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Medical societies are reversing decades of support for gender-affirming care in youth — but is it the science driving the shift, or the politics? This episode walks through the evidence, from randomized trials to regret rates, and finds a more complicated picture than either side presents.
Publication Date: 05/04/2026
Duration: 13 minutes, 09 seconds
Transcript:
KELLIE NEWSOME: As medical societies join the backlash against gender-affirming medical therapies for youth, we look at the evidence. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.
CHRIS AIKEN: I'm Chris Aiken, editor in chief of the Carlat Report.
KELLIE NEWSOME: And I'm Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
LINDSEY SPERO: I don't go to bed every night dreading waking up the next morning, or thinking that it would probably be better if I just didn't. I feel safe in my body, and I feel safe in myself.
KELLIE NEWSOME: Last week, we ended with the first malpractice judgment against clinicians who recommended gender-affirming surgery. Today we're going to examine what that means for practice — but first, a preview of the CME quiz. Earn CME through the link in the show notes, and find the answer in the research update at the end.
TRUE or FALSE: With long-term use of stimulants, patients with ADHD develop tolerance to their cognitive benefits, but not to their effects on hyperactive-impulsive symptoms.
On February 3, 2026, the American Society of Plastic Surgeons released a position statement recommending against gender transition surgery before age 19. The move came in response to pressure from the Trump administration — and, more immediately, the first successful malpractice lawsuit involving transition surgery. Since most of these procedures are performed by plastic surgeons, it practically closes the door on surgical transition for minors. That door shut further when the American Medical Association weighed in with the same position a week later, reversing the AMA’s years of support for gender-affirming care in transgender youth. Medical societies typically reverse course when compelling new evidence arises — and even then, the process is slow. Findings need replication, meta-analyses, consensus. So why now? Is it the threats from the federal government of withholding funding from hospitals that perform these procedures? Is it the $2 million verdict in New York?
CHRIS AIKEN: Perhaps it isn't a reversal at all. The WPATH standards of care already recommend that patients reach the age of majority before surgery, but they allow some flexibility based on clinical judgment. So far, that judgment has permitted fewer than 1,000 youth to undergo transgender surgery in the US each year — a number that, depending on your perspective, is either too many or too few.
KELLIE NEWSOME: Or just right. But there's another possibility. Maybe we should take the AMA at their word. The reason they give is a lack of clear evidence on the safety and efficacy of transgender surgery in youth.
CHRIS AIKEN: I'm Chris Aiken, editor in chief of the Carlat Report.
KELLIE NEWSOME: And I'm Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
LINDSEY SPERO: I don't go to bed every night dreading waking up the next morning, or thinking that it would probably be better if I just didn't. I feel safe in my body, and I feel safe in myself.
KELLIE NEWSOME: Last week, we ended with the first malpractice judgment against clinicians who recommended gender-affirming surgery. Today we're going to examine what that means for practice — but first, a preview of the CME quiz. Earn CME through the link in the show notes, and find the answer in the research update at the end.
TRUE or FALSE: With long-term use of stimulants, patients with ADHD develop tolerance to their cognitive benefits, but not to their effects on hyperactive-impulsive symptoms.
On February 3, 2026, the American Society of Plastic Surgeons released a position statement recommending against gender transition surgery before age 19. The move came in response to pressure from the Trump administration — and, more immediately, the first successful malpractice lawsuit involving transition surgery. Since most of these procedures are performed by plastic surgeons, it practically closes the door on surgical transition for minors. That door shut further when the American Medical Association weighed in with the same position a week later, reversing the AMA’s years of support for gender-affirming care in transgender youth. Medical societies typically reverse course when compelling new evidence arises — and even then, the process is slow. Findings need replication, meta-analyses, consensus. So why now? Is it the threats from the federal government of withholding funding from hospitals that perform these procedures? Is it the $2 million verdict in New York?
CHRIS AIKEN: Perhaps it isn't a reversal at all. The WPATH standards of care already recommend that patients reach the age of majority before surgery, but they allow some flexibility based on clinical judgment. So far, that judgment has permitted fewer than 1,000 youth to undergo transgender surgery in the US each year — a number that, depending on your perspective, is either too many or too few.
KELLIE NEWSOME: Or just right. But there's another possibility. Maybe we should take the AMA at their word. The reason they give is a lack of clear evidence on the safety and efficacy of transgender surgery in youth.
