What began as a compassionate response to the distress of those experiencing gender dysphoria, gender incongruence, or GI, has, in recent years, morphed into a practice plagued with psychological poison and peril.
Most right-thinking people have much empathy for gender dysphoria sufferers. If one believes that one is psychologically the opposite gender to genetic reality, the problems that causes are substantial in almost every area of life.
We would not want that pain or those challenges for anyone we know or love. Neither would we want a loved one who suffered from GI to have their problems worsened by well-intentioned but misguided “affirmation only” ideologues.
Is it “affirming” to endorse a GI patient’s self-perception without rigorous scrutiny? Does that untested validation amount to collusion in, and reinforcement of, mental delusions? Could this approach, claimed by some as “progressive”, actually be dangerous, irresponsible, and even cruel?
“These questions strike at the heart of ethics in psychology and medical practice (or lack thereof). Drawing from psychological principles, let’s dissect this contentious issue. We will explore how gender-affirming care risks elevating subjective feelings over objectivity, facts, evidence and even reality itself. We will consider if the “affirmative only” approach has the potential for long-term harm, and if so, whether such an approach may be the worst form of institutional irresponsibility.
By drawing on evidence and reason, we can move beyond ideology towards a more balanced, principled approach: one that prioritises genuine healing over ill-conceived ideological affirmations.
How good intentions turned toxic through the rise of gender-affirming healthcare
Gender-affirming healthcare emerged from a wise and laudable intention. That was, to alleviate the genuine suffering of individuals whose sense of gender does not align with their biological sex; gender dysphoria, GI sufferers.
Based in, and growing from, movements that advocated LGBTQIA+ rights, “affirmative only” approaches gained momentum in the 2010s, influenced by social media and activist campaigns.
Terms like “transgender” and “non-binary” became mainstream, and medical interventions, which range from puberty blockers and hormone therapy to surgeries, were claimed to be, and positioned as, “essential” for mental health of GI sufferers.
Yet, as with many well-meaning shifts, something went terribly wrong; the road to Hell is infamously paved with good intentions. What started as empathy was twisted into an authoritarian dogmatic framework where questioning “affirmative only” is taboo, and act worthy of attack and cancelling.
Echoing the “toxic wokery” I have previously critiqued, (psychreg.org “Has toxic wokery destroyed the UK?”), this “affirmative only” model often prioritises and elevates claimed emotions over chromosomal facts, evidence, and science.
The World Professional Association for Transgender Health (WPATH) guidelines, for instance, advocates “affirmation” without any, let alone mandatory, psychological evaluation. In the majority of cases that means potentially bypassing the need to explore causal underlying issues such as trauma or co-occurring mental health conditions, (known as comorbidities).
Consider the lack of reasoning here. In decision-making, as I’ve explored in prior writings, emotions often override, overpower, and even ignore all logic.
When a young person claims to have a gender identity that is incongruent with their biology, the affirmative ideologue’s response is immediate: “You know yourself best. Your emotions are your reality.”
Is that wise, ethical, or even rational?
Psychological research shows that adolescents are particularly susceptible to biases, social influences, and identity exploration. Affirming their claimed GI without any evaluation carries serious risks. It can, and in many cases, does, turn a transient phase, a fad, an exploration, a passing developmental crisis, into a permanent and life-changing medical pathway.
The consequences are horrendous: brain damage, sterilisation, nerve damage, urinary tract infections, and being rendered anorgasmic for life.
Is this the psychological core of the issue?
At its heart, gender-affirming “care” raises a profound psychological question: What happens when we validate a delusion rather than challenge it, treat it, or correct it?
Delusions, in clinical terms, are fixed false beliefs which are resistant to any and all contrary evidence. In the past people delusionally believed that the world was flat. They believed the earth was the centre of the universe. They believed in all sorts of invented supernatural events based on their attempts to explain their own experience.
For many people experiencing gender dysphoria, the conviction that one is “born in the wrong body” may stem from deeper psychological distress autism, abuse, or societal pressures, rather than any innate truth. They may be trying to understand their troubled inner world. Indeed, the research shows that 80%+ of GI sufferers have one or more comorbidities: other mental health problems which could be driving their GI symptoms.
