It is striking how in many recent cases of violent acting out behavior in America the mass shooter or perpetrator of assassination has been a very angry, conflicted, and unstable transsexual young person acting out violently towards political figures or children’s schools, often religious schools.

Careful studies (such as “National Estimates of Gender-Affirming Surgery in the US” by Doctors Wright, Chen, and Suzuki, describing 48,019 transsexual surgeries done in America from 2016 to 2019) indicate that transsexual patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age seven years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. It is interesting that the authors comment that it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. I would include contemporary youths’ normal experiences of identity questioning, experimenting, and fads that get misidentified as a gender dysphoria diagnoses. 

During my work as a psychiatrist, I saw a significant number of persons referred for consultation with a transsexual diagnosis, (Current psychiatric term, Gender Identity Disorder). The referring surgeons requested psychiatric evaluation prior to proceeding with transsexual surgery. I often advised against transsexual surgery because the patient met criteria for transvestism (cross dressing), severe personality disorder, pre-existing psychosis, severe anxiety, or identity disorders that required the recommendation for further extensive evaluation or treatment. The relatively small percentage of patients I recommended for transsexual surgery for were free of major psychiatric disorders and as the JAMA Network authors found, they had genuine and pervasive feelings and perceptions of themselves as truly born in the wrong gendered body. Severe gender dysphoria was found in several patients where there was significant lack of acceptance by the patient’s parents or family. Sometimes extensive individual, couple, and family therapy was necessary prior to and after the surgery. The other patients had families and friends who recognized that they were transsexual and were accepting and supportive even when the adult surgical experience was difficult surgically, (especially female to male), and the social cultural and vocational adjustments were complex or difficult.

None of my patients were children and only one an adolescent whom I strongly recommended further psychological testing and psychotherapy before transsexual surgery could be considered. That person got surgery regardless. Follow-up revealed that the complicated female to male reconstructive surgery was followed by major severe medical and behavioral problems and suicidal depression requiring extensive therapy. 

Dr. Robert Stoller had extensive experience with transsexual persons. Stoller thought that transsexual persons who were carefully diagnosed according to his specific criteria should be operated on as early as possible so that the normal pre-adolescent and adolescent developmental maturational hurdles could be navigated with more likely success. Stoller found a very small incidence of true transsexualism in the general population. Unfortunately, and particularly in today’s highly conflicted political climate and even 40 years ago in Stoller’s day, such careful evaluation and treatment by knowledgeable and experienced clinicians was/is hard to find. In addition, the impact of the psychological isolation during the COVID-19 epidemic, the fluid sexual and identity portrayals in the contemporary American entertainment world and social media, and the complicated LGBTQ? political power movement with the conservative cultural political counter reaction, has led to enormous complexity for effective and rational medical care to take place. 

Stoller observed that if transsexual reconstructive surgery was done in a teenager or adult in the direction contrary to the core gender identity established in the first six years of the patient’s life in their family, then severe identity conflict, severe depression, anxiety, or acting out behavior is common. Violent acting out can often occur.

Diane McCormick Sanchez in an Epoch Times article points out that since 2018, there have been at least six shootings at schools and businesses involving persons who identified as transgender or indicating gender-confusion.

In a high-profile case in 2023, 28-year-old Audrey Hale, a woman who identified as a man, attacked the Covenant School in Nashville with a gun. Three nine-year-olds and three adults were gunned down before police shot and killed Hale.

In another case, Robert Westman, who changed his name to Robin, killed two children and wounded 21 others before killing himself at Annunciation Catholic Church in Minneapolis in August, 2025. In his/her manifesto he allegedly said, “tired of being trans” and scrawled anti-Christian messages and the words “kill Donald Trump” on weapons.

The attempted assassination of Supreme Court justice Brett Kavanaugh also involved the actions of a young man who claims male to female transgender identification dynamics as part of his legal defense. Such cases bring assassination attempts into the arena of violent acting-out connected to gender identity conflicts.

In many recent cases of violent acting out behavior in America, the perpetrator has been a very angry conflicted transsexual young person acting out violently towards children’s schools, often religious schools. The term ROMO (Rage Over Missing Out), can be used. Missing out on a normal happy childhood, missing out on a normal supportive family life, and missing out on a normal fulfilling and satisfying sexual life. The violent acting out appears directed out of deep envy, bitterness, and resentment toward happy normal school kids and their families. 

Prevention of such violent acting out requires early detection of persons showing signs of significant psychological and identity conflicts. We as a society need wisdom, careful research, and resolution of ignorance and judgmental attitudes about the process of normal gender identity formation and the psychologically complex struggles about gender identity that some persons need extensive help in resolving.

Image: AT via Magic Studio