What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria

Abstract

The rising incidence of trans youth throughout the world and the new policy of many European countries and 25 US states that psychotherapy should be the first therapeutic response to Gender Dysphoria have made a reexamination of a comprehensive psychiatric evaluation (CPE) urgently relevant. Two conflicting views of the purpose of the CPE exist based on etiologic beliefs and convictions about the best therapeutic approach. This paper provides one clinician’s synthesis of the elements, processes, goals, values, benchmarks of CPE and its usual recommendation for psychotherapy. The CPE recommended herein provides cogent hypotheses about the origins of the intrapsychic creation of a trans identity that are to be strengthened, weakened, or supplanted by explanations that emerge from psychotherapy. It also strengthens familial bonds and clarifies the intention to improve the mental health, social function, and autonomy of the minor. The inescapable ethical tensions that surround trans minor health care are discussed. The recommended CPE does not prevent subsequent medical interventions.

Introduction

A fundamental question is emerging within the arena of trans health care. “What is the purpose of the comprehensive psychiatric evaluation (CPE) for trans-gender identified children and adolescents?” There are two opposing answers, both of which have the same goal of improving the patients’ mental health and social function. The gender affirmative one, favored by the many desperate young patients and many providers, has been to qualify the patient for the sequence of social transition, hormones, and surgery based on patients’ desires (Coleman et al., 2022). The more recent answer, favored by many parents, anxious minors, and a growing number of mental health professionals is to clarify what is occurring to create an efficient focus for a psychotherapy (Genspect, 2023). This CPE is sometimes described as a psychodynamically informed detailed case formulation. Despite this essential disagreement, almost all clinicians agree that a CPE is the necessary first step to considering how to respond to parents and their transgender-identified offspring. Twenty-three treatment guidelines published since 1998 from 12 countries share this agreement (Taylor et al., 2024).

Relevance of the purpose of the CPE

Epidemiology

Individuals began exploring hormonal interventions to modify their secondary sex characteristics in the 1950s in relatively small numbers (Benjamin, 1966). The incidence has rapidly increased during this century among young people throughout the world. (Kaltiala et al., 2020; Zucker, 2017). This dramatic cultural shift has elicited explanations from a variety of academic disciplines. Early on, and continuing to the present, some professionals promoted a prenatal determinative explanation–“a strong biological basis” (Turban et al., 2022). There are those who justify early affirmative care including social transition, hormones and even surgery (Rafferty, 2018; Shumer et al., 2016) and those who feel it is unjustified in youth (Hruz, 2020; Malone et al., 2021). All positions in this debate have been complicated by sociopolitical passions and animus toward those who disagree (McNamara et al., 2022, Cass, 2024). Buried within the two basic views about the purpose of the CPE are differing etiological assumptions about the explosion of youth now identifying as transgender, gender diverse, and non-binary.

Policy/law changes

Changes in national and state recommendations for treating trans-identified youth have also increased the relevance of the question of the purpose of the CPE. In 2023, England announced it would be closing its centralized gender care services and young people in the future will be referred to local clinics in 2024. Unlike the Europeans, the US has always used local clinics. Sweden (SBU, 2022), Finland (COHERE, 2020), Norway (which currently intends to review its policy), England, and 25 US states have limited access to hormonal treatment and surgical treatment for minors. New directives on both continents have emphasized that the first line of treatments for patients with gender dysphoria/incongruence should be adequate trials of psychotherapy by mental health professionals (MHP) before considering medical intervention (Drobnič Radobuljac et al., 2024). Most recently, the European Society for Child and Adolescent Psychiatry and the Cass Report reached the same conclusions (Drobnič Radobuljac et al., 2024; Cass, 2024). For the last decade or more, MHPs in the US had just referred these patients for hormonal care, either believing this was the only treatment that could bring relief or fearing censure if they did not (Jenkins & Panozzo, 2024). I have been repeatedly surprised when some child-focused mental health professionals say that they do not know how to evaluate these minors.

