Growing Focus on Detransition
A new study of individuals who medically or surgically transitioned and subsequently detransitioned has been published in the Archives of Sexual Behavior by Dr. Lisa Littman. To qualify as medically or surgically transitioned, participants needed to have had one or more of the following interventions for the purpose of transitioning: puberty blockers, cross-sex hormones, anti-androgens, or a surgical procedure, and then detransitioned by stopping the medications or having surgery to reverse the changes from transition.
The demographics of the detransitioners reveal that the majority are female (70%) and white (90%), and over 80% have graduated from college or completed some college coursework. Slightly more experienced an early onset of gender dysphoria (56%) vs. the post-puberty onset (44.0%). However, more than half of the female participants had a post-puberty onset of gender dysphoria (55%). The female study participants were on average 20 years old when they sought care to transition and 24 when they decided to detransition. Males were considerably older: the average ages to seek medical transition and to subsequently detransition were 26 and 33, respectively.
Specific to endocrine interventions, the vast majority (96%) took cross-sex hormones as part of their transition. Females took testosterone for an average 2 years, while males took estrogen for 5 years and anti-androgens for 3 years. Surgically, one third of females underwent a mastectomy and 16% of males had breast augmentation. Genital surgeries in females were uncommon (1%), while men had genital surgeries as frequently as breast augmentation (16% each).
In order to detransition, the vast majority of respondents (95%) stopped cross-sex hormones and 9% underwent surgical procedures.
Reasons for Transition / Detransition
Besides wanting to be perceived as the target gender, which was the top reason to transition among both sexes (77%), the leading reasons for transition for females were not wanting to be associated with their natal sex/gender (74%), feeling "wrong" in their bodies (73%), and the belief that transition was the only option for feeling better (73%). For males, the key reasons for transition were that they identified with the target gender (77%), a belief that they would become their true self through transition (71%), and the belief that transition would eliminate their gender dysphoria (71%). Another marked difference between female and male study subjects is in gender-related harassment. While only 16% of male participants reported transitioning to reduce gender-related harassment, 51% of female participants named it as a reason for transition.
Nearly a third (30%) endorsed the response “someone else told me that the feelings I was having meant that I was transgender and I believed them” to describe how they felt about identifying as transgender in the past. Many participants selected social media, online communities, and in-person friend groups as sources that encouraged them to believe that transitioning would help them.
The leading reason for detransition for both sexes was becoming more comfortable with identifying with their natal sex due to a change in personal definition of female and male; this notion was cited by 65% of females and 48% of males. However, other reasons for detransition differed between female and male participants. For females, the second and third most frequently cited reasons for detransition were concerns about potential medical complications from transitioning (58%) and dissatisfaction with the physical results/too much change (51%). In contrast, males endorsed dissatisfaction with the physical results/too little change, deteriorating physical health, continued mental health problems, and feeling that they were discriminated against (36% each). For females, discrimination was among the less frequently endorsed reasons for detransition (17%).
Although not all detransitioned patients expressed regret, 50% reported strong or very strong regret. Eleven percent of respondents indicated that they were glad that they transitioned and 30% indicated that they wished they had never transitioned. The majority of respondents were dissatisfied with their decision to transition (70%) and were satisfied with their decision to detransition (85%). At the time of survey completion, 61% had returned to identifying with their birth sex, 14% identified as nonbinary, and 8% identified as transgender.
Gaps in Medical Care
The study raises concerns about the the quality of medical and mental health care provided to many of the participants. Although 55% of the respondents had been diagnosed with at least one psychiatric or neurodevelopmental issue and 37% reported experiencing trauma prior to the onset of gender dysphoria, the majority of participants (65%) reported that their clinicians did not evaluate whether their desire to transition was secondary to trauma or a mental health condition. Only 27% reported that the counseling and information they received prior to transition was accurate in terms of the benefits and risks associated with transition, with nearly half (46%) reporting that the counseling was overly positive about the benefits of transition.
Alarmingly, some participants reported that mental health and medical clinicians pressured them to medically transition. Less than a quarter of the participants (24%) told their treating clinicians that they discontinued medical treatment. This, in turn, suggests that clinicians may be unaware of their own patients who detransition and that clinic rates of detransition are likely underestimated.
This study describes the experiences of the individuals who transitioned largely before 2015, the year when the landscape of gender care drastically changed. The numbers of young people expressing gender-related distress have sharply risen in 2015 for reasons that remain poorly understood. At the same time, the "gender-affirmative" approach to treating gender dysphoria, which supports the use of hormonal and surgical interventions as first-line treatment, has become widely adopted, while the "informed consent model of care" eliminated the requirement for mental health evaluations. It is likely that the problems highlighted by the study are even more prevalent today, and if not addressed, they may lead to increasing numbers of individuals subjected to inappropriate medical interventions for their gender distress.
The study suggests that the rate of detransition should be systematically studied to ascertain its prevalence and to begin to develop alternative, non-invasive approaches for gender dysphoria management in young people. SEGM supports the study's call for inclusion of a measure of detransition in nationally representative surveys that collect health data, such as the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Behavior Risk Survey (YRBS). According to the latest available estimates from the YRBS, 1.8% of youth identify as transgender and an additional 1.6% are unsure. As the number of young people seeking and receiving irreversible medical and surgical gender interventions grows, it is vital to begin to track detransition data to prepare the healthcare system to better meet the needs of this novel patient segment.