The care of children and youth presenting with gender dysphoria has recently changed from watchful waiting and psychotherapeutic exploration to primarily an affirmative medical pathway involving social transition, puberty suppression, cross-sex hormones and surgery. This shift has occurred alongside a rapid increase in referrals and has been reinforced by political and legal frameworks that strongly favor gender-affirming care (GAC) while restricting alternative therapeutic approaches. This article critically examines the influence of legislation on clinical practice for gender-distressed youth. We argue that current policies have normalized a single explanatory model for any associated issues—the minority stress framework—while discouraging or prohibiting psychotherapeutic exploration of developmental, psychological, familial, and social factors that may contribute to gender dysphoria. In many jurisdictions, such exploration is conflated with “conversion therapy,” resulting in legal risks for clinicians and a narrowing of treatment options for patients and families. Drawing on established principles of evidence-based psychotherapy, we highlight the limitations of a one-pathway model that assumes gender identity to be innate and non-explorable. We argue that ethical and effective care requires comprehensive biopsychosocial assessment and access to a plurality of therapeutic models, including cognitive-behavioral, psychodynamic, family-based, and dialectical approaches. The politicization of clinical guidelines and the expansion of conversion therapy bans risk undermining informed consent, clinical judgment, and patient autonomy. An evidence-based approach to pediatric gender dysphoria should prioritize psychotherapy as a first-line intervention and preserve space for individualized, developmentally sensitive care that allows for multiple outcomes. • The gender-affirming model often deemphasizes possible interplay between psychiatric comorbidity and gender dysphoria. • Medical interventions risk making permanent changes for transient gender distress. • Political institutions increasingly constrain pediatric gender care, interfering with best practices in psychotherapy. • Broad conversion therapy bans risk conflating exploratory psychotherapy with coercive practices. • Ethical care requires comprehensive biopsychosocial formulation and significant improvement in psychiatric comorbidities prior to irreversible interventions. • Limits on therapeutic inquiry undermine patient autonomy and informed consent.
Mason et al. (Fri,) studied this question.