The range of mental health professionals

In the trans arena, psychotherapy is variously referred to as psychosocial therapy, psychological therapy, supportive care, counseling, or conversion therapy. Other than commonly misunderstood concept of “conversion therapy” (D’Angelo, 2023), which denotes a direct attempt to create or recreate a cis-gender identity, I don’t mind any term for psychotherapy. MHPs are influenced by various schools of thought. They may be psychoanalysts, cognitive-behavioral therapists, behaviorists, family systems followers, social psychologists, systemic therapists, social justice therapists, or others. It is vital that a CPE reveals the patient’s individuality because interventions for those who share a diagnosis must consider the factors that make the patient unique. When an evaluation only ascertains the diagnosis of gender dysphoria, most of the patients seem to be essentially alike to the hormone provider or surgeon.

What the mental health professional can learn

In evaluating minors and their families, the MHP has much to consider besides the diagnosis of gender dysphoria. If the evaluator believes in the gender affirming purpose of the CPE, the process will focus on the patient’s readiness for gender transition. When psychotherapy is provided, it is to ensure that co-existing mental health problems are under “reasonable control.” If, however, the evaluator understands the focus of the CPE to be on identifying the predisposing, precipitating, and maintaining forces on the patient’s identity, a long list of influences will be explored. Problems such as, autism, ADHD, difficulty making friends, crises of loneliness, depression, restrictive or excess eating, sexual abuse, and feedback from virtual friends will be investigated. The MHP will explore suicidality, self-harm, pre- and post-trans-identity psychiatric problems, and relationships with each parent. The parents will provide a developmental history beginning with pregnancy. When these topics are understood, it is more difficult to then conclude co-morbidities are under “reasonable control.”

The ethical challenges

In trans youth health care, ethical tensions exist for many reasons including therapists’ or institution’s biases, unknown long-term outcomes, divergent views of what science has established, religious values, differing health care roles and political beliefs (Levine, 2021a). Ethical unease can be felt from four definable conflicts.

1. Changing the healthy anatomic and physiologic body to conform to a current form of gender identity flies in the face of a 2500-year-old principle, Above All Do No Harm (nonmalficience). This time-honored guidance remains relevant since there are many indicators that the long-term outcomes bring sterility, sexual dysfunction, reduced stable pair bonding, substance abuse, and shortened life expectancy to many (Hembree et al., 2017; Jackson et al., 2023; Newcomb et al., 2020). These facts raise the question whether short term outcomes such as, patient happiness and pleasure with bodily effects of hormones (Chen et al., 2023), are sufficient to claim that affirmative care is beneficent. Even when such patient happiness is reported, methodologic concerns need to be considered: only those who participate in the follow-up are included.

2. While endocrine and surgical treatment can enable feminization of trans-identified women and masculinization of trans-identified men, the question with any minor is, “Should this be done?” (Vrouenraets et al., 2020) The patients’ life inexperience and cognitive immaturity creates a tendency in some to say, “No!” (Latham, 2022) while others find that minors can give consent (Clark & Virani, 2021). Consent for gender affirming interventions is complicated by the presentation of its safety, effectiveness, and long-term benefits without adequate discussion of the data on its harms (Levine et al., 2022).

3. “Does the patient’s stated desire, which speaks to the principle of Respect for Patient Autonomy, take precedence over beneficence and nonmalficience” (Levine & Abbruzzese, 2023; Dierckxsens & Baron, 2023)? Beginning with the publication of WPATH’s 7^th versions of its Standards of Care (Coleman et al., 2012), many clinics and medical institutions thought they resolved all ethical questions by privileging autonomy (Lemelman & Voss, 2023).

4. Policies from medical institutions represent a commitment to advocacy, presumably based on science. There is much disagreement about what science has established. Some presume that the science is settled (Coyne et al., 2023; McNamara et al., 2022) even though numerous systematic reviews have concluded benefits for minor are far from certain (Brignardello-Peterson & Wiercioch, 2022; Thompson et al., 2022; Ludvigsson et al., 2023, Cass, 2024).

These ethical concerns historically have been minimized in four ways.

1. By disparaging the psychiatric evaluation as “gatekeeping” for over a decade (Coleman, 2012).

2. By naming the preparation for hormone therapy as “the informed consent model “(O’Connor, 2024). The name creates the illusion that legal and ethical requirements for informed consent are being met (Levine et al., 2022), even without a psychiatric evaluation. Australia has made it illegal to provide a hormone without a psychiatric evaluation conducted in a multidisciplinary setting (Parkinson, 2021).

