Last July, I wrote about how Ohio's budget language — specifically Section 333.13 of HB96 — would inevitably be used to target any therapy that affirmed trans people's genders, including talk therapy. Several people responded to tell me that such a law would be unenforceable. Several therapists I interviewed in the weeks after insisted that affirming someone's identity in talk therapy doesn’t count as "gender-affirming care."

Unfortunately, they were wrong.

On March 2, Texas Attorney General Ken Paxton issued a legal opinion declaring that the state's existing ban on gender-affirming care for minors — SB 14, passed in 2023 — applies very broadly, even including underwear retailers. All mental health professionals licensed by the Texas Behavioral Health Executive Council are subject to these laws, according to Paxton: professional counselors, psychologists, marriage and family therapists, and social workers. Under his interpretation, any therapist who affirms a trans youth's gender identity is "facilitating" illegal treatment and committing child abuse. Therapists who violate the opinion risk losing their licenses, losing Medicaid funding, and facing criminal penalties. The opinion also invokes mandatory reporting requirements, meaning therapists could be legally obligated to report colleagues — and potentially parents — for supporting a child's gender identity.

The opinion doesn't just prohibit affirming care. It effectively mandates conversion therapy. Paxton's memo cites professional ethics rules requiring therapists to help clients with "stabilizing," "alleviating," or "overcoming" underlying conditions — while simultaneously declaring that affirming a child's gender identity is illegal. As Aleksandra Vaca at Transitics wrote, "Under Paxton's opinion, doing anything other than push a child to accept being their assigned sex at birth will result in providers losing their license and/or being imprisoned. This is conversion therapy, which is recognized by the United Nations as being tantamount to torture."

Paxton's opinions aren't technically legally binding. But they carry enormous weight. In 2022, he issued a similar opinion declaring parents of trans youth guilty of child abuse, which Governor Greg Abbott used to direct the Department of Family and Protective Services to investigate families across the state. That directive terrorized parents and threatened to remove children from their homes before a state court blocked it. Paxton has also leveraged SB 14 to go after physicians directly — Dallas pediatrician May Lau surrendered her medical license last year after becoming the first doctor he sued under the law. The timing of this latest opinion — released one day before the Texas Republican primary for U.S. Senate, in which Paxton is running — tells you everything about the political calculations at work.

And Texas isn't the only front. Nine days later, the Fourth Circuit Court of Appeals ruled that West Virginia can exclude gender-affirming surgery from Medicaid coverage — and in doing so, became the first federal appeals court to extend the Supreme Court's Skrmetti framework from minors to adults. The all-Republican, mostly Trump-appointed panel went further than any court before it, writing that it is constitutional for a state to restrict care in order to "encourage citizens to appreciate their sex." The ruling effectively provides a legal roadmap for outright adult care bans, arriving just weeks after Heritage Foundation president Kevin Roberts declared on a podcast that eliminating transgender adult care was the organization's next target.

Meanwhile, the Supreme Court is still deliberating Chiles v. Salazar, a case that could determine whether states can regulate conversion therapy bans at all. During oral arguments last October, the court's conservative majority appeared sympathetic to the argument that conversion therapy is protected speech under the First Amendment. A decision is expected by June. If the court rules in favor of Chiles, it could gut conversion therapy bans in more than 20 states — while states like Texas are simultaneously moving to make affirming care the thing that's illegal.

Read that again: one arm of the legal system is working to protect SOGICE (sexual orientation and gender identity change efforts) as free speech while another is criminalizing the act of using a trans kids pronouns.

The question for therapists on the ground is no longer theoretical. What do you do when the state tells you that evidence-based care and professional ethics are a crime?

When I put out a call for therapists willing to speak about what these developments mean for their practice, the responses, while few, were striking — not for their fear, but for their clarity.

Cherise Miles is a licensed professional counselor in New Braunfels, Texas. They specialize in trauma and LGBTQ+ care, and run a pay-what-you-can practice. They are, in other words, exactly the kind of provider trans Texans depend on. Their response to Paxton's opinion was unequivocal.

"I will continue to follow my code of ethics and the WPATH standards of care. It will not change how I care for my clients," Miles told me on Threads. "Some laws are unjust and should not be followed."

This is a calculated ethical position from someone who could face license revocation, loss of support and funding, or even criminal liability for continuing to do what every major medical and psychological professional association says is the standard of care.

