

have been no studies on the effects of conversion 

therapy on children, though adults’ retrospective 

accounts of their experiences of conversion therapy 

during childhood or adolescence suggests that many 

were harmed (American Psychological Association, 

2009). No new studies have been published that 

would change the conclusions reached in the APA 

Taskforce’s 2009 review. 

Given the lack of evidence of efficacy and the 

potential risk of serious harm, every major medical, 

psychiatric, psychological, and professional mental 

health organization, including the American 

Psychological Association, the American 

Psychiatric Association, the National Association 

for Social Work, the Pan American Health 

Organization, and the American Academy of Child 

and Adolescent Psychiatry, has taken measures 

to end conversion therapy efforts to change 

sexual orientation. To the extent that children and 

adolescents experience distress related to their 

sexual orientation, treatment efforts should focus on 

identifying and ameliorating the sources of distress. 

The discussion surrounding conversion therapy 

with gender minority youth is complicated by 

the fact that though diverse gender expressions 

and transgender identities are now understood to 

be part of the normal spectrum of human gender 

(American Psychological Association, 2015a; 

Coleman, et al., 2012; Knudson, De Cuypere, 

& Bockting, 2010), there remains a related 

psychiatric diagnosis: Gender Dysphoria (formerly 

Gender Identity Disorder (American Psychiatric 

Association, 2013a). Although there is much debate 

over whether Gender Dysphoria should remain a 

psychiatric diagnosis (for example, see Bockting 

& Ehrbar (2005)), such a discussion is beyond 

the scope of this report. However, the shift from 

Gender Identity Disorder to Gender Dysphoria 

in version five of the Diagnostic and Statistical 

Manual of Mental Disorders does reflect a shift 

away from a pathological view of gender diversity 

towards a focus on the distress experienced as a 

result of the incongruence between one’s physical 

body and gender identity (American Psychiatric 

Association, 2013a; Simons, et al., 2014; Vance, 

et al., 2014). Thus, the distress remains the target 

of intervention, rather than gender identity. There 

is also scientific consensus that for many people, 

medical intervention in the form of hormone 

therapy or gender affirming surgeries may be 

medically necessary to alleviate gender dysphoria 

(American Medical Association, 2008; American 

Psychological Association, 2008; Anton, 2009; 

World Professional Association for Transgender 

Health, 2008). 

Historically, conversion therapy efforts to make 

children’s behaviors, dress, and mannerisms more 

consistent with those stereotypically expected of 

their assigned sex at birth (i.e., more stereotypically 

masculine expression for those assigned male at 

birth and more stereotypically feminine expression 

for those assigned female at birth) were the 

primary clinical approach used with children 

experiencing gender dysphoria (Vance, et al., 

2014; Zucker, 2004). Efforts to change children’s 

gender expression have been made with the goal of 

preventing a transgender identity, as well as with 

the goal of preventing a future minority sexual 

orientation. Such efforts were based on the belief 

that variations in gender identity and expression 

are pathological and that certain patterns of 

family relationships cause a transgender identity 

or minority sexual orientation; research has not 

supported these theories or interventions (American 

Psychological Association, 2009). Because there 

is scientific consensus that gender dysphoria 

in adolescence is unlikely to remit without 

medical intervention, even those who support 

gender identity change efforts with pre-pubertal 

children generally do not attempt such efforts 

with adolescents experiencing gender dysphoria 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 25
 
(Adelson & AACAP CQI, 2012; American 

Psychological Association, 2008). Alternative 

affirmative and supportive approaches to therapy 

with transgender and gender diverse children have 

been developed and are becoming increasingly 

common (Edwards-Leeper, Leibowitz, & 

Sangganjanavanich, in press; Hidalgo, et al., 2013; 

Lev, 2005; Menvielle & Tuerk, 2002; Menvielle, 

Tuerk, & Perrin, 2005). 

No research has been published in the peerreviewed literature that demonstrates the efficacy 

of conversion therapy efforts with gender minority 

youth, nor any benefits of such interventions to 

children and their families. Researchers have 

reported that these interventions are ineffective in 

decreasing the likelihood of a future same-gender 

sexual orientation or minority sexual identity 

(Zucker & Bradley, 1995). In addition to a lack of 

evidence for the efficacy of conversion therapy with 

gender minority youth, there are concerns about the 

ethics of this practice (Byne, et al., 2012; Coleman, 

et al., 2012) as well as the practice’s potential for 

harm (Minter, 2012; Wallace & Russell, 2013). 

Although no research demonstrating the harms of 

conversion therapy with gender minority youth has 

been published, the potential harms of conversion 

therapy are suggested by clinicians’ observations 

that the behavioral issues and psychological 

distress of many children and adolescents with 

gender dysphoria improves markedly when their 

gender identities and expressions are affirmed 

through social and/or medical transition (de Vries, 

Steensma, Doreleijers, & Cohen-Kettenis, 2011; 

Edwards-Leeper & Spack, 2012), as well as by the 

body of literature demonstrating the negative effects 

of both rejection and a lack of support on the health 

and well-being of gender minority youth (e.g., 

research from Kosciw, et al. (2014), Ryan, et al. 

(2010), and Travers, et al. (2012)). 

In conclusion, given the lack of evidence for 

the efficacy conversion therapy and the fact that 

conversion therapy efforts are based on a view 

of gender diversity that runs counter to scientific 

consensus, in addition to evidence that rejecting 

behaviors and a lack of support have adverse 

effects on the psychological well-being of gender 

minority youth – conversion therapy, as well as any 

therapeutic intervention with an a priori goal for a 

child’s or adolescent’s gender expression, gender 

identity, or sexual orientation, is inappropriate. 

Given the potential for harm associated with 

conversion therapy efforts, other affirmative 

behavioral health interventions are recommended 

for individual or family distress associated with 

sexual orientation and gender identity. 

Appropriate Interventions for Distress in 

Children, Adolescents, and Families18 

Behavioral health providers are in a unique position 

to provide accurate information on the development 

of sexual orientation and gender identity and 

expression; to increase family and school support; 

and to reduce family, community and social 

rejection of sexual and gender minority children and 

adolescents. The descriptions of interventions below 

provide general guidance to behavioral health 

providers working in this area. 

Client-Centered Individual Approaches 

Behavioral health providers should provide 

children, adolescents and their families with 

developmentally-appropriate multiculturallycompetent and client-centered interventions that 

emphasize acceptance, support, assessment, and 

understanding. A clear treatment goal is to identify 

sources of distress and work to reduce any distress 

experienced by children, adolescents and their 

families. 

Appropriate approaches support children and 

adolescents in identity exploration and development 

without seeking predetermined outcomes related 

to sexual orientation, sexual identity, gender 

identity, or gender expression. Such approaches 

include an awareness of the interrelatedness of 

multiple identities in individual development as 

well an understanding of cultural, ethnic, and 

religious variation in families. Specific approaches 

can include (a) providing a developmentallyinformed cognitive, emotional, mental health 

26 ▬
	
and social assessment of the child and family; 

(b) supporting children and adolescents in their

developmental processes and age-appropriate

milestones and facilitiating adaptive coping; (c)

providing developmentally-appropriate affirmative

information and education on sexual orientation,

gender identity, gender expression, sexuality, and

the identities and lives of lesbian, gay, bisexual,

transgender people and those who are questioning

their sexual orientation or gender identity (LGBTQ)

to children and adolescents, parents or guardians

and community organizations; and, (d) reducing

internalized negative attitudes toward same-gender

attractions, gender diversity, and LGBTQ identities

in children and youth and in parents or guardians

and community institutions (e.g., schools and

community social groups).

Behavioral health providers should provide 

developmentally-sensitive interventions to children 

and adolescents. Such interventions include a 

comprehensive evaluation taking into account 

appropriate developmental emotional and cognitive 

capacities, developmental milestones, and emerging 

or existing behavioral health concerns. Specific 

evaluation procedures for children and adolescents 

with persistent gender concerns have been described 

by Leibowitz and Telingator (2012). 

Behavioral health providers should not have an 

a priori goal for sexual orientation or gender 

expression, or identity outcomes. The goal of 

treatment should be the best level of psychological 

functioning not a specific orientation or identity. 

Rather, behavioral health providers should focus on 

identity development and exploration that allows the 

child or adolescent the freedom of self-discovery 

within a context of acceptance and support. 

Behavioral health providers should strive to 

incorporate multicultural awareness into their 

treatment, considering age, ethnicity and race, 

gender and gender identity, sexual orientation and 

attraction, ability and disability issues, religion and 

spirituality, generation, geographic issues and other 

notable factors. A key aim is to dispel negative 

stereotypes and to provide accurate information in 

developmentally-appropriate terms for children and 

adolescents. Identity development is multifaceted 

and may include multiple and intersecting identities, 

such as ethnic and racial and religious and spiritual 

identities. Sexual orientation, gender identity and 

expression are fluid concepts and in flux, requiring 

the consideration of generational changes and norms. 

Supporting youth in age-appropriate tasks such 

as developing positive peer relationships, positive 

parent and family relations, dating, exploring gender 

expression, sexuality, multiple identity development 

and disclosure as appropriate is a critical 

consideration. Behavioral health providers should 

take into consideration potential sources of social 

support and community resources. Client-centered 

and exploratory approaches specific to gender 

minority youth have been discussed in numerous 

publications (Edwards-Leeper, et al., in press; 

Hidalgo, et al., 2013; Lev, 2005; Menvielle & Tuerk, 

2002; Menvielle, et al., 2005; Yarhouse, 2015c). 

Behavioral health providers should describe their 

treatment plan and interventions to children, 

adolescents and their families and to ensure the 

goals of treatment as well as potential benefits 

and risks are understood. Where appropriate 

developmentally, behavioral health providers 

should obtain informed consent with all parties 

to treatment. If informed consent is not a 

developmentally appropriate option (as the child 

cannot cognitively or legally provide consent), 

behavioral health providers should explain 

treatment in a developmentally appropriate manner 

and receive assent for treatment. Interventions 

that are involuntary, especially those in inpatient 

or residential settings, are potentially harmful and 

inappropriate. In addition, interventions that attempt 

to change sexual orientation, gender identity, 

gender expression, or any other form of conversion 

therapy are also inappropriate and may cause 

harm. Informed consent cannot be provided for 

an intervention that does not have a benefit to the 

client. 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 27
 
Family Approaches 

Parental attitudes and behaviors play a significant 

role in children’s and adolescents’ adjustment and 

parents’ distress often is the cause of a referral 

for treatment (APA Task Force on Appropriate 

Therapeutic Responses to Sexual Orientation, 2009; 

Ryan et al., 2009, 2010). Family rejection, hostility, 

and violence are key predictors of negative health 

outcomes in LGBTQ children and adolescents 

(Ryan, et al., 2009; Ryan & Rees, 2012). Reducing 

parental rejection, hostility, and violence (verbal or 

physical) contributes to the mental health and safety 

of the child and adolescent (Ryan, et al., 2009; R. 