3. By using the political mantra that minors “know who they are” and have the right to have the treatment they desire.

4. By declaring those who disagree are examples of “science denialism” which is a result of religious zeal, ignorance, and transphobia (McNamara et al., 2022).

A decree of normality

The DSM-5-TR and ICD-11 are diagnostic manuals. The diagnosis of Gender Dysphoria or Gender Incongruence does not provide only one therapeutic plan any more than a diagnosis of a mood disorder dictates how the person’s symptom complex must be handled. Those who provide hormones on a first visit, such as some Planned Parenthood clinics advertise, act as though these documents are treatment manuals. In my experience as a chart reviewer, consultant, and psychotherapist, many MHPs have uncritically accepted the dictum that no form of gender identity qualifies as a symptom of a disease. This decree did not arise from data analysis; it was proclaimed by an American Psychiatric Association (APA) Committee in 2012 and WPATH’s 7^th version of the Standards of Care (SOC) to decrease social stigma (Coleman et al., 2012). Well before this pronouncement, there was strong consistent evidence of serious preexisting mental health problems in adult cohorts (Benjamin, 1966; Dhejne et al., 2011). Since then, the preexisting problems of trans-identified youth have been repeatedly demonstrated (Elkadi et al., 2023; Kaltiala et al., 2023; Kozlowska et al., 2021; Ristori & Steensma, 2016). Ignoring the evidence that most minors and adults have significant mental health conditions, WPATH and the APA simply declared trans identities are not to be considered as indicators of any abnormality.

Nosologic paradox

The political processes and etiologic assumptions that underlie the gender diagnoses in the two nosologies are well-documented (Reed et al., 2016; Zucker, 2016). Gender diagnoses are in special sections of each manual to reduce stigma and discrimination. The disorder of Gender Dysphoria in DSM-5-TR is based on the suffering, which is labeled distress. The ICD-11 does not have this requirement. Writers of both nosologies recognized that insurance coverage necessitated a disorder category. Thus, two paradoxes: distress may or may not be a requirement to obtain insurance coverage; these gender identity states are “disorders” or “conditions” but not necessarily mental illnesses.

The mental health professional as soother of ethical unease

Once the MHP offers a letter of recommendation for hormones or surgery, these specialists do their own briefer evaluation. Based on my recurrent experiences, often by the second visit, a prescription for hormones is given or surgery is scheduled. Parents of minors sign a consent form. Historically, the purpose of the initial evaluation was to either say yes or no to affirmative care. When the answer was no, the patient often disappeared. When the answer was yes, a new unstated role of the MHP came into focus. It was to reassure the hormone prescribers and surgeons that it was ethical to proceed. Although this concept has been lost sight of in recent decades, this was explicitly known in the earlier versions of the standards of care (Levine et al., 1998). Although there are those who advocate bypassing the psychiatric evaluation entirely by providing hormones and surgery upon request (Ashley, 2023), most primary care physicians, nurse practitioners, pediatricians, endocrinologists, and surgeons desire a CPE, as WPATH version 8 recommends (Coleman et al., 2022). The MHP continues to be the soother of ethical discomfort.

The MHP’s judgment discernments

The MHP must grapple with ten questions in making a referral for hormones or surgery.

1. Does the minor meet criteria for a diagnosis of gender dysphoria or gender incongruence (F64.0) or a related one such as, gender dysphoria unspecified (F64.9)?

