If I'm a Texas-licensed psychologist, counselor, social worker, or marriage and family therapist, am I covered by SB 14's restrictions on gender-transition care for minors — even though I can't perform surgeries or write prescriptions?

Plain-English summary

Senate Bill 14 (passed in 2023, codified primarily in Subchapter Y of Chapter 161 of the Health and Safety Code) bans certain medical procedures and treatments — including gender-transition surgeries and puberty-blocking, testosterone, and estrogen prescriptions — for minors in Texas, and bars public funding for any "health care provider" that provides or facilitates them.

The Texas Behavioral Health Executive Council (which licenses psychologists, licensed professional counselors, licensed marriage and family therapists, and social workers) asked the Attorney General to clarify: are our licensees covered by SB 14, given that they can't perform surgeries or write prescriptions in the first place?

Attorney General Paxton answered yes on both counts:

1. Mental health professionals are "health care providers" under § 161.701(2) — the statute's definition is broad ("a person other than a physician who is licensed... to provide or render health care"), and "health care" plainly includes mental health care. The Council's argument that mental health professionals shouldn't be covered because the prohibited procedures fall outside their scope of practice was rejected.

2. A licensee who "facilitates" a prohibited procedure can lose access to public funds and may face discipline. Section 161.704 prohibits public money from going "directly or indirectly" to a health care provider who provides or facilitates a prohibited procedure. The opinion treats writing assessments, recommendation letters, or pre-procedure mental health evaluations supporting a minor's gender-transition care as "facilitation."

The opinion also notes that mental-health professionals are "professionals" under Tex. Fam. Code § 261.101 with mandated-reporter status — meaning they may have a duty to report what the AG characterizes as child abuse. Failure to report is itself an offense, and a criminal conviction can trigger license revocation.

What this means for you

If you're a licensed Texas psychologist, counselor, MFT, or social worker

This opinion treats your license as bringing you within SB 14's "health care provider" definition. Practical implications:

On clinical work with minors who are exploring gender identity: You can still see minors and discuss gender. The statute does not ban clinical conversation, supportive psychotherapy, or general assessment. What it bans (and what facilitates it) is concrete: pre-procedure assessments, letters supporting hormone therapy or surgery, treatment plans recommending puberty suppression, and similar work product that "helps bring about" a § 161.702-prohibited procedure.

On public funding: If your practice receives any public funds — Medicaid, CHIP, state contracts, county mental health funding, school-district mental health contracts, state-grant-funded clinics — you cannot use them on facilitation activities. Section 161.704 reaches "directly or indirectly," so structuring around it is risky. Documentation that public-funded time was used for unrelated, lawful clinical work is essential.

On license risk: The Council can discipline you under the existing professional-conduct rules cited in the opinion (e.g., 22 Tex. Admin. Code §§ 465.13, 781.301, 681.41, 801.42). And the opinion warns that a criminal conviction tied to facilitation-as-child-abuse would trigger automatic-discipline analysis under Tex. Occ. Code § 53.021.

On mandated reporting: The opinion takes the position that gender-transition treatment of a minor "could be" child abuse and that mental health professionals have a Tex. Fam. Code § 261.101(b) duty to report when they have "reasonable cause" to believe abuse occurred — including failure to stop another professional or parent. Note: this is hotly contested and the subject of pending Texas Supreme Court cases (Abbott v. Doe, Muth v. Voe). The legal landscape may shift.

Concrete action items:
1. Review your active client roster for minors receiving gender-transition care or being assessed for it.
2. Talk to your licensing-defense attorney about how to handle in-progress assessments without facilitating a § 161.702-prohibited procedure.
3. If you accept public money in any form, audit your billing to ensure no public funds touch facilitation work.
4. Document the clinical scope of work for minors clearly in records.