Savin-Williams, 1994; Wilbur, Ryan, & Marksamer, 

2006). 

Family therapy that provides anticipatory guidance 

to parents and guardians to increase their support 

and reduce rejection of children and adolescents 

is essential. Interventions that increase family 

and community support and understanding 

while decreasing LGBTQ-directed rejection are 

recommended for families. School and community 

interventions are also recommended to reduce 

societal-level negative attitudes, behaviors and 

policies, as well as provide accurate information 

and social support to children, adolescents, and 

families. 

A key focus of treatment should be addressing 

parental concerns regarding current or future sexual 

orientation and gender identity. Behavioral health 

providers should provide family members with 

accurate developmentally-appropriate information 

regarding minority sexual orientations and strive 

to dispel myths regarding the lives, health, and 

psychological well-being of sexual and gender 

minority individuals. 

Ryan, et al. (2010) recommended that behavioral 

health providers assess family reactions to LGBTQ 

children and adolescents, specifically the presence 

of family rejection. Further, behavioral health 

providers should attempt to modify highly rejecting 

behaviors, providing anticipatory guidance to 

families that include recommendations for support 

on the part of the family, and explaining the link 

between family rejection and negative health 

problems in children and adolescents. Behavioral 

health providers should seek ways to ameliorate 

parents’ distress about their children’s sexual 

orientation and/or gender, such as exploring 

parental attributions and values regarding minority 

sexual orientations and gender diversity. Family 

therapy may be helpful in facilitating dialogues, 

increasing acceptance and support, reducing 

rejection, and improving management of conflicts 

or misinformation that may exacerbate a child 

or adolescent’s distress (Mattison & McWhirter, 

1995; Ryan, et al., 2009; Salzburg, 2004, 2007). 

Such therapy can include family psychoeducation 

to provide accurate information and teach coping 

skills and problem-solving strategies for dealing 

more effectively with the challenges sexual and 

gender minority youth may face and the concerns 

the families and caretakers may have (Ben-Ari, 

1995; Perrin, 2002; Ryan & Diaz, 2005; Ryan & 

Futterman, 1998; Ryan, et al., 2009; Salzburg, 2004, 

2007; Yarhouse, 1998). 

When working with families of young children, 

behavioral health providers should counsel parents 

who are concerned that their children may grow 

up to be lesbian, gay, bisexual, or transgender 

to tolerate the ambiguity inherent in the limited 

scientific knowledge of development. A two-prong 

approach may be helpful: (a) provide information 

to reduce heterosexism and cisgenderism (that is, 

attitudes and actions that a heterosexual orientation 

and gender identity and expression that conform to 

stereotypical norms are preferable to a same-gender 

sexual orientation, transgender identity, or diverse 

gender expression) within the family and increase 

the family’s capacity to provide support; and (b) 

introduce information about sexual and gender 

minority issues into family discussions to increase 

the child’s own self-awareness and self-acceptance 

and to counter negative attitudes directed toward 

the self that might reduce self-esteem. For example, 

consider ways in which respect and value of all 

persons is frequently a shared goal. Even in cases 

in which family members may disagree about 

decisions each person may make, there may be 

opportunity to agree on broader principles and 

28 ▬
	
concepts that can lead to mutual understanding 

(Yarhouse, 2015b). 

Families with strong beliefs who see same-gender 

attractions or relationships and gender diversity 

as undesirable and contrary to those beliefs may 

struggle with a child’s emerging minority sexual 

orientation or gender. Ryan and Rees (2012) and 

Yarhouse (1998; Yarhouse & Tan, 2005; Maslowe 

& Yarhouse, 2015) have suggested that family 

therapy focus encouraging love of their child. This 

involves focusing on superordinate values such 

as unconditional love and changing behaviors 

to reduce rejection. The authors stress that these 

positive steps can lay a constructive foundation 

for communication and problem solving and 

reduce family discord and rejection (Yarhouse 

& Tan, 2005). Ryan, et al. (2009) and Ryan and 

Rees (2012) focus on reframing family concerns 

as a manifestation of care and love and focus on 

teaching non-rejecting ways to communicate those 

positive emotions. For example, providers can help 

the family create an atmosphere of mutual respect 

that ensures the safety of each person from being 

hurt or bullied as a natural extension of seeing 

each person as having intrinsic worth (Yarhouse, 

2015b). One of the most important messages that 

can be communicated to a young person is that 

their safety is important to the provider and to the 

family. It is helpful to set an atmosphere of mutual 

respect for one another in the home and then to see 

the value of extending that to other settings, such as 

neighborhood, school, and places of worship. Safety 

in this context is not just physical safety, but also 

emotional safety (Yarhouse, 2015b). 

Many families may feel they have to choose 

between competence (in a provider) and deeply 

held beliefs. It is ideal when a family can work 

with competent providers who also share their 

deeply held beliefs and who are affirming of sexual 

orientation and gender diversity. However, when 

such providers are not available, it is important 

for families to work with competent providers 

who will be sensitive to the family’s deeply held 

beliefs and values while offering competent, 

appropriate services for sexual and gender minority 

minors (Yarhouse, 2015b). Thus, behavioral 

health providers may wish to increase their own 

competence in working with certain communities 

with deeply held beliefs and focus on viewing these 

beliefs through the imperative of multicultural 

competence and mutual respect (Bartoli & Gillem, 

2008). This is includes understanding how to 

translate between psychology and deeply held 

beliefs rather than judging those beliefs. Certain 

language, such as acceptance, might not resonate 

with communities that have strongly held beliefs, 

whereas the concept of unconditional love might 

(Yarhouse, 2015a). 

Providing multiculturally-sensitive anticipatory 

guidance to all parents to address their unique 

personal concerns can be helpful (Ryan & 

Futterman, 1998). Behavioral health providers 

can help the parents plan in an affirmative way 

for the unique life challenges that they may face 

as parents of a sexual or gender minority child. 

Also, parents must deal with their own process of 

“coming out” and resolve fears of discrimination 

or negative social reactions if they risk disclosure 

within their communities, at work, and to other 

family members (Ryan & Rees, 2012). Further, 

behavioral health providers can address other 

stresses, such as managing life celebrations and 

transitions and coping feelings of loss, and aid 

parents in advocating for their children in school 

situations—for example, when they face bullying 

or harassment. Multiple family groups led by 

behavioral health providers might be helpful to 

counter the isolation that many parents experience 

(Menveille & Tuerk, 2002). 

School and Community Interventions 

Research has illustrated the potential that schoolbased and community interventions have for 

increasing safety and tolerance of sexual and 

gender minorities, preventing distress and negative 

mental health consequences, and increasing the 

psychological well-being and health of sexual 

minority children and adolescents (American 

Psychological Association, 2015c; D’Augelli & 

Patterson, 2001; Goodenow, et al., 2006; Harper, 

Jamil, & Wilson, 2007; Kosciw & Diaz, 2006; 

Safren & Heimberg, 1999). For instance, sexual 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 29
 
and gender minority adolescents in schools with 

support groups for LGBTQ students reported lower 

rates of suicide attempts and victimization than 

those without such groups (Goodenow, et al., 2006; 

Kosciw & Diaz, 2006; Szalacha, 2003; Toomey, et 

al., 2011). 

These support groups provided accurate affirmative 

information and social support, and the groups’ 

presence was also related to increased school 

tolerance and safety for LGB adolescents 

(Goodenow, et al., 2006; Kosciw & Diaz, 2006; 

Szalacha, 2003; Toomey, et al., 2011). School 

policies that increased staff support and positive 

school climate have been found to moderate 

suicidality and to positively affect sexual minority 

children’s and adolescents’ school achievement and 

mental health (Goodenow, et al., 2006). 

Additional Appropriate Approaches with 

Gender Minority Youth 

In addition to the appropriate therapeutic 

approaches described above – comprehensive 

evaluation, support in identity exploration and 

development without an a priori goal of any 

particular gender identity or expression, and 

facilitation of family and community support 

– social transition and medical intervention are

therapeutic approaches that are appropriate for

some gender minority youth.

Social Transition 

Social transition refers to adopting a gender 

expression, name, and pronouns consistent with 

one’s gender identity. Over the past ten years, 

the age at which individuals socially transition 

has decreased dramatically, and it has become 

increasingly common for children to present to 

specialty gender clinics having already socially 

transitioned (Cohen-Kettenis & Klink, 2015; 

Steensma & Cohen-Kettenis, 2011). There is 

less controversy around social transition with 

adolescents, for whom gender identity is typically 

more stable and desistence of gender dysphoria 

(without social transition or medical intervention) is 

less common. Gender specialists recommended that 

adolescents socially transition at or before the time 

they begin medically transitioning with hormone 

therapy, though many adolescents will socially 

transition earlier (Cohen-Kettenis & Klink, 2015). 

There is no research evidence on the benefits 

vs. risks of social transition among pre-pubertal 

children, and the impact of social transition on 

likelihood of persistence or desistence of gender 

dysphoria has not yet been studied (Adelson & 

AACAP CQI, 2012; Leibowitz & Telingator, 

2012). A divergence of expert opinion exists 

among specialists treating gender minority children 

(Adelson & AACAP CQI, 2012; Leibowitz & 

Telingator, 2012). Given the lack of data on the 

risks and benefits of social transition in childhood, 

the American Academy of Child and Adolescent 

Psychiatry suggests that concerns related to social 

transition in school environments should be 

weighed against the risks of not doing so, including 

distress, social isolation, depression, or suicide 

due to lack of social support (Adelson & AACAP 

CQI, 2012). Edwards-Leeper and Spack (2012) 

outline several factors that need to be considered 

in determining when and if a child should socially 

transition, including the child’s needs, the potential 

impact on the child’s siblings, whether it is safe 

for the child to socially transition in his or her 

community, and emphasizing to the child and 

family the possibility that the child’s gender identity 

and gender expression may change as development 

continues. 

Medical Intervention 

The appropriateness of medical interventions vary 

by the age of the child. No medical interventions 

are currently undertaken or recommended for 

children with gender dysphoria before the initial 

onset of puberty. Medical intervention has proven 

efficacious in improving the well-being of young 

adolescents with gender dysphoria both during 

and well after treatment (Cohen-Kettenis & van 

Goozen, 1997; de Vries, et al., 2011; Smith, et al., 

2001), and most adolescents who seek medical 

intervention usually have extreme forms of gender 

dysphoria beginning in childhood (Cohen-Kettenis 

& Klink, 2015). Pubertal suppression and hormone 

30 ▬
	
therapy are medical interventions used to treat 

gender dysphoria in adolescents. 

