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How Often Do People Regret Transitioning?

It’s a complex question, but we do have some data..

An opinion piece recently came out in the New York Times looking at the ongoing debate on transgender youth. If you’ve read the piece, you might be forgiven for thinking that huge swaths of children are receiving surgery for gender dysphoria, and that many or even most of them regret their transitions. “I realized that I had lived a lie for over five years,” one destransitioning teen told the Times . Members of the trans community who track legislation and critique media coverage called the piece misleading , and even suggested it followed the “ climate denier playbook .”

Now, I have no particular stake here. I’m not trans, I don’t work in that area of health care, and I’m a cis man. I am, however, an epidemiologist, and I spend a lot of my time checking scientific facts that are online with the goal of helping people better understand health, science, and how the media covers those things. In this case, one key question arose from the New York Times piece that author Pamela Paul did not really answer: What proportion of people who access medical care to transition genders regret doing so?

You might answer, “Why does anyone care?,” which is, to be honest, not unreasonable . Some proportion of people experience regret for any medical procedure, from chemotherapy to orthopedic surgery. Nonetheless, we don’t see op-eds about the awful risks of hip replacements. It’s inevitable that some percentage of teens who transition will regret it; the real question is whether the medical care is beneficial on the whole—not whether the occasional person later regrets a medical choice they made in their youth.

It’s also important to note that we don’t really care about the crude number of people who regret transition, we care about the rate . If more people choose to transition, then more people, in total, will regret it. If the number of people transitioning goes from (to use arbitrary numbers) 1,000 to 100,000, but the number of people regretting it goes from 50 to 100, then the rate has dropped massively and it’s a very good thing, even though the crude number has doubled.

A good place to start when looking at the rate of regret for people transitioning in modern medical settings is to think about the upper and lower bounds. The highest estimate that I’ve come across is this recent study of people using the U.S. military health care system. It doesn’t deal with regret head-on, though. The authors looked at transgender or gender-diverse people who were using their parent’s or spouse’s military health care to access hormones for gender-related care, and looked at how many of them stopped getting these drugs over a four-year period. At the end of the study, about 30 percent of the people who started accessing hormones through this system stopped, with a lower rate for kids and higher rate for adults. (They may have gone elsewhere for hormones, though.)

The lowest estimate I’ve seen for regret after gender-related care is based primarily on people who have had gender-affirming surgery. A recent systematic review and meta-analysis —a type of study where the authors aggregate lots of papers into one big estimate—that combined such studies found an overall rate of 1 percent for regret after surgery for both transmasculine and transfeminine surgeries. This echoes other large cohorts which have found that only a tiny proportion of the people who have these surgeries eventually report regretting the procedure.

The issue here is that neither of these extremes are reliable estimates of regret. The 30 percent figure obviously does not map onto regret. Many people stop using their parent or partner’s health care for reasons completely unrelated to transition regret (i.e., divorce). And the studies of surgery in the review are mostly surgeons following up with their own patients, with quite high dropout rates. It’s not surprising that only 1 percent of people report to a surgeon who did an operation that they regret it!

There’s also a problem here about how we define “regret.” One of the biggest studies on transition-related regret was on the Amsterdam gender clinic , including nearly 7,000 people over 43 years. These authors defined “regret” as a patient who came back to the clinic after surgery to access hormones that would reverse their gender transition (and who had this noted in their records). By this definition, less than 1 percent of people regretted their surgery. But this is obviously not a particularly useful definition, because it will miss all of the people who regretted their procedures but went elsewhere for their follow-up care, or simply never got back to the original clinic about their regret.

Perhaps the most useful way to examine regret is to look at the proportion of people who cease their transition and go back to the gender they were originally. A large national study found that 13.1 percent of transgender people participating in the U.S. Transgender Survey reported detransitioning at some point in their lives. I think that’s a fairly reasonable estimate of the rate of people experiencing some measure of regret around their transition experience.

The authors of this study are careful to argue that the 13.1 percent figure isn’t a measure of regret, saying that “these experiences did not necessarily reflect regret regarding past gender affirmation.” Most of them reported that external factors were behind their detransition—a common reason was “pressure from a parent”—and all of them still identified as trans when they took part in the survey.

However, I think that the figure in that study is useful for precisely the reasons discussed in the study itself: Neither detransition nor regret are simple concepts. Transition, as with all social phenomena, is complex. You can stop taking hormones and still be trans. You can regret taking steps that alienate you from your family, even as you wish your family would accept you living how you want to live. You can even regret some aspects of a treatment (any kind of medical treatment!) while being grateful for the knowledge you gained by trying it out. Regret doesn’t always mean that people wish they hadn’t transitioned, it just means that there are some parts of the story that they long to change.

Paul published a short follow-up in the Times pushing back on criticisms of her column, arguing that we simply don’t know how many trans teens will seek medical care and then go on to detransition. It’s true that we don’t have good U.S. data on the number of people who detransition, but other countries have fairly useful, recent papers showing that detransition is quite uncommon . Paul even cited one of these in her piece, although she dismissed it out of hand . It’s possible that we don’t have all the information yet, but we can consider the constellation of evidence that we do have. What’s clear from this evidence is that the vast majority of people do not experience regret, howsoever defined, after transitioning genders. Regret rates are actually much higher for a lot of medical procedures. For example, in the U.S. military study above, 26 percent of children stopped getting hormones through their parent’s insurance after four years; a national British study looking at antidepressant use in children across the country found that half of the kids had stopped taking these medications after just two months.

Ultimately, the question of what proportion of kids or adults regret their transition is only important to a select group: the people who want to transition, and their clinicians. At worst, the rate of regret is still better than other treatments which don’t require national debates over their use, which really begs the question of why anyone who isn’t directly involved with the treatment of transgender people is even weighing in on the topic at all. Indeed, a lot of what I’ve said in this piece has been raised by everyone from journalists to activists to trans folks just trying to live their lives. But as long as columnists are asking questions, maybe I can help by offering answers.

FACT CHECK: Is The Rate Of Regret After Gender-Affirming Surgery Only 1%?

A post shared on social media  claims only 1% of people regret their gender-affirmation surgery.

  View this post on Instagram   A post shared by matt bernstein (@mattxiv)

Verdict: Misleading

While the study cited does find a 1% regret rate, it and other subsequent studies share disclaimers and the limitations of research, suggesting the rate may actually be higher.

Fact Check:

The Instagram post claims that only 1% of patients regret their gender transition surgeries. The source used is “Regret after Gender-affirmation Surgery: A systematic Review and Meta-analysis of Prevalence” from the National Library of Medicine (NLM).

The caption is misleading, due to several factors and lack of research that were identified by the study itself and other subsequent papers. (RELATED: Did Canada Release A New Passport That Features Pride Flags?)

This study did not conduct original research, but rather compiled research done in many different places which resulted in a disclaimer warning of the danger of generalizing the results. “There is high subjectivity in the assessment of regret and lack of standardized questionnaires,” which varies from study to study, according to the NLM document.

The study quotes a 2017 study published in the Journal of Sex and Marital Therapy , which conducted a follow-up survey of regret among patients after their transition. The study notes a major limitation was that few patients followed up after surgery.

“This study’s main limitation was the sample representativeness. With a response rate of 37%, similar to the attrition rates of most follow-up studies,” according to the study. Out of the response rate, six percent reported dissatisfaction or regret with the surgery, the study claims.

Additional data found in a Cambridge University Press study showed subjects on average do not express regret in the transition until an average of 10 years after their surgery. The study also claimed twelve cases out of the 175 selected, or around seven percent, had expressed detransitioning.

“There is some evidence that people detransition on average 4 or 8 years after completion of transition, with regret expressed after 10 years,” the study suggests. It also states that the actual rate is unknown, with some ranging up to eight percent.

Another study published in 2007 from Sweden titled, “ Factors predictive of regret in sex reassignment ,” found that around four percent of patients who underwent sex reassignment surgery between 1972-1992 regretted the measures taken. The research was done over 10 years after the the procedures.

The National Library of Medicine study only includes individuals who underwent transition surgery and does not take into account regret rates among individuals who took hormone replacement. Research from The Journal of Clinical Endocrinology and Metabolism (JCEM) found that the hormone continuation rate was 70 percent, suggesting nearly 30 percent discontinued their hormone treatment for a variety of reasons.

