KELLIE NEWSOME: A series of lawsuits are threatening to upend gender-affirming care, as patients who regret their transitions take aim at the therapists and surgeons who brought them there. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

KELLIE NEWSOME: 2026 has been a year of change for gender-affirming care, and in this podcast series, we're going to bring you up to speed on the controversy. You'll hear from patients who found new life after transition, and from rare cases where people felt deceived and later detransitioned. You'll learn how lawsuits and legislation are threatening to shut down gender-affirming care — forcing the president of the US association into exile.

CHRIS AIKEN: We're not going to take sides. We'll cover problems in the science of gender-affirming care that the movement tried to conceal. But both sides have worked to suppress information, and we'll apply equal scrutiny to the politicians who've distorted these treatments — rebranding them as "forced sterilization" and "surgical mutilation," and even attempting to censure this podcast. Come along as we walk the line between transition and mutilation, optimism and therapeutic overreach, identity and diagnosis. And at the end of this episode, a research update on GLP-1 agonists in depression.

KELLIE NEWSOME: But first, let's clarify some terms. Non-binary refers to people who don't identify within the exclusive male/female binary. They may identify with elements of both genders, or neither — carving out their own path. That identity can shift over time, and when it does, it's called gender fluid. Gender dysphoria is the distress that comes from a mismatch between a person's gender identity and their assigned sex at birth. That's what this series is about. Not everyone who is non-binary has gender dysphoria, and many people with gender dysphoria do identify with a binary gender — so these aren't the same thing. Transgender is the umbrella term. It encompasses anyone whose gender identity or expression differs from the sex assigned at birth.

CHRIS AIKEN: Both non-binary identity and gender dysphoria are on the rise — particularly in teens and young adults. Non-binary identity is three to six times more common than gender dysphoria, affecting around one in thirty people under 30 in the US.

KELLIE NEWSOME: We start in 2015, in Chapel Hill, North Carolina. A 15-year-old girl arrived for her first visit with a pediatrician. She'd been struggling with mental health, and the physician she chose had more experience in that area than most. She was on faculty at UNC-Chapel Hill, where she'd founded the section on adolescent medicine and directed a program on eating disorders. The patient — we'll call her S.D. — had recently been hospitalized for depression. She'd been to the emergency department for self-cutting and carried other diagnoses: obsessive-compulsive disorder and anorexia. As she told her story, S.D. traced these problems to a sexual assault that had happened the year before, when she was 14. We don't know exactly what transpired in that consulting room, but according to S.D., her pediatrician told her she was having a "gender identity crisis."

CHRIS AIKEN: S.D. started therapy with a counselor in nearby Greensboro, North Carolina — a city where I've also practiced since 2003. Her therapist had experience in gender identity and was credentialed by the World Professional Association for Transgender Health, the group that sets the standards for gender-affirming care, better known as WPATH. Again, we don't know precisely what was said, but over one to two years of therapy, S.D. came away with the impression that transitioning from female to male would cure her psychiatric problems.

KELLIE NEWSOME: At 17, she started testosterone. Shortly after turning 18, she scheduled a top surgery with a plastic surgeon to have her breasts removed. What happened next was a serious disappointment. She developed pain in her shoulders, neck, and chest. It became painful to speak — her vocal cords altered by the testosterone. She experienced vaginal atrophy and unwanted hair growth. But worst of all, her mental health didn't improve. S.D. filed a malpractice lawsuit against her pediatrician, two therapists, and her plastic surgeon. Her claim: that gender transitioning had been presented as a cure, and she hadn't been informed of the risks. For three years, that case hung in the balance. Initially, courts accepted the malpractice claim but rejected it on timing, she'd filed past the statute of limitations. Then, in 2025, North Carolina extended the window, allowing up to ten years to file. S.D. filed again, but this time it was dismissed with prejudice, deemed to lack material fact. Her remaining avenue is appeal — and with the world divided over gender norms, she has a chance.