RJK Jr: Current evidence does not support claims that puberty blockers, cross-sex hormones, and surgeries are safe and effective treatments are pediatric gender dysphoria. These announcements are grounded in evidence and shaped by compassion.
CHRIS AIKEN: So let's look at that evidence — starting at the top of the hierarchy. Randomized, double-blind, placebo-controlled trials. There are none. No one has found a placebo for gender transition, and blinding the procedure is impossible. Moving a step down, there are a few small randomized trials of voice training for gender dysphoria, where patients are trained to speak in a register aligned with their gender identity. The treatment is non-invasive, non-controversial, and beneficial. But surgery? No controlled trials. For hormone therapy, we know of one randomized trial.
KELLIE NEWSOME: Brendan Nolan and colleagues in Australia randomized adult women seeking male transition into two groups. Half received testosterone immediately; half waited three months. Over that period, those who received treatment had less depression, less suicidality, and less gender dysphoria. But the study was small — 64 people — and lasted only three months. It’s also not a fair comparison: all participants were actively seeking treatment, so it's unsurprising that those randomized to waiting-list fared worse.
CHRIS AIKEN: Moving further down the evidence ladder, we have uncontrolled before-and-after and cross-sectional studies of gender transition — around 46 in total. Most focus on hormonal therapy, and they tell us that patients are more satisfied with their appearance and less distressed after transition. Other mental health outcomes are less consistent — some studies show gains, others show no change. Without randomization, we have no way to know what's driving these changes. And that limitation is unlikely to satisfy even the most open-minded scientist.
KELLIE NEWSOME: These studies haven't identified major harms, but they aren’t finding the kinds of global mental health benefits some hoped for. The effects may also vary by the direction of transition. When people take hormones to transition from male to female, they have more empathy and are more aware of their own emotions, but not all emotions. In one study, they had fewer positive emotions in the three years after transitions. These differences are slight, but they were recently confirmed in a trial out of Amsterdam that tracked mood in nearly 200 patients over a year after starting hormonal therapy. Those transitioning to male showed slight improvements in energy, while those transitioning to female experienced a slight decrease in mood. Why? We don't know. But it follows a consistent finding in gender research: women are two to three times more likely to experience depression than men, whether because of they are treated like second-class citizens in most societies, they have more empathy, or more anxiety, or because women have a surplus of the serotonin-sensitizing estrogen hormones that those who undertake transition are seeking.
CHRIS AIKEN: Kellie mentioned that study comes from Amsterdam, and that matters here. The Netherlands rank high on measures of gender equality. We visited Amsterdam recently, and women who had relocated there spoke about walking the streets at night without fear — something they hadn't been able to do elsewhere. Compared to the US, rates of sexual assault are lower, equal pay is protected, and LGBTQ and transgender identities are more broadly accepted. But that’s not the only reason the outcomes may differ. The Dutch are more accepting, but they are also more selective. They screen patients more carefully before transitioning with multiple assessment and a multi-disciplinary team. By comparison, America is the Wild West. We don’t have a centralized government-funded health system, and we are polarized into extremes – those who want to open the gates wide, and those who want to outlaw the procedure entirely.
KELLIE NEWSOME: That difference shows up in regret rates. In countries with careful screening, roughly one in 200 people regret their transition after undergoing full surgery — gonadectomy. In the United States, the regret rate after surgery is about four times higher, between one and two percent. For context, we see greater rates of regret with breast augmentation, around 5%, but there’s no political movement to outlaw that. And if you’re thinking of getting a tattoo, call Dr. Aiken – seriously, his daughter is a tattoo artist – but consider this first: 16% of people regret getting inked. Although the rate of regret is only 1-2% after gender surgery in the US, around 8% of people ultimately elect to detransition — but the reasons are more complex than simple regret.
CHRIS AIKEN: Most people detransition because of external pressures — disapproval from family or friends, or because they can’t find a job. Only around 16% do so for internal reasons, because their own sense of gender is unstable. But those rates may increase as restrictions ease. A growing number of people are attributing all of their mental health difficulties to gender dysphoria and seeking transition as the solution.
KELLIE NEWSOME: We see hints of that in this statistic. In a cross-national survey of people who detransitioned, 70% said they did so because they came to believe their gender dysphoria was connected to other issues. These respondents carried high rates of comorbidities: 70% had depression, 24% ADHD, 20% autism spectrum disorder, 19% eating disorders, and 17% personality disorders. Around one in three said they detransitioned because those mental health problems had resolved — suggesting they may have sought transition, hoping to treat those problems, and later found other, more effective paths.