“In the largest surgery study, approximately 1% of patients regretted having gender-confirmation surgery,” Christina Roberts, M.D, a professor of Pediatrics at the University of Missouri-Kansas City School of Medicine and a participant for the study for the JCEM, told Check Your Fact via email.

Roberts stated that while there were multiple major factors in regards to those regretting the surgery, including poor cosmetic outcome and lack of social support, she claimed discontinuation of hormone therapies and other treatment are “not the same thing as regret.”

“This is an apples to oranges comparison,” Roberts added. (RELATED: Is Disney World Replacing The American Flag With The LGBTQ+ Pride Flag In June 2023?)

Check Your Fact reached out to multiple doctors and researchers associated with the above and other studies and will update this piece if responses are provided.

Joseph Casieri

Fact check reporter.

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How common is transgender treatment regret, detransitioning?

FILE - South Dakota Republican Rep. Jon Hansen speaks during a news conference at the state Capitol, Tuesday, Jan. 17, 2023, in Pierre, S.D. Hansen is pushing a bill to outlaw gender-affirming health care for transgender youth. (AP Photo/Stephen Groves, File)

FILE - People gather in support of transgender youth during a rally at the Utah State Capitol Tuesday, Jan. 24, 2023, in Salt Lake City. Utah lawmakers on Friday, Jan. 27, 2023, gave final approval for a measure that would ban most transgender youth from receiving gender-affirming health care like surgery or puberty blockers. (AP Photo/Rick Bowmer, File)

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Many states have enacted or contemplated limits or outright bans on transgender medical treatment, with conservative U.S. lawmakers saying they are worried about young people later regretting irreversible body-altering treatment.

But just how common is regret? And how many youth change their appearances with hormones or surgery only to later change their minds and detransition?

Here’s a look at some of the issues involved.

WHAT IS TRANSGENDER MEDICAL TREATMENT?

Guidelines call for thorough psychological assessments to confirm gender dysphoria — distress over gender identity that doesn’t match a person’s assigned sex — before starting any treatment.

That treatment typically begins with puberty-blocking medication to temporarily pause sexual development. The idea is to give youngsters time to mature enough mentally and emotionally to make informed decisions about whether to pursue permanent treatment. Puberty blockers may be used for years and can increase risks for bone density loss, but that reverses when the drugs are stopped.

Sex hormones — estrogen or testosterone — are offered next. Dutch research suggests that most gender-questioning youth on puberty blockers eventually choose to use these medications, which can produce permanent physical changes. So does transgender surgery, including breast removal or augmentation, which sometimes is offered during the mid-teen years but more typically not until age 18 or later.

Reports from doctors and individual U.S. clinics indicate that the number of youth seeking any kind of transgender medical care has increased in recent years.

HOW OFTEN DO TRANSGENDER PEOPLE REGRET TRANSITIONING?

In updated treatment guidelines issued last year, the World Professional Association for Transgender Health said evidence of later regret is scant, but that patients should be told about the possibility during psychological counseling.

Dutch research from several years ago found no evidence of regret in transgender adults who had comprehensive psychological evaluations in childhood before undergoing puberty blockers and hormone treatment.

Some studies suggest that rates of regret have declined over the years as patient selection and treatment methods have improved. In a review of 27 studies involving almost 8,000 teens and adults who had transgender surgeries, mostly in Europe, the U.S and Canada, 1% on average expressed regret. For some, regret was temporary, but a small number went on to have detransitioning or reversal surgeries, the 2021 review said.

Research suggests that comprehensive psychological counseling before starting treatment, along with family support, can reduce chances for regret and detransitioning.

WHAT IS DETRANSITIONING?

Detransitioning means stopping or reversing gender transition, which can include medical treatment or changes in appearance, or both.

Detransitioning does not always include regret. The updated transgender treatment guidelines note that some teens who detransition “do not regret initiating treatment” because they felt it helped them better understand their gender-related care needs.

Research and reports from individual doctors and clinics suggest that detransitioning is rare. The few studies that exist have too many limitations or weaknesses to draw firm conclusions, said Dr. Michael Irwig, director of transgender medicine at Beth Israel Deaconess Medical Center in Boston.

He said it’s difficult to quantify because patients who detransition often see new doctors, not the physicians who prescribed the hormones or performed the surgeries. Some patients may simply stop taking hormones.

“My own personal experience is that it is quite uncommon,” Irwig said. “I’ve taken care of over 350 gender-diverse patients and probably fewer than five have told me that they decided to detransition or changed their minds.”

Recent increases in the number of people seeking transgender medical treatment could lead to more people detransitioning, Irwig noted in a commentary last year in the Journal of Clinical Endocrinology & Metabolism. That’s partly because of a shortage of mental health specialists, meaning gender-questioning people may not receive adequate counseling, he said.

Dr. Oscar Manrique, a plastic surgeon at the University of Rochester Medical Center, has operated on hundreds of transgender people, most of them adults. He said he’s never had a patient return seeking to detransition.

Some may not be satisfied with their new appearance, but that doesn’t mean they regret the transition, he said. Most, he said, “are very happy with the outcomes surgically and socially.”

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

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Breaking news, ‘i literally lost organs:’ why detransitioned teens regret changing genders.

“I was failed by the system. I literally lost organs.”

When Chloe was 12 years old, she decided she was transgender. At 13, she came out to her parents. That same year, she was put on puberty blockers and prescribed testosterone. At 15, she underwent a double mastectomy. Less than a year later, she realized she’d made a mistake — all by the time she was 16 years old.

Now 17, Chloe is one of a growing cohort called “detransitioners” — those who seek to reverse a gender transition, often after realizing they actually do identify with their biological sex. Tragically, many will struggle for the rest of their lives with the irreversible medical consequences of a decision they made as minors.

“I can’t stay quiet,” said Chloe. “I need to do something about this and to share my own cautionary tale.”

In recent years, the number of children experiencing gender dysphoria in the West has skyrocketed. Exact figures are difficult to come by, but, between 2009 and 2019, children being referred for transitioning treatment in the United Kingdom increased 1,000% among biological males and 4,400% among biological females. Meanwhile, the number of young people identifying as transgender in the US has almost doubled since 2017, according to a new Centers for Disease Control & Prevention report .

Historically, transitioning from male to female was vastly more common, with this cohort typically experiencing persistent gender dysphoria from a very young age. Recently, however, the status quo has reversed, and female-to-male transitions have become the overwhelming majority .

Dr. Lisa Littman, a former professor of Behavioral and Social Sciences at Brown University, coined the term “ rapid onset gender dysphoria ” to describe this subset of transgender youth, typically biological females who become suddenly dysphoric during or shortly after puberty. Littman believes this may be due to adolescent girls’ susceptibility to peer influence on social media.

Helena Kerschner, a 23-year-old detransitioner from Cincinnati, Ohio, who was born a biological female, first felt gender dysphoric at age 14. She says Tumblr sites filled with transgender activist content spurred her transition.

“I was going through a period where I was just really isolated at school, so I turned to the Internet,” she recalled. In her real life, Kerschner had a falling out with friends at school; online however, she found a community that welcomed her. “My dysphoria was definitely triggered by this online community. I never thought about my gender or had a problem with being a girl before going on Tumblr.”

“There was a lot of negativity around being a cis, heterosexual, white girl, and I took those messages really, really personally.” Helena Kerschner, on how the online trans community made her feel pressured to change gender

She said she felt political pressure to transition, too. “The community was very social justice-y. There was a lot of negativity around being a cis, heterosexual, white girl, and I took those messages really, really personally.”

Chloe Cole, a 17-year-old student in California, had a similar experience when she joined Instagram at 11. “I started being exposed to a lot of LGBT content and activism,” she said. “I saw how trans people online got an overwhelming amount of support, and the amount of praise they were getting really spoke to me because, at the time, I didn’t really have a lot of friends of my own.”

Experts worry that many young people seeking to transition are doing so without a proper mental-health evaluation. Among them is Dr. Erica Anderson, a clinical psychologist specializing in gender, sexuality and identity. A transgender woman herself, Anderson has helped hundreds of young people navigate the transition journey over the past 30 years. Anderson supports the methodical, milestone-filled process lasting anywhere from a few months to several years to undergo transition. Today, however, she’s worried that some young people are being medicalized without the proper restraint or oversight.

