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As medical societies join the backlash against gender affirming medical therapies for youth, we look at the evidence. Welcome to the Carlite Psychiatry Podcast, Keeping psychiatry honest since 2003.
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I'm Chris Akin, the editor in chief of the Carlite Psychiatry Report.
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And I'm Kelly Newsom, a psychiatric NP and a dedicated reader of every issue.
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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.
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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 analysis, 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?
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Or perhaps it's not a reversal at all. The WPATH Standards of Care already recommend that patients reach the age of maturity before surgery, but they allow some flexibility based on clinical judgment. So far, that judgment has permitted fewer than a thousand youth to undergo transgender surgery in the US Each year, a number that, depending on your perspective, is either too many or too few or just right.
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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.
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Current evidence does not support claims that puberty blockers, cross sex hormones and surgeries are safe and effective treatments or pediatric gender dysphoria. These announcements are grounded in evidence and shaped by compassion.
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That was Robert F. Kennedy Jr. December 2025. 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 that aligns
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with their gender identity.
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The treatment is non invasive, non controversial and beneficial. But surgery? No controlled trials for hormone therapy. We know of one randomized trial, Brendan
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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.
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Moving further down the evidence ladder, we have uncontrolled before and after and cross sectional studies of gender transition around 46 in all. Most of these 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 though, we have no way to know what's driving these changes and that limitation is unlikely to satisfy even the most open minded scientist.
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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 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.
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Kelly mentioned that 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 in the Netherlands. Equal pay is protected, and LGBTQ and transgender identities are more broadly accepted. But that's not the only reason that outcomes may differ by country. The Dutch are more accepting, but they are also more selective in transgender care. They screen patients more carefully before transitioning, with multiple assessments and a multidisciplinary team. By comparison, America is the Wild West. We don't have a centralized, government funded health system, and we are polarized as a nation into extremes. Those who want to open the gates for these procedures wide, and those who want to outlaw them entirely.
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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 1 and 2%. 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. Akin. 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 to 2% after gender surgery in the U.S. around 8% of people ultimately elect to detransition. But the reasons are more complex than simple regret.
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Ah, this is where statistics really starts to get exciting. I mean, if 2% of people regret the surgery, then why are 8% detransitioning in the U.S. other research explains why most people detransition because of external pressures, disapproval from family or friends, or because they couldn't find a job. Only around 16% detransition for internal reasons because their own sense of gender is unstable. But those rates might increase as the restrictions on the surgery ease. A growing number of people are attributing all of their mental health problems to gender dysphoria and seeking transition. And as the solution, we see hints
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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.
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As regrets rise, so do the lawsuits. Several dozen malpractice cases are working their way 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 and thank
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you to Lindsay Spiro, who graciously shared their audio testimony about the benefits of transitioning. Lindsay is a transgender rights advocate in Florida who transitioned through hormones and surgery from female to male.
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Do ADHD medications stop working over time? The answer from this paper by Christopher Smith and colleagues in CNS Drugs is yes and no is the first systematic review to examine tolerance and tachyphylaxis to stimulant medications. Directly, the authors gathered 17 trials lasting up to 10 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.
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Around 10 to 20 years ago, the pharmaceutical industry sought approval for stimulants like Vyvanse and Concerta as augmentation in depression. These medications failed no difference from placebo in four large trials, no difference early and no difference late in the course of treatment. Patients might appreciate the initial boost they give in confidence, energy or reward, but that isn't an antidepressant effect, and it doesn't last. When stimulants work in adhd, they are not energizing. Patients feel calmer, more organized, better able to prioritize. And those are the effects that hold if a patient isn't getting a meaningful benefit and is asking for a higher and higher dose. Beyond the FDA max tapering off might
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be the better option.
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You can now search Dr. Akin's research updates by topic. Go to ChrisakinMD.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 a promo code podcast to get $30 off your first year subscription and help us stay in the shrinking ranks of publications that don't accept advertising alongside Consumer Reports, the Medical Letter
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and Beverage Digit Sam.