If you run a clinic, hospital, or counseling group that employs licensees

Compliance reach-through. Even if no individual at your organization performs surgeries or writes prescriptions, your organization may be a "health care provider" under § 161.701(2), and:

• You cannot receive public funds — directly or indirectly — for any work that "facilitates" a § 161.702 procedure.
• Cross-referrals, intake assessments, mental-health letters used elsewhere as gating documents, and similar work product all carry compliance risk.
• The AG has enforcement authority under § 161.706(a). Civil penalties and injunctive relief are available remedies.

Build a written policy. Train clinicians. Audit billing.

If you're a parent of a transgender minor in Texas

This opinion does not change SB 14 itself; it interprets how SB 14 applies to mental health professionals. But it tightens the practical landscape:

• Some mental health professionals may decline to provide gender-affirming assessments or letters of support to avoid the regulatory and discipline risk this opinion describes.
• Mental health professionals may be more likely to interpret their § 261.101(b) duty as requiring a report to DFPS if they learn of gender-transition care. The opinion explicitly invites that reading.
• Pending Texas Supreme Court cases (Abbott v. Doe, Muth v. Voe) and federal litigation (including Skrmetti, decided 2025) may shift the landscape further. Speak with a family-law or civil-rights attorney experienced in this area before making decisions based on this opinion alone.

If you're a state agency or local government making mental-health grants or contracts

Section 161.704's bar on public money is broad. Before disbursing funds:

• Assess whether the funded work could include "facilitation" of a § 161.702 procedure for any minor.
• Build attestation and clawback language into grant agreements.
• Consider periodic audits of funded providers for billing patterns that could include facilitation.

If you're a healthcare attorney advising a Texas mental-health professional

Two distinct risk vectors:

1. Public-funding exposure under § 161.704 — civil enforcement by AG, potentially clawback of public funds.
2. License-discipline exposure under the Council's existing scope-of-practice rules and Tex. Occ. Code § 53.021 (criminal-conviction discipline).

Note that the opinion also relies on the Loe and Skrmetti decisions to characterize gender-transition treatment for minors as scientifically unsupported. Plaintiffs and licensees challenging an enforcement action may dispute that framing as a matter of evidence, but as a matter of state-law interpretation the AG's reading of § 161.701(2) and § 161.704 is now on record.

The opinion expressly declined to address the First Amendment implications (citing pending Chiles v. Salazar before the U.S. Supreme Court) and the Texas Supreme Court appeals in Abbott v. Doe and Muth v. Voe.

Common questions

Q: I'm a licensed counselor — does SB 14 apply to me even though I can't write prescriptions?
A: According to this AG opinion, yes. The statute's definition of "health care provider" is "a person other than a physician who is licensed... to provide or render health care," and the AG concluded mental health professionals are clearly licensed to provide health care (specifically mental health care). The fact that you can't perform the prohibited procedures doesn't take you out of the "health care provider" category — it just means the way you can violate SB 14 is through "facilitation," not direct provision.

Q: What counts as "facilitation"?
A: The statute uses the word "facilitate" without defining it, and the opinion turns to the dictionary definition: "to make easier" or "to help bring about." The opinion specifically cites mental health professionals who write letters supporting hormone therapy or surgery, who conduct pre-procedure assessments, and whose recommendations "initiate" the prohibited procedures. Whether more general supportive psychotherapy counts is not explicitly addressed; the safer reading is that work product that has the effect of unlocking a § 161.702 procedure is risky.

Q: Does this AG opinion ban me from seeing transgender minor clients?
A: No. AG opinions are not legislation. The opinion does not prohibit clinical interactions; it interprets two consequences for licensees: (1) ineligibility for public funding when "facilitating" a prohibited procedure (§ 161.704), and (2) potential professional discipline through existing standards-of-practice rules. General clinical work — listening, assessing, supporting — is not banned by the underlying statute or this opinion. Specific clinical advice still requires consultation with your licensing-defense attorney.