Medical intervention with gender dysphoric 

adolescents is a multi-disclipinary endeavor 

including Behavioral health providers, pediatricians, 

and often pediatric endocrinologists (Hembree 

et al., 2009; Leibowitz & Telingator, 2012). A 

comprehensive assessment, including assessment 

of the degree of an individual adolescent’s gender 

dysphoria and desire to seek gender reassignment, 

helps determine the risks and benefits of medical 

interventions (for featured examples of assessments 

with children and adolescents, see Leibowitz and 

Telingator (2012)). Importantly, not all individuals 

who experience gender incongruence or gender 

dysphoria necessarily experience a complete crossgender identity, want hormone therapy as well as 

gender affirming surgeries, or want to live as the 

other gender permanently or completely (Coleman 

et al., 2012). 

If a diagnosis of gender dysphoria is assigned and 

the adolescent desires and is eligible for treatment, 

readiness for medical treatment must be considered 

(Cohen-Kettenis & Klink, 2015). Adolescents and 

their parents or guardians must be informed about 

possibilities and limitations of pubertal suppression, 

hormone therapy, and other types of treatment, such 

as psychological interventions, in order to give full 

informed consent (Coleman et al., 2012; Vance 

et al., 2014). Taking into account developmental 

considerations when working with adolescents is 

key. Youth should realize that medical intervention 

or a complement of hormone therapy and gender 

affirming surgeries are not the only treatment option 

to solve gender dysphoria, and should realize that 

gender dysphoria may exist in many forms and 

intensities (Cohen-Kettenis, Delemarre-van de 

Waal, & Gooren, 2008). Continued mental health 

treatment should be offered when an adolescents’ 

gender incongruence requires further exploration 

and/or when other psychological, psychiatric, 

or family problems exist. Adolescents receiving 

medical intervention without these additional 

concerns may also benefit from continued 

psychological treatment (Vance et al., 2014); given 

that pubertal suppression or administration of 

hormone therapy occurs over many years during 

important developmental periods, the need for 

psychological treatment may change with time 

as new questions arise (Cohen-Kettenis & Klink, 

2015). 

Pubertal suppression using gonadotrophinreleasing hormone (GnRH) analogues prevents 

the development of unwanted secondary sex 

characteristics in a peri-pubertal adolescent, which 

are irreversible and highly distressing for some 

adolescents with gender dysphoria (Leibowitz & 

Telingator, 2012). Pubertal suppression is fully 

reversible and serves as an extended diagnostic 

period, providing additional time for gender 

exploration as well as cognitive and emotional 

development that allows adolescents to become 

psychologically and neurologically mature enough 

to make decisions regarding their gender and 

to provide informed consent years later for the 

partially irreversible treatment interventions (e.g., 

hormone therapy) without having to experience 

distressful, irreversible changes of puberty 

(Hembree et al., 2009; Edwards-Leeper & Spack, 

2012; Leibowitz & Telingator, 2012). Pubertal 

suppression also has therapeutic effects, often 

resulting in a large reduction in the distress the 

physical changes of puberty were producing (de 

Vries et al., 2011; Edwards-Leeper & Spack, 2012). 

Pubertal suppression for young adolescents 

remains controversial, with concern over whether 

adolescents are able to make far-reaching decisions 

and understand the impact of pubertal suppression 

on their lives and over the lack of robust research 

on the long-term effects of pubertal suppression on 

brain and bone development in these populations 

(Cohen-Kettenis & Klink, 2015; Leibowitz & 

Telingator, 2012). However, results of preliminary 

research on the long-term effects of pubertal 

suppression are promising (Delemarre-van de 

Waal & Cohen-Kettenis, 2006; Cohen-Kettenis, 

Schagen, et al., 2011; Staphorsius et al., 2015). 

Abstaining from treatment in adolescence comes 

with risks as well: adolescents can experience 

refusal for treatment and the progression of 

secondary sex characteristic development as 

extremely psychologically painful, and a refusal 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 31
 
of medical intervention can lead to worse 

psychological adjustment and risky behaviors 

(e.g., self-mutilation, self-medication, or suicide; 

Cohen-Kettenis & Klink, 2015; Leibowitz & 

Telingator, 2012; Vance et al., 2014). Given the 

current evidence that diagnosis can be made 

reliably in adolescence, that gender dysphoria that 

worsens with puberty rarely subsides afterwards, 

and that – with careful diagnostic procedures – 

early pubertal suppression leads to good outcomes 

with young adults, withholding GnRHa is not 

considered a neutral option (Cohen-Kettenis & 

Klink, 2015). According to the Endocrine Society 

Guidelines, pubertal suppression with GnRH 

analogues is considered a medical standard of care 

for adolescents in Tanner stage 2 or 3 of puberty, 

once appropriate mental health assessments and 

recommendations are in place (Hembree et al., 

2009). However, the importance of full informed 

consent for both adolescents and their parents or 

guardians is important and must include awareness 

and consideration of the risks and benefits involved, 

as well as an emphasis on continued exploration of 

gender identity. 

The initiation of hormone therapy (estrogen and 

testosterone blocking medication for those assigned 

male at birth and testosterone for those assigned 

female at birth) around age 16 promotes the 

development of secondary sexual characteristics 

consistent with one’s gender identity (Coleman et 

al., 2012; Hembree et al., 2009). While a minimum 

age of 16 was previously a requirement, the optimal 

time for initiation of hormone therapy is now 

determined by duration of GnRH analogue use 

(when used) and the adolescent’s psychological 

state (Cohen-Kettenis & Klink, 2015). Unlike 

GnRH analogues, which are completely reversible, 

hormone therapy is only partially reversible. 

Again, once hormone therapy is indicated and 

an adolescent has been carefully assessed for 

readiness, care must be taken to get the informed 

consent of the adolescent and his or her parents 

or guardians before hormone therapy is initiated, 

including a full understanding of the potential risks 

and benefits of hormone therapy and the impact 

of hormone therapy on future fertility and options 

related to fertility (Cohen-Kettenis & Klink, 2015; 

Edwards-Leeper & Spack, 2012; Leibowitz & 

Telingator, 2012). The support of a behavioral 

health professional during this process can aid an 

adolescent in adjusting to their changing physical 

characteristics and the response from people in 

different aspects of the adolescent’s life. 

In addition to hormone therapy, some transgender 

adolescents desire and will eventually pursue 

gender affirming surgeries. The age of legal 

consent for surgery is 18, so most surgeries are 

not performed on adolescents, though behavioral 

health providers and medical providers working 

with adolescents may need to obtain and provide 

knowledge of the surgical processes in order to 

assist in navigating the emotional issues leading up 

to gender affirming surgeries; additionally, those 

assigned female sex at birth may be considered 

for virilizing mammoplasty beginning at age 16 

(Edwards-Leeper & Spack, 2012; Leibowitz & 

Telingator, 2012). 

Future Directions for Research 

Areas of opportunity for future research, as well 

as the validity and quality of extant research are 

discussed in several sections of this report and were 

topics of conversation during the APA Consensus 

Panel Meeting in July, 2015. Methodologically 

rigorous, longitudinal, and peer reviewed research 

is vital to improving our understanding of the 

complexities of sexual orientation and gender 

identity and expression among children and 

adolescents. Several potential areas for future 

research are identified below. 

32 ▬
	
Development of sexual orientation and 

gender identity 

Little is known about the development of sexual 

orientation and gender identity in childhood and 

adolescence. Basic research on the developmental 

pathways of these fundamental issues is necessary. 

How these identities are embedded in cognitive and 

emotional development and other developmental 

processes would aid in the understanding of human 

development as well as appropriate interventions. 

Culturally-specific mitigation of distress 

relating to sexual orientation, gender 

identity, and gender expression 

More targeted research that acknowledges the 

intersections of identity, including race, ethnicity, 

faith, and class, among others, could shed light on 

positive and appropriate whole-family therapeutic 

approaches to addressing these issues. Researchers 

should evaluate these practices and integrate them 

into behavioral health care. Researchers should 

also work collaboratively with young people 

and families from faith communities to better 

understand the interplay between deeply held 

religious beliefs and the importance of ensuring the 

safety and well-being of LGBTQ young people. 

The work of the Family Acceptance Project, cited 

throughout this report, speaks to the necessity 

of an increased focus on approaches specific to 

various communities including culturally diverse 

communities and those with deeply held morals 

and values that include conversations about sexual 

orientation, gender identity, and gender expression. 

Addressing the needs of disconnected 

LGBTQ youth 

LGBTQ youth experiencing homelessness, in 

juvenile justice facilities, or otherwise in out-ofhome care may lack permanent and stable family 

connections in part because of family distress 

around issues relating to their LGBTQ identity. 

These vulnerable populations, as well as lowincome and racial and ethnic minority LGBTQ 

youth, are often neglected in research studies 

that most often recruit youth who are already 

connected to clinics or providers. This need for 

more representative sampling and better recruitment 

efforts should be addressed by future researchers 

interested in sexual orientation and gender identify 

among youth. 

Long-term Outcomes 

More research is necessary to explore the 

developmental trajectory of sexual orientation, 

gender identity, and gender expression, in addition 

to the long-term medical and behavioral health 

outcomes associated with early experiences of 

family and community distress due to sexual 

orientation and gender identity and expression. 

Other recommended areas of opportunity for longterm research topics include: 

• A nuanced exploration of the factors that may

differentiate children and adolescents who

continue to experience gender dysphoria into

adolescence and those who do not.

• Long-term outcomes from early social

transition and pubertal suppression (including

effects on brain development, sexual health

function, fertility, etc.).

• Rigorous evaluation of current practices

and protocols, including affirmative models,

structural interventions, and culturally-specific

models, among others.

• Prospective research focusing on younger

children, in partnership with pediatric clinics.

• Sources of distress among sexual and gender

minority youth, focusing on distinguishing

between internal and external factors that may

drive gender dysphoria.

• Methods of supporting positive behavioral

health for LGBTQ youth, including building

resiliency against suicidality, self-harm and

risky behaviors, depression, anxiety, substance

abuse, and other behavioral health issues.

Integration, Collaboration, and Dissemination 

Researchers and clinicians should examine and 

evaluate the best methods of integrating and 

disseminating best and promising practices for 

addressing sexual orientation and gender identity 

and expression among children and youth, and 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 33
 
how to successfully collaborate with parents and 

guardians, caregivers and providers, and community 

leaders. This could include conducting studies with 

these populations focused on knowledge, attitudes, 

and beliefs relating to efforts to change sexual 

orientation, gender identity, or gender expression. 

Finally, the behavioral health community can work 

to support community-based organizations to 

develop common ground and consensus on these 

topics and promote the health and well-being of 

youth. This could also include the development 

of treatment registries, support for sexual health 

research across the country, and the inclusion of 

LGBT-specific questions in national behavioral and 

mental health surveys. 