CHRIS AIKEN: Meanwhile, a case in New York has sent shockwaves through the profession — and is already reshaping standards of care. On January 30, 2026, a jury in White Plains, New York, awarded a woman $2 million in damages for a double mastectomy she received as a teenager, which she said had left her disfigured. This case carries different lessons. It begins around 2018. I.Z. was 14 when she sought therapy for depression, anxiety, social phobia, and an eating disorder. At first, she was diagnosed with autism. After about two years of treatment, she began questioning her gender. She cut her hair, changed her name to something more androgynous, began binding her breasts, and told her psychologist she was interested in transitioning. Her psychologist had no training in transgender care — but went along with his client's wishes, referring her for transitioning care. In his referral letter, he listed I.Z.'s diagnosis as body dysmorphic disorder. Not gender dysphoria. And that is where this case differs from the one in North Carolina. Plastic surgery is contraindicated in Body Dysmorphic Disorder, because the patient just becomes fixated on the surgical changes, or on other body parts, leading to repeated surgeries. Plastic surgeons who practice ethically, or who have basic self-preservation instincts, won't take these cases. Nearly half of plastic surgeons report receiving threats from patients with body dysmorphic disorder who slipped through their screenings — mostly legal threats, but threats of violence are common too, and a few surgeons have been murdered. How that diagnosis went unflagged is still a mystery. The psychologist claims he didn't believe I.Z. had body dysmorphic disorder — that he had used the diagnosis for insurance billing. How many times have you seen this happen in practice? TMS isn’t covered for, say, bipolar, so the diagnosis is changed to major depression. But if the TMS causes problems, that diagnostic pivot starts to look like negligence. Or suppose we leave out any mention of a substance use disorder because the patient doesn’t want it in their chart. If they die of an opioid overdose and we were prescribing a sedative, it doesn’t look so good. When patients ask me to change a diagnosis so insurance will cover something or they’ll look better in custody court, I get real serious. I can’t do that. It would be unethical. And if it was discovered – which is likely – my ability to treat you, to get you care covered, or to stand up for you in custody court would crumble.

KELLIE NEWSOME: That kind of negligence is what turned this case against the clinicians. The body dysmorphic diagnosis was either flatly wrong, a careless mistake, or a deliberate misrepresentation — and none of those holds up in court. There were other problems, too. The therapist and surgeon didn't coordinate adequately. The family said they felt pressured, claiming the psychologist warned that I.Z. was at risk for suicide if she didn't transition. WPATH itself has distanced from the outcome, clarifying that the verdict is a ruling against malpractice, not against gender-affirming care. The providers in North Carolina, by contrast, followed WPATH guidelines, and their case was dismissed. Groups like WPATH emphasize the limited scope of this case, but other medical societies are changing course. Shortly after the New York decision, the American Society of Plastic Surgeons released a new position statement recommending against gender-related chest, genital, and facial surgeries before age 19. The AMA was quick to second that motion, citing a lack of evidence for the safety and efficacy of gender surgery in youth. Next week, we’ll look at that evidence, but first, a research update. Gender transition. Aerobic exercise. Weight loss medications. Each of these can have mental health benefits, but we’re also noticing a trend: People are stretching those benefits beyond what the evidence supports. Today's update looks at whether GLP-1 agonists treat depression or whether they just improve general well-being. Tsung Hung and colleagues analyzed 25 randomized trials that tested GLP-1s for other indications — diabetes, obesity, Parkinson's disease, binge eating disorder, and alcohol use disorder — but measured depression or well-being as secondary outcomes.

CHRIS AIKEN: The results: GLP-1 agonists improved well-being, but not depression. The benefit in well-being was small and largely driven by a handful of trials. But wait, none of these 25 trials tested it in depressed patients. This year, the first randomized trial of a GLP-1 – semaglutide – in major depressive disorder just came out. Across the board, all the outcome measures were negative. This new study confirms that, and carries another gem that has implications for clinical trials of gender affirming hormone therapy, as we’ll see in episodes to come.

KELLIE NEWSOME: Here's what you'll find in the upcoming May issue of the Carlat Report: a guide to making anti-manic medications more tolerable, and how to distinguish borderline personality disorder from bipolar. Not a subscriber yet? Get $30 off your first year's print subscription with the promo code PODCAST.