The Cost of Trust

Moral injury in gender-affirming care

In the gender-critical world, moral injury is everywhere, but it is rarely named. At least, that is how it appears to me. I am not an expert in gender-related care or moral injury, but as a psychotherapist, I pay attention to patterns in people’s experiences. I first came across the concept of moral injury in my own recovery from cult involvement, where moral injury is often part of the aftermath. As I have listened to people’s experiences in gender-related care, I have begun to recognize similar patterns that deserve attention.

When parents, clinicians, therapists, and detransitioned individuals speak about their involvement in gender affirming care, there is often a deep sense of betrayal in what they describe. They talk about trust placed in doctors, therapists, supervisors, and professional bodies, who were expected to know better and uphold the basic principle of doing no harm. What they are left with, in some cases, is the feeling that not only was harm done, but it was done within a system that framed those actions as necessary or even good.

At the same time, the focus does not remain only on institutions. Many of these individuals turn the weight of that experience inward. They describe anger, guilt, shame, and regret. They speak about acting in good faith and believing they were doing the right thing, only to question those decisions in a serious way at a later stage. This combination of perceived betrayal by authority and self-condemnation is consistent with what has been described in the literature on moral injury, particularly in the work of Jonathan Shay (1994, 2014) and later expanded by Brett Litz and colleagues (Litz et al., 2009).

Betrayal and Self-Blame

To make sense of these conflicting emotions, the language of moral injury can be helpful. It provides a way of understanding how a person can feel both wronged by others and responsible themselves, and how that tension can lead to a deeper and more persistent form of psychological distress (Griffin et al., 2019).

The concept of moral injury was first developed by Jonathan Shay (1994) in his work with Vietnam veterans. What he found was that some psychological wounds did not come primarily from fear or threat. They came from a violation of what a person believed was right, often in situations involving betrayal by authority or participation in actions that conflicted with one’s conscience. Later, Brett Litz and his colleagues expanded this idea. They described moral injury as arising not only from what a person does, but also from what they fail to do, what they witness, and from betrayal by trusted individuals or institutions (Litz et al., 2009).

Moral injury is not an official diagnosis, but it is widely recognized as a real form of suffering. It often overlaps with trauma, but it is not the same thing. Trauma is often organized around fear and threat. Moral injury centers more around conscience, meaning, and the sense that something has gone wrong at a deeper level. In practice, the two often come together, which is part of what makes these experiences so difficult to work through (Griffin et al., 2019; Shay, 2014).

At the center of moral injury is a shift in how we see ourselves. It is not just that something bad happened. It is the realization that we did something wrong, or failed to act, or were part of something that now feels at odds with our values, and now we have to live with that. It is more than regret, because it begins to call into question who we are as people. Are we as good as we thought we were?

There is no officially accepted diagnostic list for moral injury, but there are well-recognized patterns. It often evokes feelings of guilt, shame, anger, and a sense of being unforgivable. There are also often feelings of betrayal, especially toward trusted leaders or institutions that were expected to uphold certain values and did not.

At the level of thinking, it can show up as persistent self-blame, loss of trust in oneself and others, intrusive thoughts about what happened, and a broader loss of meaning, purpose, or clarity about one’s place in the world. This can arise suddenly or deepen over time, leading to withdrawal from others, a loss of faith in oneself or in institutions, and a deep sense of alienation. It is not unusual for people who have experienced moral injury to engage in self-sabotaging behavior or substance use as a way of coping.

There can also be symptoms that overlap with trauma, such as insomnia, hypervigilance, and avoidance of certain places, situations, or people (Litz et al., 2009; Griffin et al., 2019; Shay, 2014).

When I listen to people speaking about transgender-related experiences, I hear these patterns more often than is acknowledged. Some parents speak about supporting a child’s transition in good faith, only to later feel confusion, regret, or a sense that they failed to protect their child. Some clinicians describe looking back on their work and questioning their role in ways that carry real moral weight. Some detransitioned individuals speak about feeling misinformed, rushed, or just lost, and now are trying to make sense of decisions they made that have lasting consequences.

Parents, clinicians, and detransitioners are often left struggling to understand their actions and may begin to doubt their ability to discern what is right and wrong. They wonder how they could have been so mistaken. Many believed they were doing the right thing by trusting medical doctors, psychotherapists, and scientific or governmental institutions, only to later question or even regret that trust. The doubts, the regrets, the sense of betrayal, and especially the feeling of “I may have caused harm” or “I failed to act differently” are hallmarks of moral injury.

Understanding the Reality of Human Limitation

The experience of moral injury is not surprising. Decisions are sometimes made in environments that are highly charged, where uncertainty is downplayed and questioning is discouraged. In those conditions, people can act with good intentions and still end up feeling that something went wrong. When that realization sets in, the psychological impact can be significant.

Recovery from moral injury is not quick. It is not just about reducing symptoms. It involves reworking how a person understands themselves, what they value, and how they want to live going forward. People often move through cycles of self-blame and blame of others. As one resolves this cycle, one may come to a more grounded understanding that holds both responsibility and the reality of human limitation.

Self-forgiveness is a central part of this process, but it is not easy. It does not mean excusing what has happened. It means being honest about it while also recognizing the conditions that shaped those choices. That includes pressure, incomplete information, trust in authority, and the desire to do what seemed right at the time.

For many, healing also involves what is sometimes called a living amends. When a person cannot undo what has been done, they try to live differently now. They speak out. They help others avoid similar harm. They align their actions with what they have come to see more clearly. What looks like advocacy or whistleblowing can also be part of an attempt to repair something at a moral level.

In discussions about gender-related care, most of the focus is on identity, rights, and outcomes. Much less attention is given to the moral and psychological aftermath that some people carry. If moral injury is part of that picture, even for a portion of those involved, then it needs to be named.

There is something deeply human in realizing that we may have acted in ways that do not sit well with us, or that we were part of something we no longer trust. That realization can be painful, but it can also be very humanizing. Faced directly, it can lead to greater responsibility, humility, and care for others. Avoided, it can eat at us and lock us in shame and guilt.

It seems to me that we are only at the beginning of this conversation. Naming moral injury does not resolve it, but it does begin to bring into the open something that many people are already carrying.

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References

Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. Scribner.

Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182 to 191. https://doi.org/10.1037/a0036090

Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., and Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29(8), 695 to 706. https://doi.org/10.1016/j.cpr.2009.07.003

Griffin, B. J., Purcell, N., Burkman, K., Litz, B. T., Bryan, C. J., Schmitz, M., Villierme, C., Walsh, J., and Maguen, S. (2019). Moral injury: An integrative review. Journal of Traumatic Stress, 32(3), 350 to 362. https://doi.org/10.1002/jts.22362

Bryan Wagner is a therapist in private practice in St. Louis who specializes in helping people recover from cult involvement and complex trauma. Drawing from his own experiences in and out of high-control groups, he brings empathy, clarity, and a deep understanding to his work. His work focuses on helping clients reclaim their autonomy and reconnect with reality in grounded, life-affirming ways.

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