Based on careful review of the research and 

the consensus of clinical experts in this field, 

conversion therapy is not an appropriate therapeutic 

intervention. Consequently, efforts should be taken 

to end the practice. The Administration has issued a 

public statement supporting efforts to ban the use of 

conversion therapy for minors, stating in part: 

“When assessing the validity of conversion 

therapy, or other practices that seek to 

change an individual’s gender identity 

or sexual orientation, it is as imperative 

to seek guidance from certified medical

experts. The overwhelming scientific

evidence demonstrates that conversion 

therapy, especially when it is practiced 

on young people, is neither medically 

nor ethically appropriate and can cause 

substantial harm. 

As part of our dedication to protecting 

America’s youth, this Administration 

supports efforts to ban the use of 

conversion therapy for minors.” (Jarrett, 

2015) 

34 ▬
	
Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 35
 

PAGE INTENTIONALLY LEFT BLANK
“PFR “created something that was 

groundbreaking. It was the best piece of work 

ever created by the federal government.

Sue Thau ” 

36 ▬
	
Approaches to Ending the Use of Conversion 

Therapy 

Several approaches have been employed as 

mechanisms for eliminating the use of harmful 

practices, and encouraging positive and appropriate 

alternatives to discussing issues related to sexual 

orientation, gender identity, and gender expression 

with children and adolescents. These efforts will be 

reviewed in depth in this section: 

1. Reducing discrimination and negative social

attitudes towards LGBT identities and

individuals

• Adoption of public policies that end

discrimination

• Increasing access to health care

• Publication of affirmative, culturally

competent resources for the public on LGBT

individuals and families.

2. Dissemination of information, training and

education for behavioral health providers

• Dissemination of professional association

and federal agency documents and

resolutions related to ending conversion

therapy

• Guidelines by professional associations on

affirmative approaches to LGBTQ children

and youth as well as LGBT adults

• Inclusion of affirmative information and

treatment models in professional training

curriculum

• Continuing education on elements of ethical

codes and licensing laws relevant to these

issues.

3. Legislative, regulatory, and legal efforts

• State and federal legislation that bans sexual

orientation and gender identity change

efforts

• Federal and state regulatory actions and

additional Administration activities

• Legal action

Reducing discrimination and 

negative social attitudes towards 

LGBT identities and individuals 

Reducing the discrimination and negative 

social attitudes that many LGBTQ children 

and adolescents experience can improve health 

outcomes. As previously discussed, negative 

social attitudes are stressors that can result in poor 

mental health. Working with individuals, families, 

communities, and diverse populations to increase 

family acceptance and change cultural norms that 

are unsupportive of sexual and gender minority 

identities is one way to improve health and wellbeing overall. 

The Administration has taken significant steps 

to reduce discrimination and negative social 

attitudes towards and increase support for LGBT 

communities,19including improving access to 

health care. Among other notable signals of social 

acceptance and support, the Administration has: 

• Ended the “Don’t Ask, Don’t’ Tell” policy in

military service for lesbian, gay, and bisexual

people, and taken steps to remove barriers to

service for transgender people;

• Supported same-sex marriage and ensured that

same-sex couples and their families have full

access to federal benefits;

• Prevented employment discrimination by

federal contractors;

• Advanced policies that expand access to quality

healthcare for millions of Americans, including

LGBT Americans; and

• Supported public information campaigns, such

as the “It Gets Better” Project, which aims to

gives LGBTQ youth hope and build public

support.

Broad dissemination of supportive actions such 

as those outlined above serves to both mitigate 

negative social attitudes, and to build more 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 37
 
accepting ones. SAMHSA, in addition to partner 

organizations and professional associations, has 

developed targeted resources geared towards 

providers working with sexual and gender minority 

youth and their families.20 

Dissemination of information, 

training and education for 

behavioral health providers 

The major health associations have issued policy 

statements critical of conversion therapy including 

the World Health Organization, the American 

Medical Association, the American Academy of 

Pediatrics, the American Academy of Child and 

Adolescent Psychiatry, the American Psychological 

Association, American Counseling Association, 

American Psychoanalytic Association, and the 

National Association of Social Workers, among 

others. Other Association publications include 

professional guidelines on affirmative practices for 

this population (APA, 2011; APA 2015a). 

In addition, some professional associations, 

including the American Academy of Child and 

Adolescent Psychiatrists, American Psychiatric 

Association, and the American Psychological 

Association, have published reports and 

professional practice guidelines on appropriate 

therapeutic efforts for this population. These 

documents provide important resources for 

providers on the types of interventions that are 

appropriate for sexual and gender minority children 

and youth as well as for LGBT adults.21 

Professional mental health, medical, and social 

services organizations can require training 

that includes appropriate interventions for this 

population. For example, The American Association 

of Medical Colleges (AAMC) produced a report on 

Implementing Curricular and Institutional Climate 

Changes to Improve Health Care for Individuals 

Who are LGBT, Gender Nonconforming, or 

Born with DSD. As part of this publication, the 

association indicates that “doctors should be able to 

demonstrate an investigatory and analytic approach 

to clinical situations by [...] identifying various 

harmful practices (e.g., historical practice of using 

‘reparative’ therapy to attempt to change sexual 

orientation; withholding hormone therapy from 

transgender individuals) that perpetuate the health 

disparities for [LGBT] patients.” 

Professional health and mental health associations 

also have ethical codes (American Psychiatric 

Association, 2013; American Psychological 

Association, 2010; National Association of Social 

Workers, 2008). These codes include provisions that 

stress aspirational principles and standards for practice 

that can be applied to sexual and gender minority 

youth and LGBT individuals broadly. Many of these 

codes are integrated into state licensing laws and thus 

govern standards of professional practice. 

Experts have suggested that the use of conversion 

therapy to change the sexual orientation or gender 

identity of clients may be inconsistent with 

the aspirational principles of behavioral health 

professions. For example, conversion therapy might 

violate the principle of “Do No Harm” through 

techniques that are deleterious rather than beneficial 

to mental health. Additionally, conversion therapy 

may be inconsistent with professional standards that 

treatment be based on the best scientific knowledge 

and standards of professional competence, in its use 

of treatments that cannot be justified by established 

scientific and clinical knowledge in the field, and 

which imply that variations in sexual orientation and 

gender identity are not normative. Experts have also 

suggested that conversion therapy is inconsistent 

with principles of non-discrimination and justice that 

guarantee all clients, including sexual and gender 

minorities, equal access to the benefits of psychology 

and to equal quality of services. Finally, by denying 

the inherent worth of LGBT individuals and engaging 

in an intervention based on negative social or cultural 

attitudes, practitioners of conversion therapy could 

potentially violate principles that dictate respect for 

people’s dignity. 

38 ▬
	
Legislative, regulatory, and legal 

efforts 

Many individuals, organizations, and several 

state legislatures have taken steps to regulate 

and eliminate the practice of conversion therapy. 

Efforts to end the practice of conversion therapy 

have included legislative bans and causes of 

action alleging consumer fraud, among others. 

Future efforts may include federal regulatory 

action, advancement of legislation at the state 

and federal level, and additional activities by the 

Administration. 

As of August 2015, four states and the District of 

Columbia have passed laws banning the practice 

of conversion therapy for minors, and 21 other 

states have introduced similar legislation. All of the 

bills bar mental health providers from practicing 

conversion therapy on minors; some also include 

protections for vulnerable adults, restrictions on 

the use of state funds, and consumer protection 

provisions. 

There is currently no federal ban on conversion 

therapy. Several bills and resolutions have 

been introduced in 2015, including H.R. 2450: 

Therapeutic Fraud Prevention Act; S.Res. 184: 

Stop Harming Our Kids Resolution of 2015; HR 

3060 Stop Child Abuse in Residential Programs for 

Teens Act of 2015; and H.Con.Res. 36: Expressing 

the sense of Congress that conversion therapy, 

including efforts by mental health practitioners to 

change an individual’s sexual orientation, gender 

identity, or gender expression, is dangerous and 

harmful and should be prohibited from being 

practiced on minors. These efforts discourage 

or ban conversion therapy or require nondiscrimination in the provision of services to sexual 

and gender minority minors. 

Stakeholders have also suggested the following as 

potential federal actions to end conversion therapy: 

• Restrictions on the use of federal or state

funding for conversion therapy by federal

programs, by recipients of such funding, or

through health insurance reimbursements.

• Policies for institutions that house out-of-home

youth (such as juvenile justice and foster care

programs) that prohibit conversion therapy

efforts on minors in care. These entities are

often licensed by states or receive federal

funding.

• Clarification of existing non-discrimination

policies to extend to prohibitions on conversion

therapy

In addition to legislative and regulatory action, 

legal action has been explored as a mechanism for 

ending the use of conversion therapy. Most notably, 

a jury found in favor of a claim brought under 

New Jersey’s consumer fraud law, finding that a 

“conversion therapy” program that offered services 

purported to change people from gay to straight was 

fraudulent and unconscionable.23 

In addition, potential claims of discrimination have 

been raised under the theory that the provision 

of ineffective and potentially harmful therapy is 

due solely to an individual’s sexual orientation or 

gender identity. 

Notably, the American Bar Association also 

passed a resolution urging “all federal, state, local, 

territorial, and tribal governments to enact laws 

that prohibit state-licensed professionals from 

using conversion therapy on minors,” as well as “to 

protect minors, particularly minors in their care, 

from being subjected to conversion therapy by 

state-licensed professionals.”24 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 39
 

Guidance for Families, Providers, and Educators
 

Being a sexual or gender minority, or identifying 

as LGBTQ, does not constitute a mental disorder. 

Sexual or gender minority status, however, is 

associated with increased risk of psychosocial 

issues such as psychological distress, mistreatment, 

and discrimination. Social support, as well as a 

lack of rejection, in family, community, school, 

and health care environments has been shown 

to have great positive impacts on both the shortand long-term health and well-being of LGBTQ 

youth (see Research Overview Section 3.2). 

Beyond eliminating the practice of conversion 

therapy with sexual and gender minority minors, 

LGBTQ youth need additional support to promote 

resilience and positive development in the spite of 

the still-pervasive interpersonal, institutional, and 

societal bias and discrimination against sexual and 

gender minorities. The following portions of this 

report provide families and others working with 

LGBTQ children and adolescents with guidance 

and additional resources to help facilitate the best 

possible outcomes for these youth. The information 

in these sections is based on research findings as 

well as clinical expertise. 

Promoting Family and Community 

Acceptance and Support 

As children and adolescents increasingly experience 

and integrate LGBTQ and gender diverse identities 

during childhood and adolescence, it is critical 

to provide support to reduce risk and promote 

well-being across social institutions and systems. 