CHRIS AIKEN: As regrets rise, so do the lawsuits. Several dozen malpractice cases are working through the courts, some with broader implications than the New York verdict. One takes aim at a physician who has played a prominent role in gender-affirming care. We'll pick up there next time and close with a research update.
CHRIS AIKEN: A thank you to Lindsey Spero, who graciously shared their audio testimony about the benefits of transitioning. Lindsey is a transgender rights advocate who transitioned from female to male.
KELLIE NEWSOME: Do ADHD medications stop working over time? The answer, from this paper by Christopher Smith and colleagues in CNS Drugs, is: yes and no. It's the first systematic review to examine tolerance and tachyphylaxis to stimulant medications directly. The authors gathered 17 trials lasting up to ten years, testing stimulants and non-stimulants in children and adults. The bottom line: the mood-elevating, energizing, and rewarding effects wore off — but the effects on core ADHD symptoms and cognitive performance endured. Unfortunately, though, patients did not develop tolerance to the cardiovascular side effects.
CHRIS AIKEN: Ten to twenty years ago, the pharmaceutical industry sought approval for stimulants like Vyvanse and Concerta as augmentation in depression. They failed — no difference from placebo in four large trials, either early or late in the course. Patients may appreciate the initial boost in confidence, energy, or reward that stimulants provide, but that isn't an antidepressant effect, and it doesn't last. When stimulants work for ADHD, they aren't energizing. Patients feel calmer, more organized, better able to prioritize. Those effects hold. If a patient isn't getting a meaningful benefit and is asking for a higher dose beyond the FDA-max, tapering off is the better option.
KELLIE NEWSOME: You can now search Dr. Aiken's research updates by topic — go to chrisaikenmd.com, click LEARN, then RESEARCH UPDATES. He posts one to two updates every day. If you like this podcast, leave us a review in the Apple store. Or subscribe online with the promo code PODCAST to get $30 off your first year's subscription — and help us stay in the shrinking ranks of publications that don't accept advertising, alongside Consumer Reports, The Medical Letter, and Beverage Digest.
CHRIS AIKEN: So let's look at that evidence — starting at the top of the hierarchy. Randomized, double-blind, placebo-controlled trials. There are none. No one has found a placebo for gender transition, and blinding the procedure is impossible. Moving a step down, there are a few small randomized trials of voice training for gender dysphoria, where patients are trained to speak in a register aligned with their gender identity. The treatment is non-invasive, non-controversial, and beneficial. But surgery? No controlled trials. For hormone therapy, we know of one randomized trial.
KELLIE NEWSOME: Brendan Nolan and colleagues in Australia randomized adult women seeking male transition into two groups. Half received testosterone immediately; half waited three months. Over that period, those who received treatment had less depression, less suicidality, and less gender dysphoria. But the study was small — 64 people — and lasted only three months. It’s also not a fair comparison: all participants were actively seeking treatment, so it's unsurprising that those randomized to waiting-list fared worse.
CHRIS AIKEN: Moving further down the evidence ladder, we have uncontrolled before-and-after and cross-sectional studies of gender transition — around 46 in total. Most focus on hormonal therapy, and they tell us that patients are more satisfied with their appearance and less distressed after transition. Other mental health outcomes are less consistent — some studies show gains, others show no change. Without randomization, we have no way to know what's driving these changes. And that limitation is unlikely to satisfy even the most open-minded scientist.
KELLIE NEWSOME: These studies haven't identified major harms, but they aren’t finding the kinds of global mental health benefits some hoped for. The effects may also vary by the direction of transition. When people take hormones to transition from male to female, they have more empathy and are more aware of their own emotions, but not all emotions. In one study, they had fewer positive emotions in the three years after transitions. These differences are slight, but they were recently confirmed in a trial out of Amsterdam that tracked mood in nearly 200 patients over a year after starting hormonal therapy. Those transitioning to male showed slight improvements in energy, while those transitioning to female experienced a slight decrease in mood. Why? We don't know. But it follows a consistent finding in gender research: women are two to three times more likely to experience depression than men, whether because of they are treated like second-class citizens in most societies, they have more empathy, or more anxiety, or because women have a surplus of the serotonin-sensitizing estrogen hormones that those who undertake transition are seeking.