By affirming their “wrong body” explanation without any, let alone a thorough assessment, “healthcare” providers may be colluding in their delusion. That is akin to affirming an anorexic patient’s belief that they are overweight. Or affirming to someone suffering paranoid delusions, that “Yes, they are out to get you.”
No rational person would take an “affirmative only” approach with a paranoid person, or an anorexic person. Indeed, given that vast numbers of the population who are dangerously obese, no right-thinking person would affirm the damage being done by a person’s obesity causing habits: “It’s OK to be so fat; it’s OK to overeat.” Here, too, affirmation would be the height of irresponsibility and cruelty.
Labels, as I warned in the psychreg.org article “How Dangerous Are Labels?” wield immense power. Calling a biological male a “woman” based solely on their self-chosen identification alters not just language but their perceptions of reality. That can, and does, disempower GI sufferers, giving them permission to abdicate responsibility for exploring alternative coping mechanisms to deal with whatever is behind their GI.
In self-responsibility therapy, the system I developed, the key turning point is when the client takes responsibility for solving their own mental health problems, for addresses their own disempowering thoughts, emotions and behaviours.
When someone refuses to take self-responsibility for their mental health challenge, there is almost no possibility of improvement. When they are actively encouraged, by trans ideologues, to deny self-responsibility, their mental health can only worsen.
There can be few more disempowering thoughts or emotions than convincing oneself, that one is trapped in the wrong body, however real those thought or emotions.
Reinforcing such disempowering thoughts by validating them must be one of the most dangerous and irresponsible acts any “therapist” can commit. Especially since all therapists know of the irreversible damage sex “change” surgery does. They also know that there is usually no mental health improvement, whatsoever, after surgery. None.
Imagine advocating a “therapy” that won’t improve mental health, and which will, with total certainty, do serious and irreparable damage. Surely that is criminal negligence at best, and grievous bodily harm at worst?
Evidence from the Cass Review, the landmark independent investigation into gender services for youth in England, confirms this danger. Led by Dr Hilary Cass, the 2024 report found a “remarkably weak evidence base” for gender-affirming interventions, particularly for minors.
Cass highlighted how puberty blockers, intended as a “pause,” often lead to irreversible cross-sex hormones, with sparse long-term data on outcomes. The review noted potential harms like bone density loss, infertility, (sterilisation), and cognitive impacts. Is that not physical cruelty masked as care?
Psychologically, the cruelty deepens. “Affirmative only” may provide short-term emotional validation and relief but builds dependency on permanent physical changes for what are, in 80% of cases, only temporary problems which resolve themselves or can be helped by therapy.
A testimony before the US House Judiciary Committee described gender-affirming care as “actively causing harm,” with clinicians ignoring red flags in pursuit of their own ideology.
Is it responsible to proceed with irreversible changes, when multiple studies show that up to 80% of childhood gender dysphoria resolves naturally by adulthood without any intervention? Most people who are not part of the “trans groupthink bubble” think such an approach is highly irresponsible.
Poor decision-making and institutional failures lead to irresponsibility
Decision-making in gender-affirming care has fallen prey to emotional biases and social pressures. As outlined in my psychreg.org article (The Psychology of Decision-Making), we frequently rationalise preferences post-hoc, ignoring rationality. Even as sophisticated adults we have a limited ability to fully process information. For vulnerable youth, who are highly influenced by peer pressure and online echo chambers, this can lead to dangerous decisions with lifelong negative consequences.
The Cass Review criticised the “affirmative model” for lacking safeguards, noting that many referrals involve complex needs such as mental health problems, neurodiversity or family trauma. Yet, some clinics proceed with blockers after no or minimal assessment sessions, despite evidence of harms. A U.S. Department of Health and Human Services report in 2025 discredited such procedures, stating they inflict “lasting physical and psychological damage.”
Bone demineralisation, cardiovascular risks, and sterility are not abstract or theoretical dangers; they are cruel realities for those who later regret being swayed by gender ideologues.
Detransition rates, while debated, reveal the scale of irresponsibility. Proponents claim regrets are rare (under 1%), but critics argue rates are vastly underreported due to stigma and hostility from the trans community, and the absence of follow-up. There are probably huge numbers of detransitioners, or those who start down the transition path and decide to abandon it. A 2024 study found detransitioners citing social influence, unresolved trauma, and medical complications as reasons for reversal.