This includes families, peers, schools, religious 

institutions, health and social systems and 

community services. 

Over the past decade, the concept of 

“connectedness” has been seen by researchers and 

clinicians as an essential aspect in helping to protect 

against risk and promote wellness for individuals 

in families and communities. For LGBTQ youth, 

family, peer and community support have been 

shown to be important sources of support, and 

among these, family support and acceptance during 

adolescence were found to have the strongest 

influence on overall adjustment and well-being 

in young adulthood. Because most young people 

are nurtured through diverse family, caregiver 

and kinship systems, LGBTQ and gender diverse 

children and adolescents need support in the context 

of their families, cultures and faith communities. 

Access to accurate information about sexual 

orientation and gender identity development is 

critical for families and caregivers who often have 

limited and inaccurate information about these core 

aspects of human development. This is particularly 

important for families and caregivers who believe 

that LGBTQ identities and gender diversity may 

be at odds with or disavowed by their religious and 

cultural values and beliefs. 

In 2014, SAMHSA worked with the Family 

Acceptance Project to publish a resource guide to 

help practitioners to provide support for families 

with LGBTQ children. The Family Acceptance 

Project has developed a family support model and 

research-based resources to help diverse families, 

including conservative families, to support their 

LGBTQ children in the context of their values and 

beliefs. 

Key Points: 

• Family reactions to learning that a child is

lesbian, gay, bisexual or transgender range from

highly rejecting to highly accepting. The largest

proportion of families are ambivalent about

having an LGBTQ or gender diverse child,

and rejecting families become less rejecting

over time. Families can learn to support their

LGBTQ children – and do so more quickly

– when guidance and services are provided

in ways that resonate for them, including

education presented in the context of cultural

and deeply held values.

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 41 
• All families and caregivers need to receive

accurate information about sexual orientation

and gender identity and expression in children

and adolescents, and they need to understand

that how they respond to their LGBTQ

children matters. For example, family rejecting

behaviors during adolescence – including

attempts to change an adolescent’s sexual

orientation – have been linked with health

risks, including suicidal behavior and risk for

HIV, during young adulthood. In addition,

family supportive and accepting behaviors

during adolescence, which include supporting

a child’s gender expression, have been found

to help protect against health risks and to help

promote well-being for LGBTQ young adults.

As family rejecting and supportive behaviors

increase, so, too, does the level of health risks

and protective role of family acceptance in

promoting an LGBTQ child’s overall health and

well-being.

• Parents and families with LGBTQ and

gender diverse children need to be heard and

understood by providers, educators and others

who provide services and support for their

children and family. This means meeting

parents and families where they are, supporting

their need to express their feelings, perceptions,

hopes and concerns for their LGBTQ child

in the context of their cultural and religious

perspectives, and being sensitive to how deeply

held values shape reactions and responses to

having an LGBTQ or gender diverse child.

• Parents and caregivers who are perceived

as rejecting their LGBTQ children and who

engage in rejecting behaviors (such as trying to

change their child’s sexual orientation or gender

expression, using deeply held values and morals

to prevent or change an adolescent’s identity or

preventing them from participating in LGBTQ

support groups) are typically motivated by

trying to help their LGBTQ child “fit in,” have

a good life and be accepted by others. The

Family Acceptance Project’s research-informed

approach to providing services and care for

LGBTQ children and adolescents uses a

strengths-based framework that views families

and caregivers as potential allies in reducing 

risk, promoting well-being, and creating 

healthy futures for their LGBTQ children. The 

family’s cultural values, including deeply-held 

morals and values, are viewed as strengths. 

Research findings related to family accepting 

and rejecting behaviors are aligned with 

underlying deeply held morals and cultural 

values (such as supporting an individual’s 

dignity and self-worth) to help families 

understand that it is specific family reactions 

and communication patterns that contribute to 

both their LGBTQ child’s risk and their wellbeing. 

• Families that are struggling with having an

LGBTQ or gender diverse child don’t have

to choose between their LGBTQ child and

their culture or their morals and values.

Many parents who are struggling believe that

responding with positive reactions such as

expressing affection once they learn that a

child is LGBTQ will condone or encourage a

behavior or identity that is at odds with their

beliefs. However, expressing affection for an

LGBTQ child is a key supportive behavior that

helps protect their child against health risks and

increases connectedness. In addition, parents

that are struggling can respond with other

supportive behaviors that help increase parentchild connectedness and have been identified

in research to help protect against risk and

help promote an LGBTQ child’s well-being -

without “accepting” an identity they believe is

wrong. This includes behaviors such as talking

with their child and listening respectfully to

understand their child’s experiences; requiring

that other family members treat their child with

respect even if they disagree; ensuring their

child’s safety by standing up for their child

when others hurt, mistreat or discriminate

against their LGBTQ or gender diverse child

because of who they are. These behaviors also

reflect the key values of dignity, mercy, and

compassion.

42 ▬
	
Resources 

Family Acceptance Project: http://familyproject. 

sfsu.edu/ 

Gender Spectrum: www.genderspectrum.org 

Institute for the Study of Sexual Identity: www. 

sexualidentityinstitute.org 

PFLAG : www.pflag.org 

References 

Brill, S. A., & Pepper, R. (2008). The transgender 

child: A handbook for families and 

professionals. Berkeley, CA: Cleis Press 

Centers for Disease Control and Prevention. (2009). 

Strategic direction for the prevention of suicidal 

behavior: Promoting individual, family, and 

community connectedness to prevent suicidal 

behavior. Atlanta, GA: Retrieved from www. 

cdc.gov/ViolencePrevention/pdf/Suicide_

Strategic_Direction_Full_Version-a.pdf. 

Malpas, J. (2011). Between pink and blue: A 

multi-dimensional family approach to gender 

nonconforming children and their families. 

Family Process, 50(4), 453–470. 

Ryan, C. (2009). Supportive families, healthy 

children: Helping families with lesbian, gay, 

bisexual & transgender children. San Francisco, 

CA: Family Acceptance Project, Marian 

Wright Edelman Institute, San Francisco State 

University. 

Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, 

J. (2009). Family rejection as a predictor of

negative health outcomes in White and Latino

lesbian, gay, and bisexual young adults.

Pediatrics, 123(1), 346-352. doi: 10.1542/

peds.2007-3524

Ryan, C., Russell, S., Huebner, D., Diaz, R., & 

Sanchez, J. (2010). Family acceptance in 

adolescence and the health of LGBT young 

adults. Journal of Child and Adolescent 

Psychiatric Nursing, 23(4), 205-213. doi: 

10.1111/j.1744-6171.2010.00246.x 

Seil, K. S., Desai, M. M., & Smith, M. V. (2014). 

Sexual orientation, adult connectedness, 

substance use, and mental health outcomes 

among adolescents: Findings from the 2009 

New York City Youth Risk Behavior Survey. 

American Journal of Public Health, 104(10), 

1950-1956. 

Substance Abuse and Mental Health Services 

Administration. (2014). A practitioner’s 

resource guide: Helping families to support 

their LGBT children. (HHS Publication 

No. PEP14-LGBTKIDS). Rockville, MD: 

Substance Abuse and Mental Health Services 

Administration Retrieved from http://store. 

samhsa.gov/product/PEP14-LGBTKIDS. 

Bullying, Harassment, and Other 

School-Based Issues 

Children and adolescents spend the vast majority of 

their time in schools and other institutional settings. 

Research has shown that students with positive 

school experiences achieve healthier outcomes 

across a range of variables. Conversely, negative 

experiences in school can have a detrimental impact 

on educational attainment, in addition to numerous 

health-related outcomes. LGBTQ young people in 

schools experience disproportionately high levels of 

bullying, harassment, and discrimination. This puts 

them at higher risk of depression, anxiety, suicidal 

ideation and attempt, substance use, and other 

mental health problems, in addition to negative 

educational outcomes. Families, guardians, and 

school-based professionals can and should take 

steps to mitigate issues that arise because students 

are, or are perceived to be, LGBTQ. Safe and 

supportive school environments are an important 

factor in ensuring the health and well-being of all 

students, including LGBTQ students. 

Key points: 

• Much of the distress that LGBTQ children and

adolescents experience is not the result of their

gender non-conformity or LGBTQ identity

– in other words, it is not being LGBTQ that

causes the distress, but rather the way they are

treated for being LGBTQ that does. This can

include being bullied, harassed, or otherwise

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 43
 
mistreated, in addition to experiences with 

structural barriers such as the lack of access 

to an appropriate restroom for a transgender 

student. School-based professionals can 

help minimize mental health issues for 

LGBTQ students by taking steps to eliminate 

structural barriers and proactively working 

to create a positive school climate, which can 

include measures such as LGBTQ-inclusive 

curriculum and intervening to stop bullying 

and harassment. 

• School-based mental health professionals may

often be one of the few trusted adults with

whom young people can be open about who

they are and what barriers they are facing as a

result. Some LGBTQ young people may not be

in a position to discuss their sexual orientation

or gender identity with their families, whether

because their family has already made it clear

that such conversations are not welcome, or

because of fears of family rejection if they

come out. In addition to providing a safe and

welcoming atmosphere, school-based mental

health professionals can equip themselves with

LGBTQ-related resources, know the warning

signs for identity-based mistreatment, and be

prepared to serve as one of the primary adults

with whom LGBTQ youth can discuss these

issues.

• It is important to understand that confidentiality

is essential; students should not be outed to

their parents or to their peers, and professionals

should not assume that the name, pronouns, or

manner of dress that a student uses in school

is the same at home; often times, school may

be the only place where a young person feels

comfortable being out or expressing their

gender in a certain way. Students should be

asked how they would like to be addressed and

in which context. Safety and support should be

of paramount concern.

• Students should never be asked to change

gender non-conforming behavior as a means

of resolving issues arising in school. Beyond

the potential for increasing psychological

distress, such requests occur within the

context of a system that already frequently 

penalizes LGBTQ youth. This population 

is disproportionately disciplined in schools, 

and is over-represented in the juvenile justice 

system. While five to seven percent of youth 

are estimated to be LGBTQ, they represent 15 

percent of the juvenile justice population, and 

up to 40 percent of homeless youth. Helping 

to ensure that LGBTQ youth can be who they 

are and stay in school is a life-changing and 

potentially life-saving intervention. 

• One of the most important steps that families

and schools can take is to ensure that schools

have inclusive and supportive policies for

LGBTQ youth that are implemented effectively.

Numerous resources have been developed

(several are listed below) that walk through all

of the ways in which a school can make systemwide changes that benefit all students, including

LGBTQ students. Beyond simply being in

the best interest of LGBTQ students and their

behavioral health, Title IX of the Education

Amendments of 1972 protects transgender

and gender nonconforming students from

discrimination. Proactive adoption of inclusive

policies can prevent costly and time-consuming

efforts to remedy issues after damage has

already occurred.