“I’m concerned that the rise of detransitioners is reflective of some young people who have progressed through their gender journey very, very quickly,” she said. She worries that some doctors may be defaulting to medicalization as a remedy for other personal or mental-health factors. “When other issues important to a child are not fully addressed [before transition], then medical professionals are failing children.”

“I’m concerned that the rise of detransitioners is reflective of some young people who have progressed through their gender journey very, very quickly.” Dr. Erica Anderson, a clinical psychologist specializing in gender, sexuality and identity, who is herself transgender.

According to an online survey of detransitioners conducted by Dr. Lisa Littman last year, 40% said their gender dysphoria was caused by a mental-health condition and 62% felt medical professionals did not investigate whether trauma was a factor in their transition decisions.

“My dysphoria collided with my general depression issues and body image issues,” Helena recalled. “I just came to the conclusion that I was born in the wrong body and that all my problems in life would be solved if I transitioned.”

Chloe had a similar experience. “Because my body didn’t match beauty ideals, I started to wonder if there was something wrong with me. I thought I wasn’t pretty enough to be a girl, so I’d be better off as a boy. Deep inside, I wanted to be pretty all along, but that’s something I kept suppressed.”

She agrees with Dr. Anderson that more psychological evaluation is needed to determine whether underlying mental health issues might be influencing the desire to transition.

“More attention needs to be paid to psychotherapy,” Chloe said. “We’re immediately jumping into irreversible medical treatments when we could be focusing on empowering these children to not hate their bodies.”

Until 2019, Marcus Evans was the Clinical Director of Adult and Adolescent Services at the Tavistock and Portman NHS Trust, a publicly funded mental-health center in the UK where many youth seek treatment for gender dysphoria. But he resigned three years ago over what he viewed as the unnecessary medicalization of dysphoric adolescents.

“I saw children being fast-tracked onto medical solutions for psychological problems, and when kids get on the medical conveyor belt, they don’t get off,” Evans said. “But the politicization of the issue was shutting down proper clinical rigor. That meant quite vulnerable kids were in danger of being put on a medical path for treatment that they may well regret.”

Indeed, transitions are getting younger and hastier. Puberty blockers are commonly administered at the first sign of development to children as young as 9, according to the World Professional Association for Transgender Health. Testosterone and estrogen injections are frequently prescribed at age 13 or 14, despite the Endocrine Society’s recommendation of 16. And serious surgeries like mastectomies are sometimes performed on children as young as 13 .

“Quite vulnerable kids were in danger of being put on a medical path for treatment that they may well regret.” Marcus Evans, former Clinical Director of Adult and Adolescent Services at the Tavistock and Portman NHS Trust

Although medical intervention for minors requires parental consent, many mothers and fathers approve surgery and hormone therapy at the recommendation of affirming medical professionals or even out of fear their child might self-harm if denied treatment.

“It’s very hard for parents to know exactly how to evaluate their own kids, and they rely quite heavily on experts to tell them,” said Jane Wheeler, a former regulatory health-care attorney who founded Rethink Identity Medicine Ethics, a non-profit that promotes ethical, evidence-based care and treatment for dysphoric children. “There’s obviously a lot of concern about the capacity for the adolescent or minor to fully appreciate what medicalization really means.”

Medical professionals typically follow the affirmative-care model, which is supported by the American Psychological Association, validating a patient’s expressed gender identity regardless of their age. As a result, detransitioners frequently report that getting prescriptions is a breeze. A total of 55% said their medical evaluations felt inadequate, according to Dr. Littman’s survey.

In Helena’s case, all it took to get a testosterone prescription was one trip to Planned Parenthood when she was 18. She said she was given four times the typical starting dose by a nurse practitioner in less than an hour, without ever seeing a doctor.

Chloe said she was fast-tracked through her entire transition — from blockers to a mastectomy — in just two years, with parental consent. The only pushback she said she encountered came from the first endocrinologist she saw, who agreed to prescribe her puberty blockers but not testosterone when she was 13. But she said she went to another doctor who gave her the prescription with no trouble.

‘I saw how trans people online got an overwhelming amount of support . . . at the time, I didn’t really have a lot of friends.’ Detransitioner Chloe Cole, 17

“Because all the therapists and specialists followed the affirmative care model, there wasn’t a lot of gate-keeping throughout the whole transition process,” she recalled. “The professionals all seemed to push medical transition, so I thought it was the only path for me to be happy.”

Evans, the author of “ Gender Dysphoria: A Therapeutic Model for Working with Children, Adolescents, and Young Adults ,” now runs his own private practice with his wife in Beckenham, England, where he helps parents struggling with how to address their children’s dysphoria.

A variety of studies suggest that as many as 80% of dysphoric children could ultimately experience “desistance”— or coming to terms with their biological gender without resorting to transition. Which is why many professionals like Evans think it’s wise to hold off on potentially irreversible medical intervention for as long as possible. “I’m not against transition. I just don’t think kids can give informed consent.”

All these treatments run the risk of side effects that critics argue are too serious for children to fully understand. In the short term, puberty blockers can stunt growth and effect bone density, while the long-term effects are still unknown since they were only approved by the FDA in 1993. Side effects of testosterone include high cholesterol, cardiovascular disease, diabetes, blood clots and even infertility. Currently just three states — Arkansas, Arizona and Texas — have policies limiting gender-affirming treatments for minors, including surgery, hormones and speech therapy.

For those who ultimately end up regretting their transition, the consequences of hormone therapy and surgery can be devastating. For Helena, testosterone caused emotional instability that culminated with two hospitalizations for self-harm.

While in the hospital she came to the realization that her transition was a mistake. “I saw a montage of photos of me, and when I saw how much my face changed and how unhappy I looked, I realized this was all f****d up and I shouldn’t have done it. It was a really dark time.”

Chloe said testosterone altered her bone structure, permanently sharpening her jawline and broadening her shoulders. She said she also struggles with increased body and facial hair. She has a large scar across her chest from her mastectomy, which disturbed her about surgery. “The recovery was a very graphic process, and it was definitely something I wasn’t prepared for,” she said. “I couldn’t even bear to look at myself sometimes. It would make me nauseous.”

Gravest of all concerns is her fertility. Although she’d like to have children one day, Chloe doesn’t know whether the viability of her eggs was compromised by years of testosterone injections. She’s working with doctors to find out, and her medical future is uncertain. “I’m still in the dark about the overall picture of my health right now,” she said.

The subject of detransitioning is often met with vitriol from the transgender activist community, which claims that stories like Chloe’s and Helena’s will be used to discredit the trans movement as a whole. 

This is understandable, although unlikely, as research reveals that up to 86% of trans adults feel that transitioning was the right long-term decision for them. But, as more and more children are entrusted to make serious medical decisions with permanent implications, the numbers of disaffected detransitioners is almost certain to grow.

That’s why Dr. Anderson feels compelled to speak out on their behalf, as a transgender woman herself. “Some of my colleagues are worried that conversation about detransitioners is going to be more cannon fodder in the culture wars, but my concern is that if we don’t address these problems, there will be even more ammunition to criticize the appropriate work that I and other colleagues are doing.”

And, like Anderson, these young people — who will forever live with the consequences of hasty transition — refuse to be silenced. “I want my voice to be heard,” said Chloe. “I don’t want history to repeat itself. I can’t let this happen to other kids.”

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Transgender regret? Research challenges narratives about gender-affirming surgeries

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You’ll often hear lawmakers , activists and pundits argue that many transgender people regret their decision to have gender-affirming surgeries – a belief that’s been fueling a wave of legislation that restricts access to gender-affirming health care.

Gender-affirming care can include surgical procedures such as facial reconstruction, chest or “top” surgery , and genital or “bottom” surgery .

But in an article we recently published in JAMA Surgery, we challenge the notion that transgender people often regret gender-affirming surgeries.

Evidence suggests that less than 1% of transgender people who undergo gender-affirming surgery report regret. That proportion is even more striking when compared to the fact that 14.4% of the broader population reports regret after similar surgeries.