Q: I'm a school counselor or social worker. Does this affect me?
A: Yes, in two ways. First, school districts that contract with you or employ you typically use public funds, so § 161.704 applies. Second, the AG's framing that gender-transition care of a minor "could be" child abuse points toward a mandated-report duty under Tex. Fam. Code § 261.101(b). The pending Abbott v. Doe and Muth v. Voe appeals at the Texas Supreme Court will likely affect how aggressively that obligation is enforced.

Q: What happens if I keep doing gender-affirming assessments for minors?
A: Two risks. (1) The AG can pursue civil enforcement under § 161.706(a) — injunctive relief and clawback of any public funds. (2) Your licensing board can discipline you under the existing standards-of-practice rules (cited in the opinion); the most severe outcome is license revocation. If your conduct is treated as facilitating child abuse, criminal-conviction discipline under Tex. Occ. Code § 53.021 also becomes a risk.

Q: Are there exceptions for kids who started treatment before SB 14?
A: There were narrow ones in § 161.703(b) — a "wean off" period for children who began treatment before June 1, 2023 and met certain therapy-attendance requirements. The AG observed in this opinion (and earlier in KP-0481) that the practical effect of these exceptions has largely expired due to the passage of time.

Q: Does this affect adult clients?
A: SB 14's prohibitions in § 161.702 apply to procedures and treatments performed on a child. Adult-only practice is not within the scope of § 161.702. But many mental health practices serve clients of all ages; if your practice serves any minors, build compliance accordingly.

Q: Is the AG's interpretation final or can it be challenged?
A: AG opinions are not binding precedent like a court ruling — they are persuasive authority. A licensee facing enforcement could challenge the AG's reading, raise First Amendment defenses (the opinion notes Chiles v. Salazar is pending before the U.S. Supreme Court), or argue that specific clinical work was not "facilitation." But until a court rules otherwise, the AG's interpretation is what the State of Texas will rely on in enforcement.

Background and statutory framework

Senate Bill 14 (88th Leg., R.S., 2023) enacted Subchapter Y of Chapter 161 of the Health and Safety Code, prohibiting certain medical procedures and treatments performed on a child for the purpose of gender transitioning, gender reassignment, or affirming a perception of sex inconsistent with biological sex. The prohibited list includes:

• Surgeries that sterilize the child
• Mastectomies
• Removal of otherwise healthy or non-diseased body part or tissue
• Prescribing or administering puberty-suppression or puberty-blocking drugs to delay normal puberty
• Supraphysiologic doses of testosterone to females
• Supraphysiologic doses of estrogen to males

The Texas Supreme Court upheld the statute's constitutionality in State v. Loe, 692 S.W.3d 215 (Tex. 2024). The U.S. Supreme Court has separately upheld a similar Tennessee law in United States v. Skrmetti, 605 U.S. 495 (2025).

The statute imposes three types of consequences:

1. Direct prohibition. § 161.702 forbids physicians and health care providers from "knowingly" performing the listed procedures or providing the listed prescriptions to a child.

2. Public-funding bar. § 161.704 prohibits any public money from being "directly or indirectly" used, granted, paid, or distributed to any health care provider, medical school, hospital, physician, or other entity "that provides or facilitates the provision of" a § 161.702 procedure or treatment to a child. Sections 161.705, 62.151(g), and Tex. Hum. Res. Code § 32.024(rr) add specific Medicaid and CHIP coverage exclusions.

3. License consequences. § 164.0552 of the Occupations Code makes provision of a prohibited surgery or prescription a "prohibited practice" requiring revocation of a physician's license. Mental-health-licensee discipline rests on existing standards-of-practice rules.

This opinion's contribution is to extend the statute's reach by interpretation: § 161.701(2)'s definition of "health care provider" includes Behavioral Health Executive Council licensees, and "facilitation" in § 161.704 is read broadly enough to capture pre-procedure mental health work that supports the eventual provision of a prohibited procedure.