Resources: 

Centers for Disease Control, Division of Adolescent 

and School Health (DASH): www.cdc.gov/ 

HealthyYouth/ 

GLSEN: www.glsen.org 

Human Rights Campaign, Welcoming Schools 

Initiative: www.welcomingschools.org 

National Center for Lesbian Rights, Youth Project: 

www.nclrights.org/our-work/youth 

National Association for School Psychologists, 

Committee on GLBTQ Issues: www.nasponline. 

org/advocacy/glb.apsx 

PFLAG : www.pflag.org 

44 ▬
	
Safe & Supportive Schools Project: http://www.apa. 

org/pi/lgbt/programs/safe-supportive/default.aspx 

References 

American Psychological Association & National 

Association of School Psychologists. (2014). 

Resolution on gender and sexual orientation 

diversity in children and adolescents in schools. 

Retrieved from http://www.nasponline. 

org/about_nasp/resolution/gender_sexual_ 

orientation_diversity.pdf 

Fisher, E., & Komosa-Hawkins, K. (Eds.). 

(2013). Creating safe and supportive learning 

environments a guide for working with lesbian, 

gay, bisexual, transgender, and questioning 

youth, and families (1 ed.). London: Routledge. 

National Association of School Psychologists. 

(2014). NASP Position statement: Safe schools 

for transgender and gender diverse students, 

from http://www.nasponline.org/about_nasp/ 

positionpapers/Transgender_PositionStatement. 

pdf 

Orr, A., Baum, J., Gill, E., Kahn, E., & Salem, 

A. (2015, August). Schools in transition: A

guide for supporting transgender students

in K-12 schools, from http://www.nclrights.

org/wp-content/uploads/2015/08/Schools-inTransition-2015.pdf

Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., 

& Russell, S. T. (2010). Gender-nonconforming 

lesbian, gay, bisexual, and transgender 

youth: School victimization and young adult 

psychosocial adjustment. Developmental 

Psychology, 46(6), 1580-1589. doi: 10.1037/ 

a0020705 

U.S. Department of Education. (2014). Questions 

and answers on Title IX and sexual violence, 

from http://www2.ed.gov/about/offices/list/ocr/ 

docs/qa-201404-title-ix.pdf 

U.S. Department of Justice. (2013). Resolution 

Agreement: Between the Arcadia Unified 

School District, the U.S. Department of 

Education, Office for Civil Rights, and the U.S. 

“ When I came out to 

my parents, they found me a 

conversion therapist who told 

me transgender people were 

sick and belonged in mental 

hospitals. He forced me to throw 

away all my girl’s clothes as part 

of my treatment, but, having 

to dress as a male sent me into 

complete despair, hopelessness, 

and depression. Thankfully, one 

of my friends recognized the 

warning signs and called social 

services, which intervened and 

got me the housing and medical 

care I needed. It is always darkest 

before the dawn, but I’m living 

proof that a smart bystander 

can save a life. ”

—Amy 

Department of Justice, Civil Rights Division, 

from http://www.justice.gov/sites/default/files/ 

crt/legacy/2013/07/26/arcadiaagree.pdf 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 45
 
Pediatric Care Considerations for 

LGBTQ Children and Adolescents 

Pediatricians are often the first health professional 

that families turn to when they need help addressing 

issues that have arisen because their child is, or is 

perceived to be, LGBTQ. Families often develop 

a longstanding, trusting relationship with their 

family pediatrician and may feel more comfortable 

discussing issues with them before reaching out 

to a behavioral health professional. They may 

rely also on them for referrals to other appropriate 

professionals. Consequently, it is important for 

pediatricians to understand appropriate therapeutic 

approaches when working with LGBTQ children 

and their families. 

In 2014, the Association of American Medical 

Colleges (AAMC) published a set of thirty 

gender, sex anatomy, and sexuality competencies 

that physicians should be able to demonstrate in 

their practices (Association of American Medical 

Colleges, 2014). Additionally, the American 

Academy of Child and Adolescent Psychiatry 

published a set of practice parameters pertaining 

to the care of LGBTQ youth that speaks to the 

importance of addressing family dynamics when 

working with families with LGBTQ youth (Adelson 

& AACAP CQI, 2012). Specifically for eligible 

transgender adolescents who meet criteria for 

gender dysphoria (GD), the World Professional 

Association of Transgender Health Standards 

of Care, 7th Edition, recommends that family 

involvement in the consent process is crucial 

for physical interventions that are prescribed by 

health professionals who are not behavioral health 

professionals. The following key principles can 

be drawn from these resources as they apply to 

pediatricians and family practice physicians when 

youth who are, or are perceived to be, LGBTQ 

present in clinical practice. 

Key points: 

• Families need accurate information about

LGBTQ identities as being normal variants

of the human experience. Specifically, this is

important in helping pediatricians respond

to family and parent questions about the 

healthiness or normality of their child’s or 

adolescent’s behavior or identity is inherently 

pathological and whether these behaviors or 

identities can or should be changed. This can 

be particularly important for transgender and 

gender nonconforming youth, who may be 

seeking medical interventions to help mitigate 

the effects of untreated gender dysphoria, 

as some parents might hold the belief that 

their youth’s gender identity is inherently 

pathological. In fact, it is the associated 

gender identity-sex anatomy discrepancy that 

characterizes gender dysphoria, and which 

is the treatable phenomena, not the gender 

identity itself. This information is readily 

available (several resources are listed below), 

and sharing it may be the most important 

way a pediatrician can support the healthy 

development of sexual and gender minority 

youth. 

• Practices should provide office climates that

allow all youth to feel comfortable disclosing

their gender identity or sexual orientation,

whether it differs from societal expectations

and cultural norms or not. Steps to do so can

include a number of things, ranging from

changing intake forms to include both gender

identity and sex assigned at birth, routinely

asking about pronoun preferences when with

youth alone, training frontline staff to use

youths’ preferred name and pronoun (and when

it is safe and appropriate to do so), to forming

partnerships with local LGBTQ organizations

and building relationships with LGBTQ

community providers to whom they can refer

youth and families to when appropriate.

• Family dynamics are particularly important to

address as they pertain to attitudes and beliefs

about gender identity and sexual orientation.

Research has shown that LGBTQ youth who

come from highly rejecting families are nearly

nine times more likely to engage in suicidal

behavior when compared to their LGBTQ

youth counterparts who come from accepting

families (Ryan, et al., 2009). Pediatricians

should be aware of the various types of

46 ▬
	
reactions from family members towards their 

child or adolescent which can range from 

subtle forms of rejection (e.g., calling their 

child’s identity a “phase”) to more overt forms 

of rejection (e.g., kicking their youth out of 

the home or physical abuse). Pediatricians 

should encourage whole-family resolutions 

of issues with which they are confronted, 

including referral to mental health professionals 

who can work with young people as well as 

for individual family members who may be 

struggling with the idea that their child or 

adolescent is or may be LGBTQ. Partnering 

with parents or family members who are 

struggling with their youths’ gender identity or 

sexual orientation may sometimes be necessary 

in order to gain family members’ trust, 

increasing adherence and reducing resistance to 

the pediatrician’s future recommendations. 

• Pediatricians should be careful not to

reinforce gender stereotypes when working

with LGBTQ and gender nonconforming

youth and their families. This can require

recognizing your own implicit biases and

working to change ingrained patterns, such

as giving certain stereotypically masculine

toys to boys and others to girls, or asking

adolescents specifically whether they have a

boyfriend or a girlfriend instead of determining

the information in a manner that does not

presuppose the gender of their romantic or

sexual interest or attraction.

• Pediatricians should be aware of the

situations when it is necessary to enlist an

interdisciplinary team of providers to address

the health of some LGBTQ youth. While some

issues may be resolved through the simple

provision of information, it may be necessary to

establish an interdisciplinary team that includes

qualified behavioral health professionals and

ongoing collaboration. For all LGBTQ youth,

recognizing and detecting signs of emotional

distress and psychiatric co-occurring diagnoses

(such as depression, anxiety, substance abuse),

requires astute screening (particularly in

the case of suicide), detection of psychiatric

conditions, and prompt referral to a behavioral

health provider. As is addressed in depth in the 

Affirmative Care section, for adolescents with 

gender dysphoria, it is important to coordinate 

the care with a qualified behavioral health 

provider and endocrinologist in determining 

eligibility and readiness for physical 

interventions such as pubertal suppression 

or cross-gender hormone therapy. In some 

situations, coordination of care with the 

behavioral health provider and surgeon may be 

necessary as well when considering surgical 

interventions for eligible adolescents with 

gender dysphoria as described in the WPATH 

standards of care (Coleman et al., 2012). 

Resources: 

American Academy of Pediatrics. (2013). Policy 

Statement: Office-based care for lesbian, gay, 

bisexual, transgender, and questioning youth. 

Pediatrics, 132(1), 198 -203 doi: 10.1542/ 

peds.2013-1282 

Makadon, H., Mayer K., Potter J., & Goldhammer, 

H. (Eds.). (2015). The Fenway Guide to

lesbian, bisexual, and transgender health (2

ed.). Philadelphia, PA: American College of

Physicians.

References: 

Adelson, S. L., & American Academy of Child and 

Adolescent Psychiatry (AACAP) Committee 

on Quality Issues (CQI). (2012). Practice 

parameter on gay, lesbian, or bisexual sexual 

orientation, gender nonconformity, and gender 

discordance in children and adolescents. 

Journal of the American Academy of Child & 

Adolescent Psychiatry, 51(9), 957-974. doi: 

10.1016/j.jaac.2012.07.004 

Association of American Medical Colleges. (2014). 

Implementing curricular and institutional 

climate changes to improve health care 

for individuals who are LGBT, gender 

nonconforming, or born with DSD., from 

https://www.aamc.org/download/414172/data/ 

lgbt.pdf 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 47
 
“ Having my family reject 

me because I’m trans broke my 

heart into more pieces than I 

could have imagined. Even more 

painful was the feeling they 

no longer loved or valued me. 

Having my Grandmother take me 

in restored my belief in love. To 

have her arms to fall into meant 

that I no longer was alone, that 

death did not seem like the only 

road to stablility, comfort, and 

joy. That perhaps I should build 

a future because I again had 

someone to help me do so and 

enjoy it with me.” —Malachi 

Coleman, E., Bockting, W., Botzer, M., CohenKettenis, P., DeCuypere, G., Feldman, J., . . . 

Zucker, K. (2012). Standards of care for the 

health of transsexual, transgender, and gender 

nonconforming people (7 ed., Vol. 13, pp. 165-

232): International Journal of Transgenderism. 

Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, 

J. (2009). Family rejection as a predictor of

negative health outcomes in White and Latino

lesbian, gay, and bisexual young adults.

