Healthcare providers are confused & angry over Nebraska’s new gender-affirming care regulations

Nebraska healthcare providers are flummoxed by a set of emergency restrictions limiting how they can provide care to trans patients.

The regulations were announced in early October by the Nebraska Department of Health and Human Services, after the passage of a state law banning anyone under the age of 19 from receiving gender-affirming surgery and restricting how and when they can receive other forms of gender-affirming care like puberty blockers and hormone therapy. 

Related: Nine-year-old trans boy sues North Carolina over gender-affirming care ban

The young boy is terrified to go through puberty in the wrong body.

The legislation required Nebraska’s chief medical officer, Timothy Tesmer – who has voiced opposition to all forms of gender-affirming care for minors – to draft guidelines regulating the use of hormone therapy and puberty blockers for trans minors. 

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The emergency regulations will remain in place while the department takes public comments on permanent guidelines. Among the new rules is a requirement that trans minors undergo 40 hours of therapy before being prescribed gender-affirming medication. That includes an “initial assessment of up to four consecutive hours” followed by a maximum of two hours per week. 

The guidelines state that “therapeutic hours must be clinically neutral and not in a gender-affirming or conversion context.” They also require doctors to determine whether “gender dysphoria is driving the patient’s distress and not other mental or physical health conditions.”

However, the idea of “neutrality” is confusing for mental health professionals, especially because the idea is not congruent with the World Professional Association of Transgender Health (WPATH) standards of care.

“The more we dove into [the new rules], especially as mental health clinicians, we realized that there are certain requirements and certain ways that this positions us in a really difficult position,” mental health practitioner Britta Tollefsrud told The Hill.

“What the Nebraska Legislature has really done and asked of us as clinicians in the last legislative session — and now especially with the emergency regulations — is to make a decision between practicing with best practices and practicing legally.”

Psychologist Camie Nitzel said the requirement that care not be provided with a gender-affirming bent is especially confusing.

“It’s unclear whether this statement is using affirming as an adjective or a ban on using the empirically supported gender affirmative model, which is a best-practice model.” She added that her practice, Kindred Psychology, where Tollefsrud also works, is interpreting the rule as “prohibiting the use of the best and the most empirically supported treatment for transgender youth that we have available to us.”

Activists and mental health professionals are also worried the confusing language could lead to an uptick in dangerous conversion therapy practices, despite rules stating therapy should not be done in a “conversion context.”

When the regulations were released, journalist Erin Reed criticized them for opening the door to “Gender Exploratory Therapy,” which she describes as a “new form of conversion therapy.”

Also worrisome to mental health care providers is the 40-hour requirement, especially coupled with only being allowed two hours of therapy per week.

Planned Parenthood North Central States’s director of gender-affirming care, Dr. Nicole Chaisson, told The Hill it could take years for some children to reach 40 hours of therapy due to the national shortage of mental health care providers. She said the requirement is “totally unnecessary” and “just a mess.”

She also emphasized that “everything we do with patients should be gender and identity affirming, even if they choose not to be on hormones. Even if I see a cisgender woman,” she added, “I should be gender affirming.”

Following public comment on a permanent set of regulations, the Nebraska DHHS plans to release a final version at the end of the month. A public hearing on the proposed permanent rules is set for November 28.