2. When did this symptom complex, subjectively and behaviorally, begin?

3. Is the trans identity likely to be stable?

4. What are the patient’s past and current medical and psychiatric co-morbidities?

5. Are the co-morbidities influential, consequential, or unrelated to the current gender identity?

6. How best to improve the patient’s mental health, social function, and interpersonal relationships?

7. Do the patient and parents grasp the short- and long-term risks of endocrine treatment?

8. Are the patient’s and parents’ expectations of the benefits realistic?

9. Is the patient emotionally prepared for the social challenges of medical or surgical transition?

10. Does the patient have the life experience, maturity, and cognitive capacity to provide assent?

The answers rely entirely upon the evaluator’s personal judgment. No MHP has a crystal ball to predict a minor’s gendered future and resultant social, educational, relational, or vocational successes. WPATH’s SOC suggest co-morbid psychiatric problems must be under “reasonable control” for hormonal therapy. This vague phrase is left to the evaluator’s discernment (Coleman et al., 2022). The SOC state five lofty knowledge requirements for evaluators that suggests expertise in subjects that few MHPs possess (p.S49-50). Recommendations for hormones have been offered by psychiatric nurse practitioners, social workers, marriage and family therapists, counselors, MA, PhD or PsyD psychologists, and psychiatrists, sometimes after a shockingly brief encounter. The previous decade has seen a rapid growth of gender clinics in the US. Many young MHPs are given the task of the CPE. Some clinics use a team of MHPs, some require recommendations from two institutionally unrelated MHPs, while others advertise that their care occurs within a multi-disciplinary team of MHPs, endocrinologists, and surgeons. This suggests cooperation and continuing communication. Courts are reassured by the concept of an interdisciplinary team (Parkinson, 2022). However, in many settings the hormone prescriber and the surgeon are not involved until the MPH writes a letter of recommendation. These letters are often brief (Yarbrough, 2018) and rarely address most of the discernments that underlie the recommendations. Communication is always a challenge among specialists.

Evidence of inadequate psychiatric evaluations

Five sources suggest that some trans-identified youths are being harmed by their psychiatric screening. These include: the presence of detransitioners (Littman, 2018); published rates of patients stopping their hormones (Hall et al., 2021; Boyd et al., 2022); Roberts et al., 2022); lawsuits over inadequate psychiatric evaluations of post-mastectomy patients (Ryan, 2023); patient reports of no mental health evaluation prior to hormones or surgery (Littman, 2021); concerns expressed from those who have worked in clinics for trans youths (Anderson & Edwards-Lepper, 2021; Ghorayshi, 2023). While it is not the only factor, these reflections of inadequate psychiatric evaluations have often been cited by the US legislative bodies that have limited endocrine and surgical care for minors.

The comprehensive psychiatric examination

I anticipate that others do not share my view that the goal of the CPE is to prepare the patient, parents, and the psychotherapist for what needs to be done to improve the minor’s mental health. They may dissent because they believe that affirmative care has already been proven to the best route to improving mental health. Hopefully this article will provoke more discussion of the issue.

One manifestation of disagreement centers on the existence of the “true trans patient.” This concept is often accompanied by a conviction of a biological cause. In my etiological understanding, which can also be found within the 8^th version of the SOC, transgendered identities arise from the interaction of biological, developmental, interpersonal, and cultural influences. I recurrently read in expert opinion reports that trans-identified youth have been genetically determined, are forever fixed in their identity, and are likely to be irreparably damaged by anything other than bodily transformations. They view psychotherapy as unethically withholding effective care (Rafferty, 2018). Some even posit that the fundamental distinction in the animal (human) kingdom between male and female forms is not binary (Sterling et al., 2023). A CPE done by a professional with such a belief system is likely to be brief and provide reassurance that the co-morbidities are likely to improve. Follow-up observations have not convincingly demonstrated this (Chen et al., 2023). Since we MHPs do not possess the capacities to predict who will benefit to what extent and for how long (Dierckxsens & Baron, 2023), we should not mislead the public that we know which intervention represents the “best practice.”

The structure: Sequence of the elements of the evaluation

The evaluation begins between the caller, typically a parent or young adult, and the intake worker who may not be a MHP. Depending on the proximity of the family to the facility, a plan is formulated. For out-of-town families, an intense multi-day process is outlined. For in town families, the process might be spread out over a month. For each scenario, insurance coverage and out of pocket costs are clarified. Even for emerging adults 18 and older, it is ideal to involve the parents. On occasion it may be appropriate to include some older or twin siblings in the evaluation process. The caller is informed of six likely elements of the evaluation:

1. An initial family meeting with minor present;

2. Two to three individual 60–90-minute meetings with the minor;

3. One to two similarly timed meetings with both parents without the minor;

4. Psychological testing of the minor;

5. A feedback session with the family;

6. A written report.

Values of the initial evaluation

Families have a right to understand the values underlying the evaluation process. In the initial family meeting, I clarify my professional values:

1. It is important to preserve and to strengthen parental-minor bonds.

2. It is important to define the influences and motivations for this identity.

3. Parental worries about the minor’s future are to be respected. They are likely to become the minor’s worries in the future.