Pediatrics, 123(1), 346-352. doi: 10.1542/

peds.2007-3524

Affirmative Care for Gender 

Minority Youth 

Increasingly, families, providers, and researchers 

alike are realizing that providing supportive, 

affirmative care to transgender children and 

adolescents results in better outcomes for youth. 

This positive development has resulted in a 

significant increase in the number of families and 

providers seeking accurate information about 

appropriate treatment protocols for working with 

gender minority (transgender and gender diverse) 

youth, including information about socially 

transitioning youth, and about medical interventions 

for adolescents. 

It is important to ensure that supportive behavioral 

health and medical care take an affirmative 

approach which aims to facilitate in children and 

adolescents the time and space they need to develop 

and transition in whatever way that might make 

sense for them, whenever they are ready. 

In this approach, children and adolescents are 

encouraged to actively explore their gender identity 

and gender expression at home, with peers, and 

within the context of supportive therapy. This 

approach encourages children, adolescents, and 

families to move away from the gender binary 

and accept the child’s developing gender identity 

and sexual orientation at whatever point they are 

in their own trajectory. With young children, this 

may include exploring all options related to social 

transitioning. For example, perhaps the child is 

assigned male at birth and prefers feminine clothing 

and toys but is not pushing for a female name and 

pronouns. Rather than assume the child should 

undergo a full social transition, an affirmative 

approach would allow the child to continue 

sorting out their gender identity over time. For an 

adolescent uninterested in medical interventions, 

an affirmative approach might include encouraging 

them to consider non-body altering ways of living 

in their affirmed gender and helping them explore 

the variety of ways to live in their individualized 

gender identity. 

48 ▬
	
Here are a few key points to keep in mind when 

considering a supportive and balanced approach for 

transgender and gender diverse, or gender minority, 

youth: 

• Affirmative work with gender non-conforming

young children should consider the option

of socially transitioning for each child

individually, carefully exploring the pros and

cons in a client-centered approach. The existing

research should be discussed with parents,

with acknowledgement that many gender nonconforming children do not persist to become

transgender adolescents and adults.

• Affirmative work with gender minority

adolescents involves offering puberty blocking

medication (at Tanner Stage 2-3) and crosssex medical interventions (generally offered

around the age of 16). However, the research

showing positive effects for these interventions

are based on protocols that require supportive,

gender-clarifying therapy and a psychological/

readiness evaluation. Offering these

medical interventions in the absence of an

interdisciplinary team that provides the mental

health component does not have empirical

support and carries risks (e.g., greater chance of

regret).

• While lowering the age requirement for

hormone treatment may be in the best interest

of some adolescent patients, this decision

carries risks as most adolescents prior to age

16 are still solidifying their identities and have

underdeveloped neurological and cognitive

functioning that allows for mature long-term

decision making. Mental health involvement,

most importantly a formal readiness evaluation,

is always recommended in these cases.

• Research shows that gender minority children

and adolescents are most likely to thrive when

they have the support of their parents. For this

reason, an affirmative approach should involve

parents in the process.

• Medical interventions (puberty blockers and

cross-sex hormone therapy) have been shown to

be helpful in decreasing gender dysphoria and

improving quality of life for transgender and

gender minority youth when the youth treated 

follow a specific protocol that involves two 

important steps: (1) gender exploring therapy 

with a qualified mental health provider, and 

(2) a comprehensive evaluation to determine

readiness for a medical intervention.

• Because of the potential impact that hormone

therapy may have on fertility, this topic should

be discussed at length with any adolescent

seeking medical interventions and should

occur with both their mental health and

medical providers. Parents should also be

made aware of these potential side effects.

Additionally, because many gender minority

young adolescents who are prescribed puberty

blocking medication eventually pursue

hormone treatment, the conversation about

fertility should happen prior to starting blockers

as well.

• Although many young adolescents who are

prescribed puberty blockers will eventually

pursue hormone treatment, blockers are not

intended as the first step in the physical/medical

transition process. The affirmative clientcentered approach reminds parents, youth (and

providers) that the primary purpose of the

blockers is to give the adolescent more time

to continue exploring their gender identity in

an effort to help them make the best decision

for themselves regarding initiation of other

medical interventions in the future. Adults that

are unable to or are uncomfortable with the

possibility that an adolescent on blockers could

change their mind may explicitly or inexplicitly

make an adolescent feel “stuck” in a gender

identity. 

• Affirmative care encourages providers,

patients, and families to critically examine

their own values and beliefs about gender and

the gender binary specifically. Providers and

parents are encouraged to accept a more fluid

expression of gender and allow their child

or adolescent the freedom to explore their

developing gender identity without pressure to

select one of two options.

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 49
 
• Due to the complexity that exists for most

transgender and gender diverse youth, due

to their evolving gender identity and sexual

orientation, their rapidly changing and

developing bodies and brains, along with a

rapidly shifting societal landscape around

acceptance of and treatment for transgender

and gender diverse people, an affirmative

approach recognizes the importance of

providing care within an interdisciplinary team,

wherein each provider’s input is valued and

perceived as equally critical to the care of the

individual patients served.

Resources 

TransYouth Family Allies: www.imatyfa.org/ 

Trans Youth Equality Foundation: www. 

transyouthequality.org 

PFLAG Transgender Network: http://community. 

pflag.org/transgender 

Gender Spectrum: www.genderspectrum.org 

Brill, S. A., & Pepper, R. (2008). The transgender 

child: A handbook for families and 

professionals. Berkeley, CA: Cleis Press. 

Ehrensaft, D. (2011). Gender born, gender made: 

Raising healthy gender-nonconforming children 

(1 ed.). New York: The Experiment. 

References 

Edwards-Leeper, L. (in press). Affirmative care 

of transgender and gender non-conforming 

children and adolescents. In Singh, A. A. & 

dickey, l. m. (Eds.), Affirmative Psychological

Practice with Transgender and Gender 

Nonconforming Clients. Washington, D.C.: 

American Psychological Association. 

Edwards-Leeper, L., Leibowitz, S., 

Sangganjanavanich, V.F. (in press). Affirmative 

practice with transgender and gender nonconforming youth: Expanding the model. 

Psychology of Sexual Orientation and Gender 

Diversity. 

Hidalgo et al., 2013. The gender affirmative model: 

What we know and what we aim to learn. Human 

Development, 56, 285-290. 

“During my senior year of 

high school, my English teacher 

would sit with me every day 

after school and listen as I told 

him how confused I was over 

my sexuality. He was one of the 

very few I told about being in 

conversion therapy. He told me 

that I had to listen to my heart 

and follow it, and not to try and 

force any specific outcome. He 

was the only person in my life 

at the time who gave me any 

assurance that I was going to 

make it through this.” —Mathew 

50 ▬
	
Summary and Conclusion
 

SAMHSA is committed to eliminating health 

disparities facing vulnerable communities, 

including sexual and gender minority children 

and youth. To build a healthy and supportive 

environment for all children and adolescents, 

families and providers need resources and accurate 

information to help inform healthy decision 

making. Two key strategies that can help prevent 

adverse outcomes and support healthy development 

for LGBTQ youth are: strong and positive family 

and community engagement, and appropriate and 

supportive therapeutic interventions by health and 

behavioral health care providers. 

These strategies are grounded in psychological 

research. Being a sexual or gender minority, or 

identifying as LGBTQ, is not a mental disorder. 

Variations in sexual orientation, gender identity, and 

gender expression are normal. Sexual and gender 

minority children have unique health and behavioral 

health needs, and may experience distress related to 

their sexual orientation or gender, as well as others’ 

responses to their current, future, or perceived 

sexual orientation, gender expression, or gender 

identity. In addition, gender minority youth may 

experience distress caused by the incongruence 

between their gender identity and physical body. 

The research, clinical expertise, and expert 

consensus make it clear that conversion therapy 

efforts to change a child’s or adolescent’s gender 

identity, gender expression, or sexual orientation 

are not an appropriate therapeutic intervention. 

No evidence supports the efficacy of such 

interventions to change sexual orientation or gender 

identity, and such interventions are potentially 

harmful. Appropriate therapeutic approaches to 

working with sexual and gender minority youth 

include: providing accurate information on the 

development of sexual orientation and gender 

identity and expression, increasing family and 

school support, and reducing family, community, 

and medical interventions, including pubertal 

suppression and hormone therapy, are additional 

therapeutic approaches that are appropriate for 

some gender minority youth. Careful evaluation, 

developmentally-appropriate informed consent of 

youth and their families, and a weighing of potential 

risks and benefits are vital when considering 

interventions with gender minority youth. 

Beyond ending potentially harmful practices, it is 

important to also build greater social acceptance 

of LGBTQ youth; to adopt appropriate and 

supportive therapies; and to provide targeted 

resources and accurate information for children, 

adolescents, their families, and their providers. 

Building better supportive environments and 

working to eliminate negative social attitudes will 

reduce health disparities and improve the health 

and well-being of all LGBTQ youth. 

“It is nearly impossible 

to describe walking into a 

therapist’s office after surviving 

conversion therapy. The 

problem is that we need help 

from a system we have only 

known to hurt us. Hearing that I 

would be okay and that my 

new therapist could help me 

learn to cope with the pain of 

my conversion therapy 

experience was like getting a 

second chance at life. ” and social rejection of sexual and gender minority 

children and adolescents. Social transition —Sam 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 51
 
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52 ▬
	
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Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 63
 
Appendix A: Glossary of Terms
 

Cisgender: A person whose gender identity, gender expression, and sex assigned at birth all align. 

Conversion therapy: Efforts to change an individual’s sexual orientation, gender identity, or gender 

expression through behavioral health or medical interventions. Any effort with an a priori goal of a gender 

expression that aligns with stereotypical norms, cisgender identity, and/or heterosexual orientation, identity, 

and sexual behaviors. 

Gender dysphoria: Psychological distress due to the incongruence between one’s body and gender identity. 

Gender expression: The way a person expresses their gender identity (e.g., through dress, clothing, body 

movement, etc.). Young children express their gender through choices for personal items such as toys and 

clothes, as well as hairstyle, colors, etc. 

Gender identity: A person’s internal sense of being male, female, or something else. Gender identity is 

internal, so it is not necessarily visible to others. Gender identity is also very personal, so some people may 

not identify as male or female while others may identify as both male and female. 

Gender nonconforming, gender diverse: A person whose gender expression differs from how their family, 

culture, or society expects them to behave, dress, and act. 

Intersex: Individuals with medically defined biological attributes that are not exclusively male or female; 

frequently “assigned” a gender a birth which may or may not differ from their gender identity later in life. 

Questioning: Individuals who are uncertain about their sexual orientation and/or gender identity. Also used 

as a verb to describe the process of exploring ones sexual orientation and/or gender identity. 

