Live not by lies

Children fearful of growing up deserve the truth and time-honoured therapy, not the harmful delusion that sex can be changed

Photo by Micah & Sammie Chaffin on Unsplash

This is a lightly edited version of a talk by US clinical psychologist Dr Lisa Duval at Genspect’s September 2025 conference “Live not by lies” in Albuquerque, New Mexico.¹ Dr Duval, who specializes in adolescent and personality disorders and has had family exposure to youth gender distress, entitled her presentation “Misdiagnosing and misattributing fear: the clinical blindspot in working with gender dysphoria”—Bernard Lane

Dr Lisa Duval

I’m honored to be here today, but I’m also angry about being here today. In spite of all the collective wisdom and the prolific work of all of you in this room and beyond, how is it possible that we still need to be here trying to protect children, teens and vulnerable adults from the harms of gender ideology?

I’m angry about the ongoing medical and psychological harm that has been disguised as care and for which my profession of clinical psychology is partially culpable.

As a clinical psychologist for over 35 years, I’ve worked extensively with children, teens and young adults. Until 10 years ago, I did not have a single trans-identified young person in my practice. While there are as many paths into a trans identity as there are individuals who are trans-identified, there are specific patterns of vulnerability to this ideology.

From my understanding of developmental psychology that is grounded in the work of Erik Erikson, and from the untold hours I have spent studying the spread of this phenomenon, my focus in my talk today is on trans identity as a maladaptive way to cope with the difficulties and fears of growing up.

I want to share a metaphor that occurs to me every time I hear a debate over the use of puberty blockers to treat gender dysphoria, and then I will expand the focus to the practice of so-called gender-affirming care in general.

A patient seeks therapy for a fear of bridges. Skilled therapists will try to understand the origins of the fear and then gradually guide the patient towards, instead of away from bridges. This is done with exposure or desensitization therapy, first talking about bridges and one’s past experiences and ideas about their dangers, then visualizing them, then in slow steps approaching them, so that the patient can eventually cross over them to all the experiences to be had on the other side.

Contrast this with a patient who seeks therapy for a fear of growing up—affirmative therapists block that patient’s puberty. Perhaps this is an overly simple comparison, but is it? Instead of being explored, the dreaded but natural puberty of a so-called trans-identified child is blocked.

Treating the fear with avoidance of the feared object or event goes against the very fundamentals of therapy and of human psychology itself, especially the concept that to be brave is to do something feared rather than to avoid the fear. It contradicts our understanding that self-confidence, self-knowledge and resilience (not to mention adventure and new horizons) all come from facing one’s fears.

“We are applying syringe and scalpel to both age-old and modern symptoms of growing up and facing the world”—Dr Lisa Duval

In these times

I hesitated even to propose this presentation because it all just seems too obvious, but since an evolutionary biologist still needs to pivot his work to explaining that sex is binary and cannot be changed, since court cases still need to be won in order to be able to declare that a woman is an adult human female, since experiments asking whether using castration drugs to block children’s puberty is a good idea are still being considered, and since the father of evidence-based medicine has regressed to the “child of activist-based medicine” by signing a letter referring to sex-change procedures for children as “medically necessary”, in spite of low evidence of benefit and increasing evidence of harm, here I am, here we all are.

Blocking puberty threatens to demolish the physical and psychological bridges to healthy cognition, bodily integrity, sexuality and adulthood in general. Fears are concretized and avoided instead of seen as metaphors for distress and challenges to overcome.

There are direct psychological correlates to the medical harms that come from blocking puberty and affirming a cross-sex identity instead of exploring the emotional and symbolic layers of gender dysphoria.

First, impeded brain development. Not allowing someone to go through the crucial life stage of adolescence at the correct time runs the risk of emotionally and psychologically stunting her capacity for complex thought. Whether the thinking is “I’m a boy wrongly in a girl’s body because I hate dresses, don’t want breasts, don’t get along with other girls, am afraid of sex, am uncomfortable with my same-sex attraction”, affirming a child at this stage and blocking puberty solidifies superficial, childlike, restrictive and regressive stereotyped thinking.

Second, osteoporosis. Like brittle, breakable bones, the inflexible, fragile thinking of “If I have to go through puberty and be the sex I don’t want to be, I will be forever miserable or even kill myself”, restricts a young person’s resilience and future ability to face discomfort.

Third, infertility and impaired sexual function. Puberty blockers, cross-sex hormones, and breast and genital surgery interfere with many aspects of healthy sexuality, including sexual arousal and intercourse itself, pregnancy and breastfeeding.