The opinion declines to address several adjacent issues:

• The scope of the U.S. Supreme Court's eventual ruling in Chiles v. Salazar (a First Amendment case about state regulation of conversion-therapy speech).
• The validity of the Third Court of Appeals' temporary injunctions in Abbott v. Doe and Muth v. Voe (concerning DFPS investigation of gender-affirming care as child abuse), now on petition before the Texas Supreme Court.

These pending cases may ultimately constrain the practical reach of this opinion.

Citations and references

Texas statutes:
- Tex. Health & Safety Code § 161.701 — Definitions, including "health care provider"
- Tex. Health & Safety Code § 161.702 — Prohibited procedures
- Tex. Health & Safety Code § 161.704 — Public funds prohibition
- Tex. Occ. Code § 164.0552 — Physician license revocation
- Tex. Fam. Code § 261.101 — Mandated reporting

Key cases:
- State v. Loe, 692 S.W.3d 215 (Tex. 2024) — upholding SB 14's constitutionality
- United States v. Skrmetti, 605 U.S. 495 (2025) — upholding similar Tennessee restrictions
- Tex. State Bd. of Exam'rs of Marriage & Fam. Therapists v. Tex. Med. Ass'n, 511 S.W.3d 28 (Tex. 2017) — agency rulemaking authority
- Abbott v. Doe, 691 S.W.3d 55 (Tex. App.—Austin 2024, pet. filed) — pending before Texas Supreme Court
- Muth v. Voe, 691 S.W.3d 93 (Tex. App.—Austin 2024, pet. filed) — pending before Texas Supreme Court

Prior AG opinions cited:
- Tex. Att'y Gen. Op. No. KP-0401 (2022)
- Tex. Att'y Gen. Op. No. KP-0468 (2024)
- Tex. Att'y Gen. Op. No. KP-0481 (2025)

Original opinion text

February 27, 2026

Mr. Darrel D. Spinks
Executive Director
Texas Behavioral Health Executive Council
1801 Congress Avenue, Suite 7.300
Austin, Texas 78701

Opinion No. KP-0518
Re: Interpretation of "health care provider" under Tex. Health & Safety Code § 161.701(2) and associated issues (RQ-0605-KP)

Dear Mr. Spinks:

You seek clarification regarding the application of S.B. 14 to "mental health care providers" licensed by the Texas Behavioral Health Executive Council. First, you ask whether the definition of "health care provider," which was codified in subsection 161.701(2) of the Health and Safety Code, encompasses the Council's licensees. If so, you also ask "how" the licensees "are impacted by S.B. 14" in relation to "mental health care services not specifically enumerated." We answer both questions in turn.

The Legislature codified various restrictions on health care providers as well as physicians involved with procedures and treatments afforded to children for gender transitioning, gender reassignment, and gender dysphoria.

The legislation at the heart of your request relates to procedures and treatments afforded to certain children for gender transitioning, gender reassignment, and gender dysphoria. See Act of May 17, 2023, 88th Leg., R.S., ch. 335, 2023 Tex. Gen. Laws 732, 732–36 (current version at Tex. Health & Safety Code §§ 62.151(g), 161.701–.706; Tex. Occ. Code §§ 164.052(a)(24), .0552; Tex. Hum. Res. Code § 32.024(rr)). See generally State v. Loe, 692 S.W.3d 215, 239 (Tex. 2024) (upholding the statute's constitutionality). It codified what is now subchapter Y in Chapter 161 of the Health and Safety Code, which prohibits the provision of certain procedures and treatments "[f]or the purpose of transitioning a child's biological sex as determined by the sex organs, chromosomes, and endogenous profiles of the child or affirming the child's perception of the child's sex if that perception is inconsistent with the child's biological sex." Tex. Health & Safety Code § 161.702. Both "physician[s]" and "health care provider[s]" are thus prohibited from "knowingly" "perform[ing] a surgery that sterilizes the child," "perform[ing] a mastectomy," or "remov[ing] any otherwise healthy or non-diseased body part or tissue." Id. § 161.702(1)–(2), (4). Neither may these individuals "knowingly[] . . . provide, prescribe, administer, or dispense . . . prescription drugs that induce transient or permanent infertility" in children — specifically, "puberty suppression or blocking prescription drugs to stop or delay normal puberty;" "supraphysiologic doses of testosterone to females;" and "supraphysiologic doses of estrogen to males." Id. § 161.702(3)(A)–(C). Ultimately, the Attorney General has enforcement authority over ongoing, completed, or threatened violations of these constraints. Id. § 161.706(a).