For example, studies have found that between 5% and 14% of all women who receive mastectomies to reduce the risk of developing breast cancer say they regretted doing so. However, less than 1% of transgender men who receive the same procedure report regret.

These statistics are based on reviews of existing studies that investigated regret among 7,928 transgender individuals who received gender-affirming surgeries. Although some of this prior research has been criticized for overlooking the fact that regret can sometimes take years to develop, it aligns with the growing body of studies that show positive health outcomes among transgender people who receive gender-affirming care.

Why access to gender-affirming surgery matters

About 1.6 million people in the U.S. identify as transgender. While only about 25% of these individuals have obtained gender-affirming surgeries, these procedures have become more commonplace . From 2016 to 2020, roughly 48,000 trans people in the U.S. received gender-affirming surgeries.

These procedures provide transgender people with the opportunity to align their physical bodies with their gender identity, which could positively impact mental health. Research shows that access to gender-affirming surgeries may reduce levels of depression, anxiety and suicidal ideation among transgender people.

The mental health benefits may explain the low levels of regret. Transgender people have far higher rates of mental health concerns than cisgender people, or people whose gender identity aligns with their sex at birth. This is largely because transgender people have a more difficult time living authentically without experiencing discrimination, harassment and violence .

Gender-affirming surgery often involves going through a number of hoops : waiting periods, hormone therapy and learning about the potential risks and benefits of the procedures. Although most surgeries are reserved for adults, the leading guidelines recommend that patients be at least 15 years old.

This thorough process that trans people go through before receiving surgery may also explain the lower levels of regret.

In addition, many cisgender people get surgeries that, in their ideal world, they wouldn’t receive. But they go through with the surgery in order to prevent a health problem.

For instance, a cisgender woman who receives a mastectomy to avoid breast cancer may ultimately regret the decision if she dislikes her new appearance. Meanwhile, a transgender man who receives the same procedure is more likely to be pleased with a masculine-looking chest.

Improving research and public policy

It’s important to note that this research is not conclusive. Views of surgeries can change over time , and patients can feel quite differently about their outcomes eight years after their surgery as opposed to one year after their surgery.

Nonetheless, the consensus among experts, including at the American Medical Association , is that gender-affirming surgery can improve transgender people’s health and should not be banned.

U.S. states such as Oklahoma and North Dakota have ignored this consensus and have restricted access to these procedures. In response, 12 states have designated themselves “ sanctuaries ” for gender-affirming care.

Although our statistics on surgical regret may change as researchers learn more, they are the best data that health care providers have. And public policies that are based on the best available evidence have the most potential to improve people’s lives.

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Regret Isn’t Rare: The Dangerous Lie of Sex Change Surgery’s Success

• June 17, 2016

We have been told sex reassignment surgery is successful. The advocates say that regret is rare, and that 98 percent of surgeries are successful. While that figure might be true for surgical complications, before we accept a narrative of surgical success we should consider the evidence. To evaluate success or failure, we need to go beyond the mechanical skill of the surgeon to examine the emotional and psychological wholeness of the patient afterwards—and not just in the first few months, but in the years to come.

Transgender advocates have worked to create a false narrative, hoodwinking the world into believing that no one ever has regrets from a surgical change of gender. They say the transgender ideology they promote is harmless, safe, even beneficial. But what happens when we dismiss the rhetoric, look at the research, and apply basic critical thinking? We see the reports of success fade and those of regret rise.

Twelve years ago, The Guardian reported that a review of more than 100 international medical studies of post-operative transgender patients by the University of Birmingham Aggressive Research Intelligence Facility found “no robust scientific evidence that gender reassignment surgery is clinically effective . . . Research from the US and Holland suggests that up to a fifth of patients regret changing sex.”

Shortly after undergoing sex change surgery, most people report feeling better. Over time, however, the initial euphoria wears off. The distress returns, but this time it is exacerbated by having a body that is irrevocably molded to look like the opposite gender. That’s what happened to me , and that’s what the people with regret who write to me say happened to them.

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A Tale of Tragic, Preventable Regret

Recently I received an email that blows the lid off the idea of sex change success and illustrates the truth about damaged lives. This man’s story of transition started in his teens. He explains:

I transitioned to female beginning in my late teens and changed my name in my early 20s, over ten years ago. But it wasn’t right for me; I feel only discontent now in the female role. I was told that my transgender feelings were permanent, immutable, physically deep-seated in my brain and could NEVER change, and that the only way I would ever find peace was to become female. The problem is, I don’t have those feelings anymore. When I began seeing a psychologist a few years ago to help overcome some childhood trauma issues, my depression and anxiety began to wane but so did my transgender feelings. So two years ago I began contemplating going back to my birth gender, and it feels right to do so. I have no doubts–I want to be male! I did have orchiectomy [the removal of one or both testicles], and that happened before my male puberty had completed, so I have a bit of facial hair which I never bothered to get electrolysis or laser for, and so the one blessing about all this is that with male hormone treatment I can still resume my male puberty where it was interrupted and grow a full beard and deep voice like I would have had if transgender feelings hadn’t intruded upon my childhood. My breasts are difficult to hide though, so I’ll need surgery to get rid of them. And saddest of all, I can never have children, which I pray God will give me the strength to withstand that sadness.

When this man’s childhood trauma was treated appropriately, his transgender feelings waned. But sadly, he lost ten years of his life and the ability to father biological children.

This young man’s story could have been foreseen and prevented if only transgender advocates had embraced the early findings of Dr. Charles Ihlenfeld. In 1979, Dr. Ihlenfeld warned his colleagues about unsuccessful outcomes . Based on six years of experience treating over 500 people with cross-gender hormones, Dr. Ihlenfeld sounded a warning on gender transition. He found that there was simply too much unhappiness among patients after changing genders, and that too many people who had sex change surgery later took their own lives. In his medical opinion, 80 percent of those who want a sex change should not do it. And for the remaining 20 percent, he found that that the sex change would only provide a temporary reprieve, not a lifelong solution.

When so many post-operative transgender individuals remain distressed, even suicidal, then a reasonable conclusion is that surgery is not sufficient to eliminate the depression.

Dangerous Levels of Psychiatric Disorders

People with a diagnosis of gender dysphoria are encouraged to undergo sex transition as treatment. But according to studies , over half of this population is likely to have one or more coexisting psychiatric disorders, such as depression, phobias, and adjustment disorders, which influence the outcomes, as we saw in the letter earlier. The coexisting psychiatric disorders should be treated first before undergoing irreversible, life-changing sex change surgeries.

A staggering 41 percent of people who identify as transgender reported in a national survey that they had attempted suicide. That’s over twenty-five times the rate of suicide attempts (1.6 percent) among the general population. Clearly, this is a group at high risk for dangerous levels of depression—and, as the work of Dr. Ihlenfeld attests, sex change surgery is not the way to help keep them safe.

Yet any report of psychiatric issues among transgenders is seen as too negative to the social justice narrative. Individuals with gender dysphoria are discouraged from seeking treatment for their depression, phobias, and adjustment disorders. Instead, it is assumed that their psychiatric difficulties are due to their “not being true to themselves,” and they are fast-tracked to transition. To my knowledge, transgender advocates have never made a point to warn the transgender community to look for other treatable disorders or to lobby the medical community for better diagnosis and care for coexisting disorders, which are present in over half the group.

I will readily admit that I have skin in the game on this topic. I was diagnosed with gender dysphoria and approved for sex reassignment surgery by the pre-eminent authority at the time, Paul Walker, PhD. He chaired the committee that authored the original Harry Benjamin International Standards of Care, which are similar to the guidelines in use today. He quickly approved me for hormone therapy and surgery without considering the comorbid disorders that might have fueled the gender dysphoria. Like the person whose story I shared above, after male-to-female surgery didn’t permanently heal my gender discomfort, I sought counseling. Amazingly, the feelings of gender discomfort I had for a lifetime died out after extensive counseling resolved the issues.

The majority of transgender people (62.7 percent, according to one study ) have at least one comorbid psychiatric disorder. Many people think transgenders are homosexual and that changing genders is about sexual relations. That wasn’t the case for me, nor for the people who have written me over the last ten years. Every single one of them had unwanted pain caused by sexual abuse, deep trauma, mental disorders, horrible loss, or terrible family circumstances in early life. Often the parents were not aware that any abuse or trauma had occurred. Treating psychological pain with sex change surgery doesn’t work.

