Roswell Gray, 17, has seen a lot of different therapists’ offices. They’re always some variation of black and white and gray, the muted tones matching the monotony of having to explain everything over and over again to a new person, in the hopes they’ll be the right fit.
But Gray said walking into a new office, about an hour away from their home in Sherman, felt different.
“It was really simplistic, but there was a lot of beautiful art, a lot of different colors and stuff that made me smile,” Gray said. “She had a little mini fridge with snacks and drinks. And it was just like, super welcoming and inviting.”
But beyond the fully-stocked fridge and the décor, Gray’s therapist used their pronouns and asked about their gender identity. Their previous therapist “wasn’t great in many aspects,” and they had been looking for a provider who was trans-affirming and could talk about their Mormon faith.
“I was partially nervous because a lot of people of faith aren’t as accepting as I would like them to be,” said Gray. “It was really nice to hear her talk about how she’s dealt with other clients like me, who are also queer.”
Because of the drive to the office outside of Grayson County, gas prices and the pandemic, Gray hasn’t gone to therapy as often as they’d like. And it’s been hard to navigate the past few months, they said, as gender-affirming care has been caught up in a legal back-and-forth.
Lawmakers in Texas have increasingly tried to prevent access to gender-affirming mental health and medical care for trans youth since last year. Attorney General Ken Paxton and Gov. Greg Abbott have both targeted families providing medical care to their children. In addition, a bill the Texas legislature passed last year bans trans athletes from sports in school.
Repeated exposure to negative messages on trans identity in the media and from political leaders can lead to increased “depression, anxiety, PTSD and psychological distress” for trans people, as researchers found in a study in the journal of LGBT Health earlier this year. The Trevor Project, a national LGBTQ youth crisis services, advocacy and research organization, reported back in January that 85% of transgender and nonbinary youth surveyed said their mental health was negatively impacted by hearing state lawmakers debate trans rights.
“Navigating Texas, with all the changes in laws and policies, has been really hard,” said Gray. “Especially when I would go on to social media, and everything I would would see is like, the state is banning trans youth from playing sports. So I spend less time on social media just to distance myself from all of the negative things.”
Gray and other trans youth are far from the only people feeling afraid and confused about the future of care in Texas.
As Texas leaders target gender-affirming care, psychologists’ work is caught in a legal back-and-forth
Mental health providers like Beck Munsey in North Texas are worried what statements from state leaders could mean for their work. Munsey is a clinician and educator who sees LGBTQ+ youth and adults. Part of Paxton and Abbott’s directives were that the Texas Department of Family and Protective Services, plus mandated reporters like physicians, mental health counselors like Munsey, and teachers, investigate and report families to the state.
“It is scary, because there may come a time where Texas law says that I’m not allowed to provide affirming care,” Munsey said. “And so I’ll have to make a moral decision on what I do with that.”
But clinicians and families are pushing back. Several families of trans youth, along with the Texas branch of the national advocacy organization PFLAG, filed a lawsuit to stop the state’s investigations. Doctors at UT Southwestern and Children’s Medical Center Dallas, which quietly closed its trans youth program GENECIS last winter due to political pressure and fear of lawsuits, are also currently in litigation to provide services to new patients.
Munsey said it’s affected his adult clients as well, who fear their access to care might be taken away next. It’s made finding a supportive therapist that much more important, but he knows how hard that can be in Texas.
“When I was living in Central Texas, I was one of the few support groups for transgender and gender nonconforming adults, and I had people driving 100 miles to come to group because there was no other support group in their area,” Munsey said.
A 2022 report by nonprofit advocacy organization Mental Health America ranks Texas last out of all states in terms of access to care. There are a lot of reasons for this, mostly around insurance, cost and workforce. The state did not expand Medicaid, which is the “single largest payer in the United States for behavioral health services,” according to the Medicaid and CHIP Payment and Access Commission.
Some insurance plans for adults and children don’t cover mental health service visits in Texas or are so expensive they create a barrier for those wanting to access care. Out-of-pocket costs for therapy in Dallas, for example, can vary anywhere between $80-$250 a session.
