At a recent state psychological convention hosted by the Pennsylvania Psychological Association, I attended a presentation describing standards for “Writing Letters in Support of Gender-Affirming Medical Procedures.”
Gender dysphoria diagnosis is a “sense of unease that a person may have because of a mismatch between their biological sex and their gender identity” used by insurance companies and doctors for gender-affirming surgery or hormone treatment.
In presentations of psychological standards, studies may be misquoted and poor research design overlooked. When clinical recommendations are made regardless of these errors, however, the impact of these errors is not benign. The seriousness of the outcome (irreversible gender-changing surgery and enactment of laws) requires strict adherence to objective science.
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In accepting the information presented at the convention, the listener was required to disregard several important factors.
Psychologists at the convention were told to take clients at their word when they say they have gender dysphoria. But many patients do not tell their doctor the truth, and the nature of adolescence and childhood limits their ability to be personally objective.
Teens are well-known for mood swings, changing aspirations, and emotional contagion among peers influencing self-perceptions. This is seen in the self-diagnosing occurring at alarming rates on TikTok, multiplying angst as youths conclude that they have bona fide symptoms of mental disorders. Normal reactions are misdiagnosed as pathology.
The surgeon general has wisely advised that no children under 13 should use social media because of the substantial negative impact on their emotional development while they are still “developing their emotional identity.”
It is standard procedure for psychologists to use well-researched tests to diagnose mental conditions. However, the presenters and audience at the convention dismissed using tests, claiming they “pathologize” an interview and could create a “power” imbalance between the client and psychologist. By doing so, they essentially acknowledged the vulnerability of youth to being influenced in a psychological interview.
High rates of suicide attempts (40 percent) and suicidal thoughts (82 percent) among transgender youth were cited as a reason to suggest clients undergo gender-affirming surgery to reduce suicide risk. The research, however, is fraught with substantial errors and does not support this sweeping conclusion.
Many studies wrongly assume that surgery or hormone therapies are the only treatments that can relieve suicidal thoughts, and they do not track persons for an adequate number of years. A recent study using longitudinal data spanning 42 years reported self-identified transgender persons as having a seven-times-higher rate of suicide attempts and a 3.5-times-higher rate of suicide deaths.
We were told that side-effect risks from hormonal treatments are outweighed by the assumed benefit of suicide reductions. Those who are using puberty blockers are often told that their body will revert back to normal development if they stop using them. This is not true. According to the American College of Pediatricians, long-term effects may include osteoporosis, mood disorders, depression, seizures, cognitive impairment, suicidal thoughts, and worsening of gender dysphoria. Puberty blockers interfere with the natural development of testosterone and estrogen important to stimulating normal brain development.
Hormones to stimulate secondary physical characteristics have several risks of their own, such as psychosis, diabetes, blood clots (heart disease, stroke, pulmonary embolism), fertility, suicidality, and cancer. Many other long-term effects of these medications started in childhood are not simply known.
Adults can think more logically because of the higher development of the prefrontal cortex, which is necessary for rational reasoning, impulse control, and emotional modulation. Connections in the pre-frontal cortex are not fully developed until about age 25. Until then, emotional centers of the brain (limbic system) dominate. The immature brain is more impulsive, influenced by feelings, susceptible to risk-taking behaviors with less regard for long-term consequences, socially hyper-sensitive, and focused more on current body image rather than long-term maturation. (READ MORE: Medically Transitioning Minors: The 6th Circuit Strikes Back)
Courts recognize what psychologists are ignoring. Criminal codes hold children to a different standard for criminal responsibility. If brain maturity is accepted as meaningless, it eviscerates the intent of child protection laws.
Rather than describe exactly what surgical changes are involved (hysterectomy, double mastectomy, castration), it is common now to use the words “bottom” or “top.”
The very fact that one has to modify the names reveals awareness that modifications are being made for an immature mind.
The audience at the convention was told that there is an extremely low rate of regret after gender-affirming surgery. Definitions of post-surgical regret, however, limits such broad conclusions. One study defined “regret” as specifically requesting reversal surgery or transitioning back to the sex assigned at birth. Those who were “grieving” after their surgery but did not request further surgery were not included in the “regret” group.
Furthermore, no information was given on dropouts, measures of depression, use of psychiatric medications, suicidal thoughts, access to counseling for de-transitioning, or actually asking patients if they had any regrets. These studies fail to describe those who feel social pressure to resist change, inability to afford treatment, withhold dissatisfaction information from their treating physician.
A new study lists several research flaws about satisfaction rates that were not mentioned at the conference. In addition to issues concerning assumption of regret, there are no control groups to compare those with treatment and without; patients are not tracked long enough (eight years is recommended to have accurate data); appropriate measures of depression and anxiety are not used; and dropout rates are high or not reported. Further, adult studies are assumed to be fully applicable to a pediatric population. Nowhere else in medicine is this acceptable.
Another oft-cited example of distorted statistics in media is the reported 10 percent of high school students who question their gender, which references a study using only two items on a questionnaire: sex assigned at birth and current gender identity. Actually, only 9.2 percent of students endorsed items of gender questions. The study’s authors, however, refer to the findings as “nearly” 10 percent, and the Hill (a newspaper published for Congress) described them as 10 percent. Further, the study reported that 91 percent of the students in the district were surveyed. In fact, only 3,168 of the 4,930 student-completed surveys were accepted by the authors, meaning that the results reflected only 64 percent, not 91 percent, of the students. Its authors also assume that all the students answered honestly.
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Legislatures, influenced by bad science, are enacting contradictory laws criminalizing parents and psychologists for both assisting and resisting both gender dysphoria transitions and detransitions. Psychologists making decisions ignoring these issues and the permanent impact on children risk professional liability. Professionals and lawmakers need to press pause and understand the permanent harm that further action will cause — and the harm already caused by current procedures. Children do not deserve this.
Tim Murphy, Ph.D., is a psychologist specializing in trauma recovery and the author of three books, including The Christ Cure: 10 Biblical Ways to Heal from Trauma, Tragedy and PTSD (2023). He served as a psychologist in the U.S. Navy Medical Service Corps, was elected eight times to the U.S. House of Representatives, and authored major mental health reform legislation receiving wide bipartisan support. His weekly podcasts on mental health are available at DrTimMurphy.com and LinkedI