Regret Is Not Rare

Most people don’t realize that the outcomes of sex transition are not tracked over time. That is, no one knows how many people are happy, how many have regrets, how many return to their birth sex, or how many have died as a result of suicide. Even when studies are conducted, the results are often based on a minority of the participants because, as The Guardian reported: “the results of many gender reassignment studies are unsound because researchers lost track of more than half of the participants. For example, in a five-year study of 727 post-operative transsexuals published, 495 people dropped out for unknown reasons.”

In addition, many studies may report misleading outcomes because they look at results over too short a period of time. Feelings of regret or suicide may not surface for ten to fifteen years after the transition, but studies don’t track patients that long. People with regret have contacted me as far out as thirty years after transition.

Today, we are told that those with gender dysphoria—whether they are four-year-old children or Olympic athletes —are better off living as the opposite sex. Putting blind trust in those who use bullying tactics to discourage debate or scientific challenge has traumatic and sometimes deadly consequences for the innocent victims. Consider the harm that occurs today as a result of this propaganda:

– Unbiased medical information and treatment is simply not available to those considering sex change. Only one course of treatment is provided: hormone treatment and sex reassignment surgery. – Hurting people who regret transitioning are bullied into silence. – Researchers can be run out of their profession if their results challenge the transgender activists’ narrative. The freedom to pursue scientific evidence is in jeopardy.

Let’s stop enabling the delusion that transition is the only answer. Let’s allow scientific research to flourish, no matter what the results show. Let’s look at the evidence and facts and encourage treatment options that address dangerous psychiatric conditions first. In that way, we can ensure the best outcomes for those who have gender dysphoria.

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'I feel angry': Why some people regret and reverse their transgender decisions

'I’m angry that every single doctor and therapist we saw told us this was the one and only option'

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By age 14, Eva became convinced she was a transgender boy. By 16, she had come out to her teachers and classmates.

Her emotionally manipulative family was less accepting of her decision. But a therapist in Toronto and trans activists she knew had a dramatic proposal.

She could move into the Covenant House youth shelter, and then freely go on hormones to push ahead with medical transition.

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“They thought it was so important for me to be on testosterone that it was OK if I left home and probably didn’t graduate high school,” recalled Eva, who asked that her last name not be published to preserve her privacy around sensitive issues. “Even at that point in life, when I was 16 and totally believed this was the only thing that was going to save me, I was more rational about it.”

She never did medically transition, a process that involves taking cross-sex hormones — testosterone for girls who transition to a male gender identity — and then undergo various surgical modifications.

And six years later, on her own at university in Manitoba, Eva decided she’d been “misled,” and was not transgender after all. She was attracted to women, and wanted to be attracted to them as a woman herself.

Eva, now 24, is part of a controversial cohort known as detransitioners and desisters, transgender people who come to rethink their decision, often having already undergone drug and surgical treatments.

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In October she founded an organization – Detrans Canada – she hopes will support individuals she said can feel ostracized by the LGBTQ community.

She believes transition is essential for some gender dysphoric youth, but questions a treatment approach she said pushes young people too forcefully in that direction.

“I feel a little bit angry, more than a little bit, because other people who’ve been in this position went much further than me,” said Eva. “I have lesbian friends who have no uterus, no ovaries, no breasts and are 21-years old. I’m angry that every single doctor and therapist we saw told us this was the one and only option.”

She is convinced that more and more people are detransitioning or desisting, the latter term covering those who did not medically transition, though their numbers are the subject of debate.

Detrans Canada has yet to launch a concerted recruitment drive and has fewer than a dozen Canadian members. But Eva noted that a Reddit forum for detransitioners – r/detrans – grew from 3,000 to over 16,000 members in just a few months this year.

And s everal studies have estimated that 60 to 90 per cent of children who identify as transgender no longer want to transition by the time they’re adults, often becoming gay or lesbian.

Other research , however, has estimated that actual detransitioners represent as little as one per cent of the trans population.

Greta Bauer, the CIHR chair in gender and sex science at Western University, said she’s aware of no research indicating destransitioners’ ranks are expanding. She said many don’t regret their choice, they have simply stopped taking hormones for various other reasons.

“What concerns me is that some people seem to think that the existence of any regret justifies denying or delaying care for everyone who needs a treatment,” said Bauer. “This is not the standard by which we evaluate any other medical treatment.”

Eva said she suffered from some physical abuse, an eating disorder and attention-deficit hyperactivity disorder as a child and by 14 was on anti-depressants. She also knew she was not heterosexual, but “didn’t know what was going on.”

Then she saw videos posted online by trans men, people who had transformed from “dumpy women into buffed men,” and the answer seemed at hand.

Years later she met friends in Manitoba who were dealing with their identity issues in other ways, and her own dysphoria eventually faded away.

But such alternative perspectives seem of little interest to the health-care system, Eva said, or a clientele convinced by the transition-focused approach.

“You have teenage girls who have issues with their bodies, issues socially with growing up, they have issues about their sexuality,” she said. “It’s no surprise that they have been given this fix, and that they want the fix.”

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• v.9(7); 2021 Apr

Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies

Sasha karan narayan.

1 Department of Surgery, Oregon Health and Science University, Portland, OR, USA;

Rayisa Hontscharuk

2 Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA;

Sara Danker

3 Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA;

Jess Guerriero

4 Transgender Health Program, Oregon Health & Science University, Portland, OR, USA;

Angela Carter

5 Primary Care, Equi Institute, Portland, OR, USA;

Gaines Blasdel

6 NYU Langone Health, New York, NY, USA;

Rachel Bluebond-Langner

Randi ettner.

7 University of Minnesota, Minneapolis, MN, USA;

8 Callen-Lorde Community Health Center, New York, NY, USA;

Loren Schechter

9 The University of Illinois at Chicago, Chicago, IL, USA;

10 Rush University Medical Center, Chicago, IL, USA;

11 The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL, USA;

Jens Urs Berli

12 Division of Plastic & Reconstructive Surgery, Oregon Health & Science University, Portland, OR, USA

Associated Data

The article’s supplementary files as

A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons’ experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients.

This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review.

The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2–0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons’ experience with patient regret and request for reversal was consistent with the existing literature.

Conclusions

In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Introduction

Over the past several years, there has been sustained growth in institutional and social support for transgender and gender non-conforming (TGNC) care, including gender-affirming surgery (GAS) ( 1 ). The American Society of Plastic Surgeons (ASPS) estimates that in 2016, no less than 3,200 gender-affirming surgeries were performed by ASPS surgeons. This represents a 20% increase over 2015 ( 2 ) and may be partially attributable to an increase in third party coverage ( 3 , 4 ). A rare, but consequential, risk of GAS is post-operative regret that could lead to requests for surgical reversal. As the number of patients seeking surgery increases, the absolute number of patients who experience regret is also likely to increase. While access to gender-affirming health care has expanded, these gains are under continued threat by various independent organizations, religious, and political groups that are questioning the legitimacy of this aspect of healthcare despite an ever-growing body of scientific literature supporting the medical necessity of many surgical and non-surgical affirming interventions. It is therefore not surprising that studies on regret and surgical reversal are scarce compared to studies on satisfaction and patient-reported outcomes. The transgender community rightfully fears that studies on this topic can be miscited to undermine the right to access to healthcare.

The goal of this study is to assist patients, professionals, and policy makers regarding this important, albeit rare, occurrence. We do so by addressing the following:

• The current literature regarding the etiology of regret following gender-affirming surgery;
• The experience of surgeons regarding requests for surgical reversal.

Based on these results, the authors propose a classification system for both type and etiology of regret.

It is important to acknowledge that the authors identify along the gender spectrum and are experts in the field of transgender health (mental health, primary care, and surgery). We hope to facilitate discussion regarding this multifaceted and complex topic to provide a stepping-stone for future scientific discussion and guideline development. Our ultimate goal is to reduce the possibility of regret and provide clinical support to patients suffering from the sequelae of regret. We present the following article in accordance with the SURGE reporting checklist (available at http://dx.doi.org/10.21037/atm-20-6204 ).