One detransitioner described “affirmative only” as “ruining people’s lives,” echoing the claimed catastrophic fallout from trans treatment bans, but here, the harm stems from the so-called “care” itself. Another online detransitioner cited the hatred and bile she received from the trans community.
Institutionally, the “affirmative only” policy adopted by many mental health organisations colludes in cruelty. Professional bodies, fearing accusations of transphobia, suppress dissent both internally and externally. Whistleblowers of the actual harms of gender ideology face retaliation by gender authoritarians.
When evidence is weak or absent, as was so clearly demonstrated by Cass, proceeding with “affirmative only” is not compassionate, it is utterly reckless.
Individual suffering and societal division
The human cost of the “affirmative only” approach is profound. Psychologically, affirming delusions can exacerbate dissociation from one’s body, leading to even higher rates of depression and anxiety after transition for some.
A Swedish study of over 2,000 trans individuals found that they suffered persistent mental health challenges despite interventions. Physically, surgeries carry risks like nerve damage, chronic pain and life-time sexual dysfunction. Those are cruelties that no amount of emotional affirmation can undo.
For youth, the level of irresponsibility borders on abuse. Adolescents’ brains are not fully developed; prefrontal cortex maturation takes place in the mid-20s. Affirming irreversible changes before then is dangerous, as evidenced by rising detransition narratives. Societally, it deepens divides, pitting “affirmers” against “critics” and epitomises the worst of toxic wokery, eroding public trust in psychiatry, psychology and medicine.
Stopping the harm
Gender-affirming care isn’t inherently evil, but in its current form risks danger, irresponsibility, and cruelty by colluding in sexuality-based misattributions at best and delusions at worst.
Of course, the ideologues will do as they usually do, engage in ad hominem attacks on anyone who challenges their evidence-free conclusions.
All right-thinking people want proper help for GI sufferers. They do not want ideologues to do even more damage. I believe that the majority of the population want to see ethical and responsible practice to help GI sufferers. That can be achieved by:
- Prioritising evidence. Comprehensive psychological assessments, as per the Cass recommendations, should be carried out on a mandatory basis, before any kind of medical intervention.
- Assessments being conducted by non-ideologues. If the assessments are carried out by people who are capable of identifying likely causes of GI, and skilled in the use of therapies to address GI, the risks of “affirmative only” can be avoided.
- Encouraging exploration. Engage in meaningful therapy to address and overcome the root causes of GI before any medical steps.
- Protecting the vulnerable. Ban all medical or surgical interventions on minors until after robust data emerges. In most countries, people cannot consent to have sex until they are 16. Surely, they cannot be allowed to consent to being rendered sterile and anorgasmic for life?
- Encourage open mutually constructive dialogue. GI is not going away. Every generation in history has had, and will continue to have GI sufferers. If we are to help and support them facing a difficult and painful challenge, we must see an end to cancel culture and allow open debate without fear.
- Being compassionate. The vast majority of people who present as GI, 80%, go on to live a gay lifestyle. Before that they struggle with social pressure to be conventional, and guilt about being different. If we, as a society, are more accepting of the range of human sexuality, fewer people would feel the need to be the opposite gender to live well, and contribute to their communities.
- Balancing of rights. For the small number of people whose GI cannot be addressed by therapy, and who do not live a gay lifestyle, we must find ways to respect their rights to live as well as they can with the challenge, while also protecting the rights to private spaces for women, and the legitimate concerns of parents and athletes.
- Develop critical thinking during education. If we can equip more of the population to question their emotional biases, and debate using fact, science, evidence and compassion, we can ensure future generations of GI sufferers live more in harmony with their communities.
By grounding GI care in compassionate reality, not ideology, we can prevent harm and promote true well-being for all GI people and for their communities. GI sufferers deserve our help, our support, our compassion.
GI sufferers deserve, and the world deserves, better than ideologically driven “affirmation only” collusion without any evaluation; they and the world deserve truth.
Professor Nigel MacLennan runs the performance coaching practice PsyPerform.