Just as sex-trait modifications limit the range of sexual and reproductive functioning, the tactics of trans activism and the rationales of gender medicine limit the development of a stable sense of self and the range of healthy interpersonal relationships. I believe that gender ideology not only hijacks the empathy of well-meaning teachers, politicians and practitioners, but it also derails the drive of young people towards the identity development and individuation that are crucial to becoming successful adults.

Under the guise of supporting trans-identified individuals’ “true selves”, gender clinicians inadvertently thwart the healthy development of a stable sense of self. The agreement with the trans-identified person’s sense of being fundamentally “wrong”, the promulgation of the suicide threat as an acceptable negotiation skill, and the focus on external change and validation from others as the paths towards happiness—these all create or solidify maladaptive personality traits, including negative self-image, and impair interpersonal space. These are hallmarks of borderline personality disorder that are magnified by so many facets of the modern world, including, most ironically, by affirmative rather than explorative therapy.

In failing to see many youths’ gender dysphoria and trans identity as manifestations of the difficulties of growing up and individuating, facing fears of sexuality in general and homosexuality in particular, and finding healthy means of self-expression and autonomy, affirming therapists prevent successful psychological development, thereby causing iatrogenic mental as well as medical harm.² This is true at the critical juncture of puberty for a gender-distressed child, but is equally applicable to those with a later, post-pubertal onset of cross-sex or no-sex identity.

For when we affirm the trans identities of youth affected by rapid-onset gender dysphoria and tell them that they are brave for “knowing who they are”, we are actually robbing them of both the actual more complicated paths to self-awareness and the confidence that comes from being able to cope with life’s fears, pains and uncertainties. Their true fears stay hidden, going dormant and certain to resurface at later, less opportune times than adolescence to be explored, especially if medicalization has literally cut off parts of the body that might be better understood, accepted and even enjoyed, with just a bit more time and exploration.

Before the current epidemic of trans identity, the youth I saw in my practice played out their extreme fears of growing up mostly through eating disorders, self-harm, risky sexual behavior, and drug and alcohol use. While these dynamics still occur, they are now often replaced by or morph into the escape hatch of the magical belief in becoming the opposite sex.

Now we instead see girls who want to be straight boys because they are ashamed of their same-sex attraction, girls who want to be gay boys because they are terrified of, yet also drawn to the male phallus, and think they would be safer engaging with male sexuality if they themselves could be in a male body. Now we also see boys who want to be straight girls because they are ashamed of their same-sex attraction, boys who want to be lesbian girls, not always due to autogynephilia, but often because they are terrified of the harm that they are constantly told can be done by their own sexuality.

In the middle of a therapy session after months of insistent “queer” identity, more than a few young women have whispered to me uncannily similar versions of, “I don’t think I’m even gay or anything. I’m just really afraid of penises”. And similarly, I’ve heard sensitive, sweet boys confess that they are terrified of the destructive force of male sexuality that they see as almost inevitable from the MeToo hashtags, the pussy hats and deeply disturbing pornography.

Video: Dr Duval talks to Genspect founder Stella O’Malley about how clinicians ignore the foundational principles of therapy and human development when confronted with youth gender distress

Perils of affirmation

We need to understand the psychological as well as the medical harms of so-called gender medicine. Social transition, blocking puberty, and hormonal and surgical sex-trait modification all bypass the opportunity for individuals to explore and understand the combination of internal turmoil and external indoctrination that has led them to their trans identities. Instead, we lock them into a false reality with a false sense that they have conquered their perceived inadequacies and visceral fears of being their natal sex, their actual selves, and we bypass the bridges to healthy adulthood.

What are we actually treating? We are not treating a fundamental and immutable characteristic of “transness”, but instead we are treating misdiagnosed and misattributed distress. This is distress with being different, perhaps from neurodivergence or from homosexuality; distress with feeling inadequate, perhaps from a temporary ugly duckling state of puberty exacerbated by all those more beautiful people on Instagram; distress with sexuality, perhaps from exposure to pornography or trauma.

We are applying syringe and scalpel to both age-old and modern symptoms of growing up and facing the world.

It has been documented that going through puberty with its sexual awakening is often a cure for gender dysphoria, especially if social transition and medicalization have not occurred. This is no different from the concept of facing rather than avoiding one’s fears as the path to working through them. Fears can be treated therapeutically with a combination of psychoanalytic methods that lead to understanding the internalized and metaphorical layers of phobias, along with cognitive behavioral methods that offer practical steps to desensitize one to feared stimuli.