A 16-question survey (see Table S1 ) was developed and uploaded to the online survey platform SurveyMonkey (SurveyMonkey, Inc., San Mateo, CA, USA). This anonymous survey was e-mailed by the senior author to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. There were no incentives offered for completing this survey. One reminder e-mail was sent after the initial invitation.

Respondents were asked to describe their practices, including: country of practice, years in practice, a range estimate of the total number of TGNC patients surgically treated, and the number of TGNC patients seen in consultation who expressed regret and a desire to reverse or remove the gendered aspects of a previous gender-affirming surgery. We limited the questions to breast and genital procedures only. Facial surgery was excluded as there are no associated WPATH criteria, so there is less standardization of patient selection for surgery. Thus, we did not feel that those patients should be pooled with those who were subject to WPATH criteria in our calculation for prevalence of regret. We did not define the term “regret” in order to capture a wide range of responses. Respondents were asked about their patients’ gender-identification, the patient’s surgical transition history, and the patient’s reasons for requesting reversal surgery. If the respondents had experience with patients seeking reversal surgery, the number of such interventions were queried to include: the initial gender-affirming procedure and the patients’ reason(s) for requesting reversal procedures. The respondents were also asked about the number of reversal procedures they had performed, and what requirements, if any, they would/did have prior to performing such procedures. Finally, respondents were asked whether they believed that the WPATH Standards of Care 8 should address this topic.

Statistical analysis

Response rate was calculated from the total number of respondents as compared to the number of unique survey invitations sent. Responses to the survey were analyzed using descriptive statistics. When survey questions offered ranges, (i.e., estimating the number of patients surgically treated), the minimum and maximum values of each of the selected answers were independently summed to report a more comprehensible view of the data. Partially completed surveys were identified individually and accounted for in analysis. Any missing or incomplete data items from the survey were excluded from the results with the denominator adjusted accordingly.

Narrative literature review

A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret and satisfaction. Terms included (regret) and (transgender) and (surgery) or (satisfaction) and (transgender) and (surgery). These terms included their permutations according to the PubMed search methodology. Original research and review studies whose abstracts addressed the following topics were included for full-text review: gender-affirming surgery, sex reassignment, patient satisfaction, detransition, regret. A total of 163 abstracts were reviewed and a total of 21 articles were closely read for the relevant discussion of regret and satisfaction.

Ethical statement

This study was approved by the Oregon Health & Science Institutional Review Board #17450 and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Survey results

Of the 154 surgeons who received the survey between December 2017 and February 2018, 46 (30%) surgeons completed the survey. The survey, including its results, can be found in Table S1 . Thirty respondents (65%) were in practice for greater than 10 years, and most (67%) practice in the United States, followed by Europe (22%). The respondents treated between 18,125 and 27,325 TGNC or gender non-conforming (TGNC) patients. Most of the respondents (72%) surgically treated over 100 TGNC patients (see Figure 1 ). Of the 46 respondents, 61% of respondents encountered either at least one patient with regret regarding their surgical transition or a patient who sought a reversal procedure—irrespective of whether their initial surgery was performed by the respondent or another surgeon. Twelve respondents (26%) encountered one patient with regret, and the remaining 12 (26%) encountered two or more patients with regret. One respondent indicated that they encountered between 10 and 20 patients who regretted their surgical gender transition. No respondent encountered more than 20 such patients (see Figure 2 ). This amounted to a total of 62 patients with regret regarding surgical transition, or a 0.2% to 0.3% rate of regret. Of these 62 patients, 13 (21%) involved chest/breast surgery and 45 (73%) involved genital surgery (see Table 1 ).

Distribution of transgender surgery experiences among respondents.

Number of transgender patients encountered who expressed regret.

Totals do not add to 100 due to incomplete responses.

Of the 62 patients who sought surgical reversal procedures, at the time of their initial gender-affirming surgery, 19 patients identified as trans-men, 37 identified as trans women, and 6 identified as non-binary. The reasons for pursuing surgical reversal were provided for 46 patients (74%) and included: change in gender identity or misdiagnosis (26 patients, 42%), rejection or alienation from family or social support (9 patients, 15%), and difficulty in romantic relationships (7 patients, 11%). In some patients, surgical complications or social factors were cited as a reason for regret and request for reversal of genital surgery—no change in the patient’s gender identity was elucidated (see Table 2 , etiologies of regret). Of the 37 trans-women seeking reversal procedures, complaints at the time of secondary surgical consultation included: vaginal stenosis (7 patients), rectovaginal fistulae (2 patients), and chronic genital pain (3 patients). Of the 19 trans-men seeking reversal procedures, complaints at the time of secondary surgical consultation included: urethral fistulae (2 patients) and urethral stricture (1 patient). A total of 36 reversal procedures were reported, with supplemental qualitative descriptions provided for only 23 procedures. The distribution of the 23 reversal procedures is found in Table 1 .

Totals exceed 100 as respondents could select multiple options.

Most respondents (91%) indicated that new mental health evaluations would be required prior to performing surgical reversal procedures. Eighty-eight percent of respondents indicated that WPATH SOC 8 should include a chapter on reversal procedures (see Figure 3 ).

Respondent’s requirements to proceed with surgical reversal.

Literature review

Overall, the incidence of regret following gender-affirming surgery has been reported to be consistently very low ( 5 - 26 ). Wiepjes et al. ( 27 ) reported an overall incidence of surgical regret in the literature in transgender men as <1% and transgender women as <2%. Landen et al. comment that outcomes following gender-affirming surgery have improved due to preoperative patient assessment, more restrictive inclusion criteria, improved surgical techniques, and attention to postoperative psychosocial guidance ( 28 ). Although retrospective, the Wiepjes et al. study is the largest series to date and included 6,793 patients over 43 years. In this study, only 14 patients were classified as regretful, and only 10 of these patients pursued procedures consistent with intent to detransition. Perhaps most importantly, the Amsterdam team categorized regret into three main subtypes: “ social regret , true regret , and feeling non - binary ”.

Many of the reviewed studies aimed to identify various variables or risk factors that may identify patients that are at risk or that may predict future postoperative regret.

Earlier studies focused on patient characteristics and identified several variables that were associated with regret in their patient populations. These variables include psychological variables ( 11 , 22 , 23 ), such as previous history of depression ( 15 , 26 ), character pathology ( 26 ) or personality disorder ( 5 , 15 ), history of psychotic disorder ( 15 , 28 ), overactive temperament ( 26 ), negative self-image ( 26 ) or other psychopathology ( 15 , 19 , 26 ), as well as various social or familial factors that include history of family trauma ( 19 , 29 ), poor family support ( 5 , 11 , 15 , 28 ), belonging to a non-core group ( 28 ), previous marriage ( 15 , 19 ), and biological parenthood ( 15 , 19 ). Landen et al. identified poor family support as the most important variable predicting future postoperative regret in transgender men and women undergoing gender-affirming surgery in Sweden between 1972–1992 ( 28 ). Defined as subsequent application for reversal surgery, the authors found that 3.8% of their study population regretted their surgery. Other factors previously associated with regret include: sexual orientation ( 5 , 7 , 15 , 19 ), impaired postoperative sexual function [most notably in transgender women; ( 29 )], previous military service ( 29 ), a physically strenuous job ( 29 ), history of criminality ( 5 ), age at time of surgery and transition [>30 year increased risk; ( 5 , 6 , 11 , 15 , 19 , 29 )], asexual or hyposexual status preoperatively ( 15 , 29 ), too much or too little ambivalence regarding prospect of surgery ( 29 ), and/or an absence of gender nonconformity in childhood ( 15 ).

Studies examining transgender women have identified postoperative sexual function to be a significant factor contributing to possible surgical regret ( 15 , 29 ). A literature review by Hadj-Moussa et al. ( 11 ) (2018) identified poor sexual function as a factor that may contribute to postoperative regret in transgender women after vaginoplasty. Lindemalm et al. ( 29 ) (1986) previously reported a rate of 30% regret in their study examining 13 transgender women in Sweden after vaginoplasty. This rate of regret is the highest reported and appears to be an outlier. In their patient population, they found that only one third had a surgically-created vagina capable of sexual intercourse. This was consistent with patient-reported poor postoperative sexual function and highlights the importance of discussing sexual function following vaginoplasty. Similarly, Lawrence et al. ( 15 ) (2003) found that occasional regret was reported in 6% of transgender women after vaginoplasty, with 8 of the 15 regretful patients identifying disappointing physical and functional outcomes after their surgery. These findings are consistent with literature reviews that have found that regret is related to unsatisfactory surgical outcomes and poor postoperative function ( 19 , 30 ).