Joel Blackstock sees the same fight from Alabama. Blackstock is a licensed clinical social work supervisor and the founder and Clinical Director of Taproot Therapy Collective in Hoover, a complex trauma-focused practice just outside Birmingham. He reached out to me directly, concerned that Alabama is running the same playbook. "When a state declares that basic, affirming talk therapy is illegal, they aren't just policing language; they are actively weaponizing the therapy room," Blackstock told me.

His framing is neurobiological, and it's worth sitting with. Trans youth, he explains, already live in a state of chronic minority stress — their nervous systems stuck in fight-or-flight because their environment is constantly signaling danger. The therapy room is for many the one place where that armor can come down. It's a space for what clinicians call co-regulation: a safe, validating professional helping a client's nervous system out of panic and into processing.

"When you legally mandate that a therapist cannot affirm a child's identity, you completely destroy that safety," Blackstock said. "You turn the therapist into an agent of the state. The child's brain immediately registers the clinic as a biological threat. The therapy not only stops working, but it actively causes trauma. You cannot treat depression or suicidality in a teenager when you are legally required to gaslight their lived reality."

For clinicians, Blackstock describes the impact as "profound moral injury." Therapists are trained to provide unconditional positive regard and safety. Being legislated into causing clinical harm to the most vulnerable patients in their caseload, he says, "completely dysregulates the clinician and accelerates massive burnout in the field."

But Blackstock, like Miles, isn't leaving.

"We stay. In Alabama, we fight this by focusing heavily on nervous system regulation," he said. "The state might try to police the exact words we use, but they cannot police the physiological safety, empathy, and somatic trauma processing we provide. We bypass the cognitive, legislated language and focus on regulating the biological hardware to keep these kids alive. It makes the job infinitely harder, but abandoning the most vulnerable patients in our state isn't an option."

There are legal arguments to be made that Paxton's opinion won't hold up. Will Francis, executive director of the Texas chapter of the National Association of Social Workers, told the Texas Tribune that mental health workers don't have to stop treating trans youth because counseling has long been considered protected speech under the First Amendment. Lambda Legal senior counsel Karen Loewy called the opinion "baseless and overreaching," adding that it goes "far beyond" what the Texas Legislature approved. Equality Texas CEO Brad Pritchett said Paxton "misrepresents the law."

But the legal arguments and the lived reality are two different things. Paxton has full enforcement power over SB 14. Even if his opinion is eventually struck down by a court, the chilling effect is immediate and intentional. Therapists who cannot afford legal risk — especially those in solo practice, those who depend on Medicaid reimbursement, those who are themselves trans — must now weigh every clinical decision against the possibility of prosecution. Some will stop seeing trans youth altogether, not because they agree with the opinion, but because they cannot afford to fight it. And with the AG going after networks like PFLAG mailing lists, these risks are more real than ever.

Unfortunately, a First Amendment argument that affirming care advocates are counting on could cut both ways. If the Supreme Court rules in Chiles v. Salazar that talk therapy is protected speech — a finding many legal observers expect — it will serve to protect conversion therapists from state bans. But whether it would equally protect affirming therapists from state mandates to practice conversion therapy is an open and deeply unsettling question. The legal landscape is one in which blue states may lose the power to ban conversion therapy while red states gain the power to require it.

For providers reading this, the practical calculus is grim but not hopeless. Blackstock's approach — focusing on somatic and neurobiological interventions that don't rely on the specific language the state is trying to police — represents one model of resistance. Miles' approach — continuing to follow professional ethics and WPATH standards regardless of what the state says — represents another. Both models, finding a balance between legal risk and moral clarity, share a common foundation: staying for the fight.

The pattern I identified in Ohio last year is now playing out across multiple states, backed by an increasingly receptive federal judiciary. Therapists who affirm their trans clients' identities are being systematically reclassified from healthcare providers into criminals, while therapists who practice conversion therapy are being reclassified from discredited religious ideologues into defenders of free speech.

Some therapists, like many other health and wellness professionals who serve queer trans patients, are definitely leaving for other states and even other countries. But many others are having necessary conversations about adapting, resisting, and staying. Providers around the US and in other nations need to start thinking about contingency plans.

How are you thinking about protecting yourself and the queer trans people you serve?