The subchapter also imposes other restrictions related to these prohibited procedures and treatments. For one, it forbids "[p]ublic money" being "directly or indirectly . . . used, granted, paid, or distributed to any health care provider, medical school, hospital, physician, or any other entity, organization, or individual that provides or facilitates the provision of a procedure or treatment to a child that is prohibited under [s]ection 161.702." Id. § 161.704. The subchapter also prohibits reimbursements from Medicaid and the child health plan program to health care providers and physicians who provide one of the prohibited procedures or treatments to a child. Id. § 161.705; see also id. § 62.151(g); Tex. Hum. Res. Code § 32.024(rr).

The Council's licensees plainly constitute health care providers under subsection 161.701(2), resulting in a bar on all public funds for those who facilitate prohibited procedures — in addition to the longstanding constraints on licensed practice.

Subsection 161.701(2) broadly defines a "[h]ealth care provider" as "a person other than a physician who is licensed, certified, or otherwise authorized by this state's laws to provide or render health care or to dispense or prescribe a prescription drug in the ordinary course of business or practice of a profession." Tex. Health & Safety Code § 161.701(2); see also id. § 161.701(4) (defining "[p]hysician"). The phrase "health care" is commonly understood to mean "efforts made to maintain or restore health . . . by trained and licensed professionals." Merriam-Webster's Collegiate Dictionary 574 (11th ed. 2020). The attributive noun "health" ordinarily refers to "physical and mental well-being." This makes clear that a health care provider engages in licensed efforts to maintain or restore health, whether in body or mind, and belies any perceived ambiguity in subsection 161.701(2).

Nor can there be any question that the Council's licensees — whom you refer to as "mental health care providers" — deal in health care. The framework governing "Health Professions" includes an entire subtitle for "Psychology and Counseling," which individually regulates the services of "Psychologists," "Marriage and Family Therapists," "Licensed Professional Counselors," as well as "Social Workers." See Tex. Occ. Code tit. 3, subtit. I, chs. 501–503, 505. These professions are unified in offering both "assessment" and "treatment" or "remediation" of various behavioral disorders. Many of these individuals are elsewhere defined as "[h]ealth care professional[s]," id. § 108.051(1)(L)–(M), and held to be "health care provider[s]" under the Texas Medical Liability Act. Fudge v. Wall, 308 S.W.3d 458, 462 (Tex. App.—Dallas 2010, no pet.); accord Mike Norgaard, LPC v. Pingel, 296 S.W.3d 284, 288 (Tex. App.—Fort Worth 2009, no pet.).

You nonetheless suggest that "mental health care providers are not intended to be encompassed within the scope of S.B. 14" because the prohibited procedures and treatments fall "outside [your licensees'] scope of practice." We disagree. The unambiguous definition of "health care provider" does not require a prescription pad or scalpel, and the Council conflates one form of unlawful conduct with a condition of membership in the entire class of health care providers. Critically, S.B. 14 codified more than a prohibition on providing certain surgeries and prescriptions; it also forbade public money from being "directly or indirectly . . . used, granted, paid, or distributed to any health care provider[] . . . that provides or facilitates the provision of a procedure or treatment . . . prohibited under [s]ection 161.702." Tex. Health & Safety Code § 161.704 (emphasis added). The undefined term "facilitate," of course, ordinarily means "to make easier" or "to help bring about." It follows that "any health care provider" who helps bring about a prohibited procedure or treatment — whether provided by a "physician" or another "health care provider" — cannot lawfully receive public funding for that venture.

