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In recent years, opponents of the gender-affirmative approach to trans youth have argued that it bears homophobic roots and may be tantamount to conversion therapy. This argument is mistaken. In this article, I first argue that there is no evidence that social and/or medical transition is motivated by homophobia. Contrary to the critique’s tacit premise, many if not most trans people are LGBQ following transition. Furthermore, despite social progress in the last decade, transphobia remains more common than homophobia. Second, the gender-affirmative approach is fundamentally dissimilar to conversion therapy, unlike clinical approaches that oppose affirmation and seek to prevent transition. The comparison to conversion therapy relies on a superficial understanding of sexual orientation, such that a change of label (e.g. straight, bisexual, gay, lesbian) is equivalent to a change of sexual orientation even without changes to the targets of sexual attraction. By contextualizing conversion therapy in relation to trans youth care, I show that, on the contrary, conversion therapy has long focused on preventing transgender youth from growing up trans.