4. I don’t view hesitant parents as transphobic; I think of them as trans-worried or trans-wary.

5. Minors are ultimately responsible for deciding how they present their current and future selves.

6. The family, not I, must ultimately decide how to proceed.

Goals of the CPE

These are also usually discussed in the first meeting with the entire family. My goals are to:

1. Form a trusted relationship with the family.

2. Learn about parental views/concerns about the minor’s identity and behaviors.

3. Obtain a developmental history beginning no later than the pregnancy.

4. Learn about the family’s milieu, marital relationship, and members’ interactions.

5. Ascertain the minor’s understanding of the sources of the current identity.

6. Share the relevant scientific knowledge in this arena of care.

Characteristics of the evaluator

While MHPs of all ages, sexes, genders, ideologies, and levels of experience perform these evaluations, all must realize that two evaluation processes simultaneously occur. The evaluator is working to obtain a comprehensive understanding of the family and patient. The parents and patient are assessing the evaluator’s warmth, interest, respect, intellect, availability, patience, knowledge, gender politics, and style. Many psychotherapy studies have concluded that the therapists’ personality characteristics are more powerful than ideology. It is not so much what one does, but how one does it. When trans-identified persons have looked up the MHP on social media, their impressions need to be addressed.

Benchmarks

The evaluator’s work is focused on generating cogent hypotheses about four vital questions:

1. What forces have influenced the minor to repudiate his or her expected gender identity?

2. When did these forces occur?

3. What characteristics of the other gender does the patient admire and wish to possess?

4. What is the relationship between medical and psychiatric co-morbidities and the trans-identity?

The answers fall into the categories of predisposing, precipitation, and maintaining influences. Predisposing factors may include the patient’s responses to biological factors such as, congenital anomalies, autism, learning disabilities, ADHD, speech problems, enuresis, asthma, diabetes, obesity, and early and late-onset puberty. They may also include the patient’s sensibilities about relationships with each parent and siblings as well as the impact of adversities involving sexual, physical, psychological abuse or neglect and responses to pornography on the minor’s developmental pathway (Nadrowski, 2023). Some of these may constitute precipitating influences. Cultural influences involving exposure to pro transition social media and gaming. Many patients are having intense virtual relationships, including early romantic/sexual explorations. These factors may precipitate and maintain the new identity. Other required considerations are not contained within these three categories but are relevant nonetheless: the assessment of suicidality and self-harm, estimating intelligence, recognizing interests, skills, talents, and capacities. The MHP should be able to elicit the minor’s worries about future as a trans person, discern the presence of ambivalence, and characterize familial and patient attitudes toward homosexuality. These diverse topics cannot be covered in a single one-hour interview. Parents often can provide their narrative freely without a great deal of interruption. When alone with the MHP, the young person typically needs to be asked more specific questions.

While the evaluation is to be comprehensive, the evaluator cannot fully cover every topic. Comprehensive should not be confused with complete. The CPE is the required beginning of what will be completed in psychotherapy.

Questionnaires and psychological testing

In research protocols, psychometrically valid questionnaires that yield numbers for analysis of group means and individual responses are necessary (Chen et al., 2023). The utility of such instruments is uncertain in the CPE. Other clinicians heavily rely on these tools. They are particularly useful for the parents and the patient to fill out while the evaluator is with the other person(s). We have long used adolescent versions of the MMPI and MCMI but have not found them cost effective. I now use them only on a case-by-case basis. I am inclined to have parents fill out autism questionnaires and to employ ADHD testing when this is a relevant question.

The feedback session

It is respectful to begin with the evaluator asking the group how they individually found the evaluation process. The MPH discusses the diagnostic findings related to gender dysphoria and co-morbid conditions along with the hypothesized forces that may have shaped the current identity. The family is taught about how these forces are divided into predisposing, precipitating, and maintaining factors. Each co-morbidity is given serious weight and placed on a priority list for treatment. Parents are informed that numerous studies from many parts of the world have demonstrated the high frequencies of co-morbidities. They are told that the wish that medicalization will lead to better mental health and function has not been clearly demonstrated in numerous studies (Hisle-Gorman et al., 2021; Kaltiala et al., 2020; Thompson et al., 2022) but that many gender affirming therapists disagree. I recommend prioritizing efforts to improve mental health via outpatient psychotherapy, psychotropic medication, and occasionally hospitalization prior to reconsidering hormonal treatment. Other intervention options are discussed–parent guidance, journaling by minor, watchful waiting with only a follow-up visit. While the feedback session is usually with the entire family, when significant marital dysfunction has occurred early in the minor’s life due to an affair or parental mental illness, or the minor is too depressed to listen, parents and the minor can be provided with separate sessions. Parents often want to talk without the minor.