CHRIS AIKEN: Kellie mentioned that study comes from Amsterdam, and that matters here. The Netherlands rank high on measures of gender equality. We visited Amsterdam recently, and women who had relocated there spoke about walking the streets at night without fear — something they hadn't been able to do elsewhere. Compared to the US, rates of sexual assault are lower, equal pay is protected, and LGBTQ and transgender identities are more broadly accepted. But that’s not the only reason the outcomes may differ. The Dutch are more accepting, but they are also more selective. They screen patients more carefully before transitioning with multiple assessment and a multi-disciplinary team. By comparison, America is the Wild West. We don’t have a centralized government-funded health system, and we are polarized into extremes – those who want to open the gates wide, and those who want to outlaw the procedure entirely.
KELLIE NEWSOME: That difference shows up in regret rates. In countries with careful screening, roughly one in 200 people regret their transition after undergoing full surgery — gonadectomy. In the United States, the regret rate after surgery is about four times higher, between one and two percent. For context, we see greater rates of regret with breast augmentation, around 5%, but there’s no political movement to outlaw that. And if you’re thinking of getting a tattoo, call Dr. Aiken – seriously, his daughter is a tattoo artist – but consider this first: 16% of people regret getting inked. Although the rate of regret is only 1-2% after gender surgery in the US, around 8% of people ultimately elect to detransition — but the reasons are more complex than simple regret.
CHRIS AIKEN: Most people detransition because of external pressures — disapproval from family or friends, or because they can’t find a job. Only around 16% do so for internal reasons, because their own sense of gender is unstable. But those rates may increase as restrictions ease. A growing number of people are attributing all of their mental health difficulties to gender dysphoria and seeking transition as the solution.
KELLIE NEWSOME: We see hints of that in this statistic. In a cross-national survey of people who detransitioned, 70% said they did so because they came to believe their gender dysphoria was connected to other issues. These respondents carried high rates of comorbidities: 70% had depression, 24% ADHD, 20% autism spectrum disorder, 19% eating disorders, and 17% personality disorders. Around one in three said they detransitioned because those mental health problems had resolved — suggesting they may have sought transition, hoping to treat those problems, and later found other, more effective paths.
CHRIS AIKEN: As regrets rise, so do the lawsuits. Several dozen malpractice cases are working through the courts, some with broader implications than the New York verdict. One takes aim at a physician who has played a prominent role in gender-affirming care. We'll pick up there next time and close with a research update.
CHRIS AIKEN: A thank you to Lindsey Spero, who graciously shared their audio testimony about the benefits of transitioning. Lindsey is a transgender rights advocate who transitioned from female to male.
KELLIE NEWSOME: Do ADHD medications stop working over time? The answer, from this paper by Christopher Smith and colleagues in CNS Drugs, is: yes and no. It's the first systematic review to examine tolerance and tachyphylaxis to stimulant medications directly. The authors gathered 17 trials lasting up to ten years, testing stimulants and non-stimulants in children and adults. The bottom line: the mood-elevating, energizing, and rewarding effects wore off — but the effects on core ADHD symptoms and cognitive performance endured. Unfortunately, though, patients did not develop tolerance to the cardiovascular side effects.
CHRIS AIKEN: Ten to twenty years ago, the pharmaceutical industry sought approval for stimulants like Vyvanse and Concerta as augmentation in depression. They failed — no difference from placebo in four large trials, either early or late in the course. Patients may appreciate the initial boost in confidence, energy, or reward that stimulants provide, but that isn't an antidepressant effect, and it doesn't last. When stimulants work for ADHD, they aren't energizing. Patients feel calmer, more organized, better able to prioritize. Those effects hold. If a patient isn't getting a meaningful benefit and is asking for a higher dose beyond the FDA-max, tapering off is the better option.
KELLIE NEWSOME: You can now search Dr. Aiken's research updates by topic — go to chrisaikenmd.com, click LEARN, then RESEARCH UPDATES. He posts one to two updates every day. If you like this podcast, leave us a review in the Apple store. Or subscribe online with the promo code PODCAST to get $30 off your first year's subscription — and help us stay in the shrinking ranks of publications that don't accept advertising, alongside Consumer Reports, The Medical Letter, and Beverage Digest.