There’s also a lack of providers in the state, including providers with specialty training in treating trans youth patients. Federally, the Health Resources and Services Administration designates counties as Health Professional Shortage Areas (HPSA) when there’s a small amount of practitioners for the total population who might seek treatment. 248 out of 254 counties in Texas have been designated as HPSAs for mental health treatment.
“There are a lot of mental health counselors who have no understanding of this population,” Munsey said. “So even if they’re allies, they might not know how to actually provide affirming care. I think that’s a gap that we need to close as mental health professionals, is understanding where my ally hat ends and where my therapeutic skills actually begin.”
And this is all too common—over half of the psychologists who responded to a 2015 survey done by the American Psychological Association (APA), said they were not knowledgeable or only slightly knowledgeable in treating trans clients. But the organization is working to change that.
New guidelines in treating trans and non-binary clients focus on client experiences
That same year, in 2015, a taskforce of providers created guidelines for the APA to help fill some of those knowledge gaps, focused on clients’ needs. Anneliese Singh, a psychologist and the chief diversity officer at Tulane University, was one of the task force chairs.
“When I first became trained as a counselor, and then later as a counseling psychologist, there weren’t actually any competencies or guidelines,” Singh said. “Previous standards of care were really focused on gatekeeping and were more about how to access hormonal treatment and surgical care.”
The guidelines include information on foundational knowledge, like gender as a construct; stigma and barriers to care like discrimination and affordability; life span development for trans youth, therapeutic interventions, and recommendations for future education for practitioners.
“If you’re in your standard counseling psychology or social work program, you’re going to get a real overview of ‘hey, trans and non-binary people exist,’” Singh said. “What you’re not going to get is when misgendering happens with your patients, that furthers distress and gender trauma. You’re not going to get these things you need to do in terms of advocacy.”
These APA guidelines, and their practical application, are one way to fill in the gaps. The organization currently has a panel working on updating the guidelines, but they’re a couple years away from completion, according to Kim Mills, the senior director of communications for the APA.
Singh said in the end, training more people to treat trans clients is about saving lives.
“If trans and non-binary people can experience the support to the point where they can see that they have a future, that there’s hope for them to live, they’re going to live,” she said. “Ultimately I would love our field to keep working towards trans and non-binary liberation, a world in which they get to be absolutely free.”
Trans youth, according to a 2019 study in the journal of Pediatrics, are at higher risk for suicide than their cisgender peers. 30-50% of trans youth attempt suicide at least one time in their lives, in comparison to a little over 8% of cis youth.
Support systems mean better outcomes for trans youth as they grow up
Affirming health practitioners, supportive family and relationship structures, and access to medical interventions are all a part of improving mental health outcomes as trans youth grow up. For example, “transgender youth who were able to use their chosen name in multiple contexts reported fewer depressive symptoms and less suicidal ideation and behavior,” according to a 2019 study in the Journal of Adolescent Health.
“I also struggled with my mental health in adolescence, and I had an amazing licensed professional counselor,” Munsey said, who worked through depression and learned grounding techniques that inspired his practice now. “I want to help people like me and the struggles I knew at that age.”
While states like Texas and Alabama are attempting to stop gender-affirming care practices, providers like Singh and Munsey are creating networks of support for other trans youth in Texas.
“I think that’s another misconception that we’re only dealing with trauma, or we’re only dealing with negative thoughts,” Munsey said. “We get to celebrate with our clients, as well, and talk about hopes and joys and successes.”
Roswell Gray also wants trans youth in Texas to know they’re not alone. They are the president of their school’s Gay Straight Alliance, and started an organization in their church for queer youth of faith.
“It’s important to remember that trans people are trans not for some agenda or to make your kids turn into demons or like some crazy thing like that,” Gray said. “It’s just part of who people are. And that’s really important.”
KERA is part of the Mental Health Parity Collaborative, a group of newsrooms covering challenges and solutions to accessing mental health care in the U.S. The partners on this project include The Carter Center, The Center for Public Integrity, and newsrooms in Arizona, California, Georgia, Illinois, Pennsylvania, and Texas.