Introducing psychotherapy

Psychotherapy should be the usual recommendation of the CPE. Parents are often relieved. Several aspects of psychotherapy are explained: absence of a predefined number of sessions; frequency of at least every two weeks in the beginning; attendance should take priority over many social opportunities. Neurodivergent minors often need more frequent parental involvement than those who are not on the autism spectrum.

While parents typically want the psychotherapy to cause their child to happily return to their expected gender role, different purposes of psychotherapy are emphasized. The family needs to be informed that psychotherapy aims to diminish psychiatric symptoms and to improve self-awareness. It facilitates the recognition of, and tolerance for, internal and interpersonal conflict, self-respect, abstract thinking, and educational and social functioning. It helps the minor to think clearly about the hoped-for benefits, recognize the already known harms, and to be able to tolerate learning about what negative outcomes other patients have had. In short, it supports autonomy (D’Angelo, 2023). The therapist is neither affirming nor critical of the internal and behavioral gender nonconformance. Parents are reminded that after the age of consent the decision will reside with their child.

The MHP attempts to help out-of-town families find a psychotherapist. In doing so, the MHP alerts the family that they should inquire about the next professional’s belief concerning the “best practice.” The in-town family, having invested so much in the initial evaluator, often prefers that he or she be the psychotherapist. This is ideal when the minor feels comfortable with the evaluator. Face to face therapy sessions is ideal, but for practical purposes these are combined with telehealth sessions.

In providing feedback the evaluator is ethically obligated to share specific relevant scientific uncertainties of the field. This applies to psychotherapy, hormonal, and surgical interventions. There are no systematic reviews of psychotherapy for gender dysphoria and, like medical and surgical interventions, no controlled studies. Psychotherapeutic treatment of adolescent’s emotional, interpersonal, and mental struggles is the most time honored and conservative body-sparing approach. There are many reports of its helpfulness, but not nearly as many as reports of the short-term helpfulness of affirmative care (D’Angelo, 2023; Midgley et al., 2021). Parents should be told that even when young people are treated with hormones, psychotherapy is often recommended (de Vries et al., 2011; 2014).

As parents everywhere report that open-minded, developmentally oriented, not immediately affirmative therapists are hard to locate, much psychotherapy occurs via telehealth. Sometimes the evaluator may be available to continue in this fashion. I urge parents to ask the future therapist if they can meet periodically for guidance when tensions around gender identity or other issues arise in the family, as they inevitably do.

How the CPE relates to subsequent psychotherapy

The evaluation provides the therapist and the family with cogent hypotheses about the influences on the minor’s intrapsychic construction of a trans identity. These are further explored—strengthened, weakened, or supplanted by emerging hypotheses. These hypotheses point to the meanings of events, incompletely processed arrays of affect from past processes, and creative defensive responses to minimize emotional pain (Acheson & Papadima, 2023). The therapist is a nondidactic teacher about such life processes, who gains skills with each patient. The parents and the patient often have withheld information about some of the adversities that have occurred before and during the minor’s lifetime. They may not have had enough time with the evaluator, felt these events were irrelevant, or were simply too embarrassed. Much emerges in the parent guidance sessions. This provides an argument not to have a different therapist for the patient and the parents. Of course, there are reasons for providing separate therapists. If one therapist is employed, everyone must understand the necessity of boundaries and honesty about the occurrence of these meetings. Some youth object to sharing the therapist, others like the idea and may want to join in the parent guidance session to talk about an issue. Parents and two therapists need to recognize that promised frequent communication between the minor’s and the parents’ therapists is easier promised than realized. When I refer to another professional, I request that the family keep in touch with me every six months for a year or more. I am happy to see them again if they so desire.