For good reason, too, given that the multidisciplinary path to medically transitioning children often starts with mental "health care." Mental health professionals serve as the "clinical gatekeepers whose assessments and recommendations initiate the interventions" prohibited by S.B. 14. Likewise, the Legislature acknowledged this in creating a limited "wean off" period for children on a course of treatment "that . . . began before June 1, 2023" so long as the child also "attended 12 or more sessions of mental health counseling or psychotherapy . . . at least six months before the . . . treatment . . . began." Tex. Health & Safety Code § 161.703(b). Even the World Professional Association for Transgender Health publicly professes that "mental health professional[s]" possess "the most appropriate training and dedicated clinical time to conduct an assessment and elucidate treatment priorities and goals when working with transgender youth." Standards of Care, Version 8 (2022).

To be sure, S.B. 14 also "amend[ed] the licensing act for physicians." Subsection 164.0552(a) of the Occupations Code now makes clear that the provision of a prohibited surgery or prescription is "a 'prohibited practice' that requires revocation of a physician's 'license or other authorization to practice medicine.'" Tex. Att'y Gen. Op. No. KP-0481 (2025) at 4. But this does not change the plain-text reality discussed above. If anything, the supplemental constraint on physicians' licenses sits comfortably beside the Council's independent obligation to discipline health care providers who transgress the Occupations Code's profession-specific "chapter[s]" or associated "rule[s]." Tex. Occ. Code §§ 501.401(1), 502.351(9), 503.401(a)(1), 505.451; see also id. § 507.404(2).

Psychologists, for example, are bound by rule to "rely on scientifically and professionally derived knowledge when making professional judgments," 22 Tex. Admin. Code § 465.10; act in their client's best interest, id. § 465.13(a)(4); and end the professional relationship if it is reasonably clear that the client "is being harmed by continued service," id. § 465.21(c). Other licensees within the Council's ambit are similarly bound to "provide services within accepted professional standards of practice" (social workers); avoid dishonestly representing the "effectiveness of services" (professional counselors); and use therapeutic services that assist with "stabilizing," "alleviating," or "overcom[ing]" a child's underlying condition (marriage and family therapists).

We have made clear that "[a]ny person that . . . facilitates these procedures or treatments could be engaged in child abuse, whether that be parents, doctors, counselors, etc." Tex. Att'y Gen. Op. No. KP-0401 (2022) at 12. Texas law also compels reporting by professionals — i.e., "an individual who is licensed . . . by the state" and "in the normal course of official duties for which [that] license . . . is required, has direct contact with children," Tex. Fam. Code § 261.101(b) — with reasonable cause to believe a child has been or may be abused. See id. § 261.109(a-1). As such, health care providers who are criminally convicted for these offenses would necessarily invite revocation of their licenses by the Council. See Tex. Occ. Code § 53.021.

Summary

The definition of a "health care provider" in subsection 161.701(2) of the Health and Safety Code unambiguously encompasses the professions regulated by the Texas Behavioral Health Executive Council. Any licensee that facilitates the provision of unlawful procedures or treatments that aim to transition a child's sex are thus forbidden from receiving public money in support of those efforts and, separately, risk revocation of their licenses to practice.

Very truly yours,

KEN PAXTON
Attorney General of Texas

BRENT WEBSTER, First Assistant Attorney General
LESLEY FRENCH, Chief of Staff
D. FORREST BRUMBAUGH, Deputy Attorney General for Legal Counsel
JOSHUA C. FIVESON, Chair, Opinion Committee
AMANDA K. ROMENESKO, Assistant Attorney General, Opinion Committee