Transgender men have been found to manifest more favorable psychosocial outcomes following surgery and are less likely to report post-surgical regret ( 26 ). These findings highlight the importance of surgical results, and their influence on surgical regret. Despite this difference between transgender men and women, overall regret continues to remain low.

While the rate of surgical regret is low, many patients can suffer from many forms of “minor regret” after surgery. Although this could skew the outcomes data ( 30 ), this is considered temporary and can be overcome with counseling. As such, this should not be calculated in assessments of true regret ( 30 ). Alternatively, lasting regret is attributed to gender dysphoria and is explicitly expressed through patient postoperative behaviors ( 30 ). Factors that have been found to contribute to “minor regret” after gender-affirming surgery include postsurgical factors such as pain during and after surgery, surgical complications, poor surgical results, loss of partners, loss of job, conflict with family, and disappointments that various expectations linked to surgery were not fulfilled ( 19 ). Previous reviews further underline the importance of following the contemporaneous WPATH Standards of Care. This is especially important regarding patient education pertaining to surgical expectations and outcomes ( 11 , 26 ). Patient education programs are thought to identify those individuals who would most benefit from surgery ( 20 ). Other issues reported to decrease postoperative regret include appropriate preoperative diagnosis ( 19 , 20 , 26 ), consistent administration of hormone therapy ( 15 ), adequate psychotherapy ( 15 ), and the extent to which a patient undergoes a preoperative “real-life test” living in their desired gender role ( 15 , 19 , 20 , 26 ).

As compared to the volume of literature regarding postoperative satisfaction following gender-affirming surgery, the literature on regret is still relatively small. However, the literature (and anecdotal surgeon reports) consistently shows low rates of regret. We juxtaposed these findings to the surgeons’ experience with patients seeking reversal surgery or verbalizing regret. We found a rate of regret between 0.2–0.3%. This is consistent with the most recent data from Wiepjes et al. who reported rates of regret of 0.3% for trans-masculine and 0.6% for trans-feminine patients ( 27 ). The question of prevalence seems relatively well-answered by the current literature.

Perhaps the most striking finding is the heterogeneity of etiologies and risk factors associated with regret. Within this context, establishing consistent definitions for both regret and its underlying etiology is essential. Furthermore, as our understanding of gender identity evolves, our definitions and understanding become more precise. We highlight the Wiepjes et al. classification as an example of how narrower definitions may preclude an understanding of evolving gender theory. This predominantly single-institution study included 6,793 individuals, and the authors classified regret into three subtypes: social regret, true regret, and feeling non-binary. They categorized patients as either trans-female or trans-male. Conversely, in the 2015 US Transgender Survey, 35% of the nearly 28,000 respondents reported a non-binary identification ( 31 ). The classification by Wiepjes et al. is important in that it recognizes that individuals may not regret “transitioning”, but rather regret specific aspects of their medical treatment. More specifically, if these individuals request a reversal procedure, they are not necessarily requesting a “reversal” of their gender identity. However, the Wiepjes et al. study does not elaborate on this topic.

Case example: a trans-masculine, non-binary individual after testosterone therapy and chest masculinization regrets having secondary sex characteristics from hormonal therapy but is highly satisfied following chest masculinization. This should be considered true gender-related regret as the individual desires, at least in part, to return to the phenotype of the sex assigned at birth (e.g., hair removal). However, the etiology regarding this type of regret can be varied. For example, the etiology may include: insufficient exploration of the individual’s gender identity [by the individual and/or mental health professional (misdiagnosis)], lack of knowledge of professionals regarding surgical options for non-binary individuals, insurance carrier mandate to undergo hormonal therapy prior to chest masculinization (healthcare stigma), etc.

Based on the reviewed literature and our consensus expert opinion, we propose the following classification of regret, examples of etiology pertaining to regret ( Table 3 ), and an overview of associated terminology regarding regret ( Table 4 ).

Regret is a general term that describes an emotional state wherein a previous decision now feels incorrect. This can be temporary (fleeting ambivalence) or permanent. Permanent regret can be divided into three forms: true gender-related regret, social regret, and medical regret.

True gender-related regret involves a person having undergone a transition in gender whether by social, medical, or surgical means, indicating a formal change in gender identity, who then desires to return to their assigned sex at birth or a different gender identity. True gender-related regret differs from other types of regret in that it implies a misdiagnosis or misinterpretation of gender incongruence at the time of transition. Based on the case example, true gender-related regret need not be related to all medical treatments, but instead may be focused on specific treatments for which the individual seeks reversal. True gender-related regret constituted 42% of the requests for surgical reversal in our study. Etiology may include: misdiagnosis, insufficient exploration of gender identity, or barriers to access for options to transition to non-binary gender expression.

Social regret refers to one’s desire to return to their sex assigned at birth to alleviate the repercussions of transitioning on their social life. The etiologies can vary widely and include feeling unsafe in public, losing partnership, feeling unable to partake in one’s community, and encountering professional barriers. An additional reason identified in this study included religious conflict, mentioned in 9% of individuals. Social regret was cited in 37.1% of the requests for surgical reversal.

Medical regret includes regret originating from a direct outcome of a surgery or an irreversible consequence thereof. This area is particularly important for the medical community as it is preventable and may increase as access to care expands. Medical regret can be further subdivided into regret secondary to medical complications, long-term functional outcomes (i.e., sexual), and preoperative decision-making.

Medical regret due to inadequate preoperative decision-making is directly related to a medical intervention, but it is not due to a change in gender identity, medical complication, functional outcome, or social stigma. Examples include choosing a simple-release metoidioplasty rather than a phalloplasty or regretting gonadal sterilization later in life ( 32 ). In these situations, individuals may not have appreciated the long-term implications at the time they underwent the procedure, may have received incomplete or inaccurate counseling, may have had a change in life goals, or may have not had access to technologies that are currently available. This form of regret may be mitigated by employing a multidisciplinary approach which includes discussions beyond surgical risks (i.e., fertility preservation, sexuality, etc.) ( 33 , 34 ). Medical regret was cited in 8% of requests for reversal, however 24% of patients were separately noted to have experienced post-operative complications.

Associated definitions

Gender fluidity is an inclusive term describing gender along a spectrum rather than a binary construct. When applied to identity, gender fluidity, sometimes called “genderqueer” ( 35 , 36 ) describes an individual who remains flexible regarding their identity and may identify differently at different times in their lives. Surgeons should work collaboratively with their mental health colleagues to help the patient understand the impact of surgery and how surgery may influence/affect future life goals. Non-identified gender fluidity can be one etiology for true gender-related regret.

Continued transition medically recognizes the concept of gender fluidity and the gender spectrum. This patient seeks additional medical treatment following their initial gender-affirming procedure(s) and may express an evolving gender identity or request further surgical consolidation of their identity. The patient need not express regret over their initial transition. An example is a patient assigned male-at-birth who takes feminizing hormones and undergoes breast augmentation. Subsequently, the patient returns to the surgeon indicating they identify as non-binary and requests implant removal. With decreased stigmatization of non-binary gender identity and ability to access non-binary affirming surgical options, this type of regret may be less common in the future.

Detransition refers to a change in gender role and/or the cessation of medical transition (e.g., hormonal treatment). This term has been used controversially and disparagingly with regards to surgical transition and fails to honor the spectrum of reasons why patients may undergo reversal surgery. However, some patients utilize this term to self-identify and to describe their experiences. This term should not be used to describe the process of surgical reversal.

Retransition is a phenomenon where a patient, following surgical reversal procedures, later feels that this reversal was wrong and seeks to re-affirm their previously expressed gender identity. A reason for retransition may include a change in societal structure that has provided a safer environment for transition. The need to distinguish continued transition from retransition results from a clash between increasing societal perception of a gender spectrum and the Western culture’s binary gender construct ( 35 ).