The letter

A written report may not be necessary when the MHP continues as the psychotherapist. It is necessary when the family is referred to another professional. This report not only saves the psychotherapist much time and the family much money, but it also enables the next MHP to quickly understand the meaning of what the patient says and how it relates to his past. My reports generally run about seven double spaced pages. I include psychometric findings. This letter can be updated if the patient ultimately wants one sent to the hormonal provider. It is fair to charge for the time spent writing the letter.

Other outcomes of the CPE

The processes of the evaluation are often powerfully illuminating for everyone. The family may not follow the recommendation for any number of reasons. They are skeptical of the effectiveness psychotherapy, of they do not perceive their child to be as impaired as the MHP perceives, they lack the ability to pay, the minor’s desire for fast transition is relentless, or there are more pressing demands on the family’s time, finances, and obligations. Some families respond to the CPE by making changes in how they function. Others who did not initially believe in gender transition eventually decide to support it. We do the best to understand the family and the patient in the short time we have. We should not be arrogant about knowing what is best for them, even though they may harbor the illusion that we do.

Limitations

Based on the Evidence-Based-Medicine hierarchy, these ideas constitute only an Expert Opinion, which is the lowest level of likelihood of correctness (Zimmerman, 2013). My concepts about CPEs are based on my experience with trans-identified adults and with many trans-identified youths and their parents (Levine, 2021a, 2021b). My experience provides no guarantee that these ideas will be applicable to every country, every setting, every interested professional, or will provide what every family desires. Many of the trans youth that I see appear to be seriously functionally impaired. I cannot know whether this represents a referral bias of those who have not prospered under the care of others, whether it reflects my heightened sensitivity to psychopathologies, or whether my findings are typical of referred trans youth everywhere. One article cannot ever be anything more than a starting point for further analysis, guideline development, and policy concerning the required structure of a CPE (Lo, 2023).

Final thoughts

The treatment of gender dysphoria is a politically passionate arena that should, and usually does, make all concerned ethically uneasy. I have offered explicit ideas about the elements and processes of the CPE, which I perceive, despite the rhetoric, has not been the universal standard of practice. Others, of course, have previously provided a CPE before making recommendations for hormones. The glaring unanswered question in trans youth health care arena concerns the long-term adult fates of these hormonally and surgically treated youth. Both clinical experience and scientific findings have influenced at least three European nations who were earlier adapters of affirmative care and 25 American states to now promote psychotherapy as “best practice” for these young people. Today, when negative outcomes ensue (Littman et al., 2024), no one can definitively discern whether they were the inherent consequences of having a sex/gender incongruence, arose from the preceding mental health problems (Elkadi et al., 2023), or were brought about by minority stress (Lefevor et al., 2019).

The responsibilities of the evaluators are great. Their recommendations should educate the subsequent professionals about the patient’s strengths and limitations, particularly to the patient’s mental health challenges. The letter should leave no doubt that a respect worthy evaluation had taken place. It should facilitate the subsequent psychotherapist-patient alliance. The psychotherapeutic process, which is far greater challenge to describe than the CPE, ideally can facilitate the minors’ maturation, improve their emotional regulation, enhance their social and educational participation, attenuate symptoms, and enable them to think clearly about the benefits/harms ratio of social transition, hormonal, and surgical care.

The CPE is not a substitute for the recommended psychotherapy. It is a first step that allows the family to appreciate the developmental and future significance of gender change for each member of the family (Marchiano et al., 2021). It is intimately connected to ethical principles and the obligation for scientific honesty (D’Angelo, 2023). It becomes apparent that parents, even those who seem supportive of gender transition, are often in conflict internally and with each other over how to proceed. Parents are influenced by their intuitive fears for the future. They almost always seem far more ambivalent than their children. Even the initial certainty of the adolescent, however, hides ambivalence, an observation that more clearly emerges during psychotherapy and explains the importance of psychotherapy. There is no reason to think that trans minors are different from other humans who experience ambivalence about most aspects of their lives. It is far more useful to discuss one’s fears and ambivalence before affirmative care than to regret one’s decisions after it has ensued.

Acknowledgement

The author thanks Zhenya Abbruzzese for her invaluable assistance in reviewing this paper. She made many instructive comments to earlier drafts. To the extent that this paper is of value to inexperienced, already involved clinicians, and policy makers, she must be given a great deal of credit.

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No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

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