Sex assigned at birth: The sex designation given to an individual at birth. 

Sexual orientation: A person’s emotional, sexual, and/or relational attraction to others. Sexual orientation 

is usually classified as heterosexual, bisexual, or homosexual (lesbian and gay), and includes components 

of attraction, behavior, and identity (Laumann et al., 1994). Sexual orientation is expressed in relationship 

to others to meet basic human needs for love, attachment, and intimacy (Institute of Medicine, 2011). Thus, 

young people can be aware of their sexual orientation as feelings of attachment and connection to others 

before they become sexually active. Sexual orientation identity is how someone labels and identifies their 

sexual orientation either publicly or privately. Sexual orientation, sexual orientation identity, and sexual 

behaviors are not always congruent. 

Transgender: A person who feels that their gender identity does not match their physical body and differs 

from the gender that others observed and gave them at birth (assigned or birth gender). 

Transition: A term used to describe the process of moving from one gender to another; in adolescents and 

adults, can be characterized by medical intervention such as the use of cross-sex hormone therapy or gender 

affirming surgeries. For all people, can include social transition, which is the process of outwardly beginning 

to present as a different gender, which can include changes in name, pronouns, and appearance. 

64 ▬
	
Appendix B: Acknowledgments 

This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) 

by Abt Associates under contract number HHSS283200700008I/HHSS28342001T with SAMHSA, U.S. 

Department of Health and Human Services (HHS). David Lamont Wilson served as the Government Project 

Officer. Elliot Kennedy served as the Task Lead. 

The lead scientific writer for this report was Laura Jadwin-Cakmak, MPH with support from W. Alexander 

Orr, MPH as the Task Lead from Abt Associates. 

The Expert Consensus Panel was convened by the American Psychological Association (APA) from July 

7 – 8, 2015 in Washington, DC and funded by a grant by the Federal Agencies Project. The APA activities 

were coordinated by Clinton W. Anderson, PhD (Associate Executive Director, Public Interest Directorate, 

Director LGBT Office) and Judith Glassgold, PsyD (Associate Executive Director, Government Relations, 

Public Interest Directorate). 

The Expert Panel consisted of a panel of researchers and practitioners in child and adolescent mental health 

with a strong background in gender development, gender identity, and sexual orientation in children and 

adolescents. The panel included experts with a background in family therapy and the psychology of religion. 

Among others, the panel included: Sheri Berenbaum, PhD; Celia B. Fisher, PhD; Laura Edwards-Leeper, 

PhD; Marco A. Hidalgo, PhD; David Huebner, PhD; Colton L. Keo-Meier, PhD; Scott Leibowitz, MD; 

Robin Lin Miller, PhD; Caitlin Ryan, PhD, ACSW; Josh Wolff, PhD; and Mark A. Yarhouse, PsyD. 

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 65
 
Endnotes
 

1. The term “sexual and gender minority” is an umbrella term. “Sexual minority” refers to individuals who have a same-gender 

(i.e., gay or lesbian) or bisexual orientation. “Gender minority” refers to individuals whose gender identity differs from their 

assigned sex at birth or whose gender expression does not conform to stereotypical cultural norms. Sexual and gender minority 

populations are also referred to as lesbian, gay, bisexual, and transgender (LGBT) populations, as many (though not all) sexual 

and gender minority individuals identify as lesbian, gay, bisexual, or transgender. At times, the phrase LGBTQ - lesbian, gay,

bisexual, transgender, and questioning – is used to be inclusive of individuals who are questioning aspects of their gender or 

sexual orientation, and is particularly common when youth are the population of focus, as here.

2. Conversion therapy consists of any efforts to change an individual’s sexual orientation, gender identity, or gender expression 

through behavioral health or medical interventions. Any effort with an a priori goal of a gender expression that aligns with stereotypical norms, cisgender identity, and/or heterosexual orientation, identity, and sexual behaviors. For a full glossary of terms, 

see Appendix A. 

3. To be inclusive of transgender populations, the term “same-gender” (as opposed to “same-sex”) is used throughout this report in

order to clearly distinguish between the constructs of gender and assigned sex and to recognize that individuals generally label

their sexual orientation with regard to their gender identity as opposed to assigned sex at birth.

4. This section is based on the consensus statements developed by an expert panel convened by the American Psychological Association, July 2015. These statements are based on the best available research and scholarly material available.

5. Efforts to change an individual’s sexual orientation, gender identity, or gender expression through behavioral health or medical 

interventions. Any effort with an a priori goal of a gender expression that aligns with stereotypical norms, cisgender identity, 

and/or heterosexual orientation, identity, and sexual behaviors. For a full glossary of terms, see Appendix A. 

6. The term “sexual and gender minority” is an umbrella term. “Sexual minority” refers to individuals who have a same-gender

(i.e., homosexual) or bisexual orientation. “Gender minority” refers to individuals whose gender identity differs from their

assigned sex at birth or whose gender expression does not conform to stereotypical cultural norms. Sexual and gender minority

populations are also referred to as lesbian, gay, bisexual, and transgender (LGBT) populations, as many (though not all) sexual

and gender minority individuals identify as lesbian, gay, bisexual, or transgender. At times, the phrase LGBTQ - lesbian, gay,

bisexual, transgender, and questioning – is used to be inclusive of individuals who are questioning aspects of their gender or

sexual orientation, particularly common when youth are the population of focus.

7. To be inclusive of transgender populations, the term “same-gender” (as opposed to “same-sex”) is used throughout this report in

order to clearly distinguish between the constructs of gender and assigned sex and to recognize that individuals generally label

their sexual orientation with regard to their gender identity as opposed to assigned sex at birth.

8. Secondary sex characteristics refer to sexually dimorphic phenotypic traits that develop due to increased sex hormones in puberty. Changes due to increase in androgens includes growth of the testicles and penis, increased height, increased muscle mass,

changes in body shape and weight distribution (e.g., broadening of the shoulders and chest), growth of facial and body hair,

and enlargement of the larynx and deepening of the voice. Changes due to increase in estrogens includes breast development,

changes in body shape and weight distribution (e.g., widening of the hips and narrowing of the waist), growth of underarm and

pubic hair, and the onset of menses (Lee 1980).

9. Homosexuality per se was removed from the International Classification of Diseases and it is explicitly stated that “sexual

orientation by itself is not to be considered a disorder.” Certain homosexuality-related diagnoses remain in the ICD, although

there is some movement underway to remove them in the next edition of ICD (Cochran, S. D., Drescher, J., Kismödi, Giami,

García-Moreno, Atalla, ..., & Reed, 2014).

10. Biological sex is itself a multidimensional construct, as the chromosomal, gonadal, and anatomical indicators of biological sex

do not always align, such as in intersex individuals/individuals with disorders of sex development (Hughes et al., 2006).

11. It should be noted that what behaviors, activities, and appearances are considered feminine or masculine, as well as the expected degree of conformity to gender expressions stereotypically associated with one’s assigned sex at birth, varies by culture and

over time. The alignment of assigned sex at birth, gender identity, and gender expression has been assumed in many, but not

all, cultures and religious traditions. Historically several different cultures have recognized, accepted, and sometimes revered

diversity in gender identity and gender expression (American Psychological Association, 2015b). This includes Two Spirit

individuals within American Indian communities.

66 ▬
	
12. The diagnosis of Gender Identity Disorder was eliminated and replaced with the diagnosis of Gender Dysphoria in the Diagnostic and Statistical Manual of Mental Disorders in 2013. Though no longer the current diagnosis, almost all existing research

includes participants who were diagnosed using the earlier criteria for Gender Identity Disorder. In addition to the diagnostic 

category of Gender Dysphoria (capitalized), the term “gender dysphoria” (lowercase) is used to broadly describe the discomfort 

or distress caused by the discrepancy between a person’s gender identity and that person’s sex assigned at birth and/or primary 

or secondary sex characteristics. We will use the term “individuals with gender dysphoria” throughout the report as inclusive of 

individuals diagnosed under both current and earlier diagnostic criteria, while recognizing that future research findings focused

on individuals with Gender Dysphoria may differ from that focused on individuals previously diagnosed with Gender Identity 

Disorder.

13. There is a third trajectory, in which individuals do not experience gender dysphoria or a diverse gender expression in childhood, 

but experience the onset of gender dysphoria in adolescence or later. This trajectory is discussed in the section on Gender in 

Adolescence.

14. Scientists now understand that while sexual orientation is not malleable to external pressures to change (American Psychological Association, 2009), some individuals experience internal changes in sexual attraction and/or changes in what sexual orientation identity label they use (e.g., straight, bisexual, gay) throughout adolescence and adulthood; this concept is referred to as 

sexual fluidity (Diamond & Butterworth, 2008; Savin-Williams & Ream, 2006). For findings related to the stability of sexual

orientation identity in adolescence and young adulthood, refer to research by Ott et al. (2010). 

15. Though opportunities for sexuality- and gender-related stressors and supports also occur throughout these social systems within 

the lives of sexual and gender minority children, research in these areas has generally not included pre-pubertal children. 

16. This section is based on the statements of professional consensus developed by an expert panel convened by the American Psychological Association, July 2015 at the request of the US Substance Abuse and Mental Health Services Administration. These

statements, listed in Section 2, are based on the best available research and scholarly material available.

17. See American Psychological Association (2009, 2012, and 2015a) 

18. This section is based on reports by American Psychological Association (2012 and 2015a) and APA Task Force on Appropriate

Therapeutic Responses to Sexual Orientation (2009). 

19. For more information see White House sources Strengthening Protection against Discrimination.

20. For example, “A Practitioner’s Resource Guide: Helping Families to Support Their LGBT Children” http://store.samhsa.gov/

product/A-Practitioner-s-Resource-Guide-Helping-Families-to-Support-Their-LGBT-Children/PEP14-LGBTKIDS. Another 

helpful resources is “Helping Families Support Their Lesbian, Gay, Bisexual, and Transgender (LGBT) Children” http://nccc.

georgetown.edu/documents/LGBT_Brief.pdf.

21. See for instance, American Psychological Association (2011). Guidelines for Psychological Practice with Lesbian, Gay, and

Bisexual Clients.

22. Association of American Medical Colleges, 2014. Implementing Curricular and Institutional Climate Changes to Improve

Health Care for Individuals Who are LGBT, Gender Nonconforming, or Born with DSD. Available at https://www.aamc.org/

download/414172/data/lgbt.pdf.

23. Ferguson v. JONAH, Law Div., Hudson Cy. (Bariso, J.S.C.), HUD-L-5473-12, February 5, 2015.

24. American Bar Association, 2015. Resolution 112., available at https://www.americanbar.org/content/dam/aba/images/abanews/2015annualresolutions/112.pdf.

Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth ▬ 67
 
HHS Publication No. (SMA) 15-4928