Walk up to that bridge and towards the real-life experiences on the other side. Sit with your pain, disappointments and fears long enough to begin to understand them, long enough to see that they are not permanent and can be worked through.

The concept of distress tolerance is a foundational element of dialectical behavior therapy specifically and good therapy in general. Without the ability to tolerate distress, one resorts to escapist, avoidant and often destructive behaviors in order to find relief. Without the ability to tolerate and move past distress, one forever stays on the safe side of the bridge, avoiding the adventures, the sense of accomplishment from overcoming difficulty and the growth on the other side. Instead of medicalization, these therapeutic methods need to be offered to those suffering from gender dysphoria, with its sense of “being in the wrong body”, feeling inadequate and wishing not to be homosexual or sexual at all.

If it weren’t for the societal, political, activist, medical and financial forces promoting gender ideology, none of us would be here this weekend saying so many of these same things repeatedly. We would be able to conceptualize that gender dysphoria is the newest addition to the symptom pool with which young people in particular are able to express their distress. We, as parents, teachers, policymakers and clinicians would thus be more able to help them work through this distress in all the ways that have been successful in the past.

Until then, we must continue to fight for reason, reality and true acceptance, no matter how clear it should already be. Do we let a child with social anxiety feel better by ordering for her at the restaurant? Do we let the teen with school anxiety feel better by keeping them home? Do we let a young woman suffering from anorexia feel better by promoting her weight loss? No, we figure out the causes of these disruptions to life and find ways for patients to face and overcome their fears so they can lead fulfilling lives.

We don’t need to invent new methods to treat distress, because they already exist from years of psychotherapeutic practice and study. We sit with people in distress and help them understand it deeply, and then help them approach their fears and find the power and expanding universe in overcoming them. We don’t have to study whether self-starvation is harmful, we don’t have to study whether blocking puberty, taking opposite-sex hormones or amputating healthy body parts are good ideas.

Whether clinicians reverse the scales at the end of the study, refuse to publish contradictory findings at all, or actually find a reported decrease in anxiety or the ill-defined “gender dysphoria” after puberty blockers, hormones or surgeries, these results all tell us nothing.

We should and do already know the consequences of interfering with healthy physical and emotional development. Just as, if we are being honest, we already know the medical harms of puberty blockers and cross-sex hormones, we should and do also already know the psychological harms of avoiding and displacing fears instead of working through them. Avoid your phobia, any phobia, and you will feel less anxious, maybe even “euphoric” for a moment, until you can’t avoid it, or until another fear or self-loathing takes its place.

In Maia Poet’s words, “The truth is, feelings like euphoria or relief aren’t ‘trans feelings’. They’re feelings that everyone experiences … when they’ve taken an action which temporarily quells their existential pain”. Existential pain? Isn’t that what makes us human? Isn’t it what inspires great art—literature, film, music—as we seek to understand our brief time here and make our mark?

Maybe this sounds odd coming from a therapist who is advocating for experiencing rather than avoiding, fear and pain, but what really is the alternative? Drug addiction, hedonism and following cult leaders into promised Shangri-las don’t work for long, not even in fiction.

“Live not by lies” is the perfect title for this conference. The [gender-affirming] practitioners across town today are lying.³ They might be well-meaning—I have called them malevolently benevolent—but they are lying. They and their followers are lying to vulnerable people, and they are robbing them, not only of healthy bodies and the myriad advantages and enjoyments that healthy bodies bring, but they are also robbing them of the chance to understand and overcome the actual sources of their fears.

They lie to children when they tell them that growing up the way they are will be too painful, and then they lie to them some more when they tell them that sex changes are possible and will cure their pain. They impede the chance to learn resilience and accept the fundamental and existential difficulty of the human awareness of our limitations, our mortality and the impossibility of a life without pain, disappointment and fear that, once survived, can bring genuine strength and true self-acceptance.

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1. “Live not by lies” was the title of a 1974 article by the Soviet dissident Aleksandr Solzhenitsyn.

2. Iatrogenic treatment is that which causes rather than cures illness.

3. Half an hour’s drive distant from the Genspect conference in Albuquerque was the “scientific symposium” of the United States Professional Association for Transgender Health (USPATH). One oral abstract illustrating the different mindset at the USPATH meeting was titled “‘Is the World Ever Gonna Accept Me?’: A Qualitative Study of Factors Contributing to Persisting Depression Among Transgender and Gender-Diverse Adolescents and Young Adults”.