A New Paper Sheds Light on Transition Regret and Detransition
No one is systematically tracking how many young people regret transition or how many are helped by it.
The article below was originally published on the Society for Evidence-Based Gender Medicine’s website on June 8, 2023.
A new peer-reviewed article, “Transition Regret and Detransition: Meaning and Uncertainties,” published in the Archives of Sexual Behavior, reviews clinical and research issues related to transition regret and detransition. The article emphasizes that “although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy,” and there is currently “no guidance on best practices for clinicians involved in their care.”
The author, Dr. Jorgensen, notes that the term “detransition” can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading to inconsistencies in its usage. Although regret and detransition overlap in many people, not everyone who regrets their transition takes steps to detransition and conversely, not all of those who detransition regret their transition. Proponents of the “gender-affirming care” model typically focus on the latter group who are driven to detransition by external forces such as discrimination, lack of support from family and friends, or difficulty accessing health care. Euphemisms such as “gender-identity journey” and “dynamic desires for gender-affirming medical interventions” have been used to describe this process.
But the author highlights studies and personal testimonies of detransitioners who do deeply regret their transition, mourn the physical changes made to their bodies, and feel betrayed by the clinicians and medical institutions that offered hormones and surgery as antidotes to their gender confusion and distress. For this group of young people, internal factors such as “worsening mental health or the realization that gender dysphoria was a maladaptive response to trauma, misogyny, internalized homophobia, or pressure from social media and online communities,” were the primary drivers of their decision to detransition.
As the author highlights, a consistent theme in studies and personal testimonies of detransitioners is that there are major gaps in the quality and accessibility of medical and mental healthcare: “Many detransitioners reported not feeling properly informed about health implications of treatments before undergoing them (Gribble et al., 2023; Littman, 2021; Pullen Sansfaçon et al., 2023; Vandenbussche, 2022). Likewise, many felt that they did not receive sufficient exploration of preexisting psychological and emotional problems and continued to struggle post-transition when they realized gender transition was not a panacea (Littman, 2021; Pullen Sansfaçon et al., 2023; Respaut et al., 2022; Sanders et al., 2023; Vandenbussche, 2022). Despite ongoing medical needs, most patients did not maintain contact with their gender clinic during their detransition.” Detransitioners report wanting more information about how to safely stop hormonal therapies and surgical reversal or restorative options, but few clinicians are sufficiently knowledgeable about these issues to manage their care.
The author notes that our ability to predict who will be helped by transition-related medical interventions and who will be harmed by them is limited and we currently have no idea how many of the young people transitioning today will eventually come to regret their decision: “no one is systematically tracking how many young people regret transition or, for that matter, how many are helped by it.” However, the increasing number of detransitioners publicly sharing their experiences suggest that historical studies citing low rates of regret are no longer applicable. Moreover, these studies suffered serious methodological flaws that would tend to underestimate the true rates of regret including high rates of attrition and narrow definitions of regret.
More recent studies that have included the current case mix of predominantly adolescent-onset gender dysphoria suggest that up to 30% of those who undergo medical transition may discontinue it within only a few years (Roberts et al., 2022). It is likely that a number of them will experience significant regret over lost opportunities and permanent physical changes.
So how did we get here?
The author suggests that less restrictive eligibility criteria for accessing transition-related medical interventions under the gender-affirmation and informed consent models, coupled with the rapid rise of adolescents and young adults presenting to gender clinics, many of whom suffer from complex mental health problems and neurodiversity, has important implications for the incidence of transition regret and detransition. Under these models of care, standard processes of differential diagnosis and clinical assessment are seen as “burdensome, intrusive, and impinging on patient autonomy.” Moreover, the author points out that hormonal therapies and surgery are now conceptualized as a “means of realizing fundamental aspects of personal identity or ‘embodiment goals,’ in contrast to conventional medical care, which is pursued with the objective of treating an underlying illness or injury to restore health and functioning.”
Furthermore, adolescents and young adults might not be mature enough to appreciate the long-term consequences of their decisions about the irreversible medical interventions used to achieve “embodiment goals,” and/or their capacity to give informed consent may be limited by comorbid mental health problems or neurodevelopmental challenges. Additionally, “feelings of profound grief about lost opportunities and negative repercussions of transition might not be fully captured by framing the emotional experience in terms of regret” because “regret is an emotion that is unique in its relation to personal agency (Zeelenberg & Pieters, 2007), but the exercise of personal agency in the transition process might have been limited for people who began transition as minors, whose decision-making capacity was compromised by mental illness, or who were not fully informed of known and potential adverse health implications.”
The author offers some suggestions for how detransition may be prevented and inappropriate transitions avoided:
Improving the process of informed consent.
Prioritizing treatment of co-occurring social, developmental and psychological problems.
Using precise language about medical interventions.
Helping young people expand their understanding of what it means to be a man or woman.
Being transparent about the quality of evidence supporting medical interventions and the uncertainty about long-term harms.
The author ends by emphasizing that when clinical cases are complicated by a lack of knowledge about the natural trajectory of the condition and a paucity of evidence supporting treatment options, “minimizing iatrogenic harm requires application of cautious, thoughtful clinical judgement, meticulous examination of the data that are available, as well as a willingness to change practice in the face of new evidence.”
Jorgensen calls on the gender medicine community to “commit to conducting robust research, challenging fundamental assumptions, scrutinizing their practice patterns, and embracing debate.”
Read more about the phenomenon of detransition:
Boyd I, Hackett T, Bewley S. Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare. 2022; 10(1):121. https://doi.org/10.3390/healthcare10010121
D’Angelo, R. (2020). The man I am trying to be is not me. The International Journal of Psychoanalysis, 101(5), 951–970. https://doi.org/10.1080/00207578.2020.1810049
Entwistle, K. (2020). Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child and Adolescent Mental Health, camh.12380. https://doi.org/10.1111/camh.12380
Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2020.1869126
Hall, R., Mitchell, L., & Sachdeva, J. (2021). Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: Retrospective case-note review. BJPsych Open, 7(6), e184. https://doi.org/10.1192/bjo.2021.1022
Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-021-02163-w
Marchiano, L. (2021). Gender detransition: A case study. Journal of Analytical Psychology, 66(4), 813–832. https://doi.org/10.1111/1468-5922.12711
Roberts, C. M., Klein, D. A., Adirim, T. A., Schvey, N. A., & Hisle-Gorman, E. (2022). Continuation of Gender-affirming Hormones Among Transgender Adolescents and Adults. The Journal of Clinical Endocrinology & Metabolism, 107(9), e3937–e3943. https://doi.org/10.1210/clinem/dgac251
Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479
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