Fleeting ambivalence (considered short-term regret) over one’s transition is common, especially if the patient experiences initial surgical complications or loss of their support communities. The normal grief experienced as a result of trauma should not be pathologized, and the patient should be encouraged to trust in their long-standing gender identification. Some patients may desire a change in gender identify as a result of feeling unsafe due to severe social stigma. Knowing this, healthcare teams should counsel patients regarding the implications of transitioning within a given societal structure prior to surgery. This may include discussions regarding the effect of transitioning on relationships, careers, personal safety in public, sexuality, etc. These discussions are often facilitated by the patient’s mental health professional and/or primary care provider.

Special considerations

We recognize that regret and surgical reversal are complex, multifaceted phenomena without an easy treatment path. While both regret and requests for surgical reversal are rare, the need for guideline development is critical in providing high-quality care for this patient population, regardless of prevalence.

A concern expressed by both providers and patients is that discussions regarding regret and surgical reversal may be used to restrict access to affirming care. The authors believe that research including feelings of grief and regret will not only help individuals who experience severe forms of regret but will also help to refine surgical indications and procedures to minimize this already rare occurrence. Finally, and perhaps most importantly, failure to study regret and surgical reversal procedures will allow these topics to be left up to interpretation and may not reflect the actual experience of patients.

Limitations

The literature review was not performed systematically and as such is subject to selection bias. Our survey involved a survey of gender surgeons but did not include other medical or mental health professionals who may evaluate patients requesting surgical reversal. In addition, the study findings are limited by its design. Because survey studies are prone to recall bias, response bias, and selection bias, they are not well-suited for calculating the prevalence of a particular condition. For example, 89% of the respondents practice in the United States and Europe. This leaves significant areas of the world underrepresented and so does not represent the experiences or desires of all international surgeons. Furthermore, the survey was distributed in English only, as it was circulated to surgeons who attended conferences in the United States. Most notably, patients may have sought consultation from multiple surgeons resulting in an overestimation of the prevalence of regret. Conversely, patients seeking surgical reversal may not have had access to additional surgical care, causing an underestimate in the prevalence of regret. While our study findings are strengthened by external validation from other studies, the true prevalence of regret remains an estimate.

Regret after gender-affirming surgery was found to be rare, both in the literature as well as in our survey of surgeons’ experiences with this topic. Regret can be classified as true gender-related regret, social regret and medical regret from complications, function, pre-intervention decision making. Guidelines in transgender health should include both preventive strategies as well as treatment guidelines if regret occurs. Future studies and scientific discourse are encouraged on this important topic.

Supplementary

Acknowledgments.

The authors acknowledge the many surgeons who were surveyed in this work, and the community members who thusly contributed to the survey results.

This research was orally presented by Dr. Sasha Narayan at the Philadelphia Trans Wellness Conference (PTWC) August 2018 in Philadelphia, PA and at the World Professional Association for Transgender Health (WPATH) International Conference, November 2018 in Buenos Aires, Argentina. This research was orally presented by Dr. Sara Danker at Plastic Surgery, The Meeting (PSTM), October 2018 in Chicago, IL.

Funding : None.

Ethical Statement : The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Oregon Health & Science Institutional Review Board #17450. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Provenance and Peer Review : This article was commissioned by the Guest Editors (Drs. Oscar J. Manrique, John A Persing, and Xiaona Lu) for the series “Transgender Surgery” published in Annals of Translational Medicine . The article has undergone external peer review.

Reporting Checklist : The authors have completed the SURGE reporting checklist. Available at http://dx.doi.org/10.21037/atm-20-6204

Data Sharing Statement : Available at http://dx.doi.org/10.21037/atm-20-6204

Conflicts of Interest : All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-6204 ). The series “Transgender Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. RBL reports that he serves on the standards of care committee of WPATH. No financial reward. Dr. AR reports that he serves as board member for World Professional Association for Transgender Health. This is an uncompensated position. Dr. LS reports other from Elsevier Publishing, other from Springer Publishing, outside the submitted work; and he serves on the board of WPATH (world professional association for transgender health), this is an unpaid position. Dr. JUB reports that he serves on the standards of care committee of the World professional association of transgender health. No financial reward associated with this. The authors have no other conflicts of interest to declare.

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Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

Bustos, Valeria P. MD * ; Bustos, Samyd S. MD † ; Mascaro, Andres MD ‡ ; Del Corral, Gabriel MD, FACS § ; Forte, Antonio J. MD, PhD, MS ¶ ; Ciudad, Pedro MD, PhD ∥ ; Kim, Esther A. MD ** ; Langstein, Howard N. MD †† ; Manrique, Oscar J. MD, FACS ††

From the * Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

† Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa.

‡ Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Weston, Fla.

§ Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C.

¶ Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Fla.

∥ Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru

** Division of Plastic and Reconstructive Surgery, University of California, San Francisco, Calif.

†† Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y.

Published online 19 March 2021

Received for publication July 27, 2020; accepted January 25, 2021.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com .

Oscar J. Manrique, MD, FACS, Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, 160 Sawgrass Drive, Suite 120, Rochester, NY 14620, E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Background: 

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

Methods: 

A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

Results: 

A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%–2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%–<1%) and 1% (CI <1%–2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin’s regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

Conclusions: 

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

The authors of the March 2021 Gender Affirming Surgery Mini-series article entitled “Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence” ( Plast Reconstr Surg Glob Open . 2021;9(3):e3477), wish to make the following corrections in the tables and figures. The systematic review was re-conducted, and the meta-analysis was re-run with the updated numbers with no significant or major changes. The updated tables and figures are included below.

Plastic and Reconstructive Surgery – Global Open. 10(4):e4340, April 2022.

Introduction

Discordance or misalignment between gender identity and sex assigned at birth can translate into disproportionate discomfort, configuring the definition of gender dysphoria. 1–3 This population has increased risk of psychiatric conditions, including depression, substance abuse disorders, self-injury, and suicide, compared with cis-gender individuals. 4 , 5 Approximately 0.6% of adults in the United States identify themselves as transgenders. 6 Despite advocacy to promote and increase awareness of the human rights of transgender and gender non-binary (TGNB) individuals, discrimination continue to afflict the daily life of these individuals. 4 , 7

Gender-affirmation care plays an important role in tackling gender dysphoria. 5, 8–10 Gender-affirmation surgeries (GAS) aim to align the patients’ appearance with their gender identity and help achieve personal comfort with one-self, which will help decrease psychological distress. 5 , 10 These interventions should be addressed by a multidisciplinary team, including psychiatrists, psychologists, endocrinologists, physical therapists, and surgeons. 1 , 9 The number of GAS has consistently increased during the last years. In the United States, from 2017 to 2018, the number of GAS increased to 15.3%. 8 , 11 , 12

Significant improvement in the quality of life, body image/satisfaction, and overall psychiatric functioning in patients who underwent GAS has been well documented. 5 , 13–19 However, despite this, there is a minor population that experiences regret, occasionally leading to de-transition surgeries. 20 Both regret and de-transition may add an important burden of physical, social, and mental distress, which raises concerns about the appropriateness and effectiveness of these procedures in selected patients. Special attention should be paid in identifying and recognizing the prevalence and factors associated with regret. In the present study, we hypothesized that the prevalence of regret is less than the last estimation by Pfafflin in 1993, due to improvements in standard of care, patient selection, surgical techniques, and gender confirmation care. Therefore, the aim of this study was to evaluate the prevalence of regret and assess associated factors in TGNB patients 13-years-old or older who underwent GAS. 20

Search Methodology

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive research of several databases from each database’s inception to May 11, 2020, for studies in both English and Spanish languages, was conducted. 21 The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by an experienced librarian, with input from the study’s principal investigator. Controlled vocabulary supplemented with keywords was used to search for studies of de-transition and regret in adult patients who underwent gender confirmation surgery. The actual strategy listing all search terms used and how they are combined is available in Supplemental Digital Content 1. ( See Supplemental Digital Content 1, which displays the search strategy. https://links.lww.com/PRSGO/B598 .)

Study Selection

Search results were exported from the database into XML format and then uploaded to Covidence. 22 The study selection was performed in a 2-stage screening process. The first step was conducted by 2 screeners (V.P.B. and S.S.B.), who reviewed titles and abstracts and selected those of relevance to the research question. Then, the same 2 screeners reviewed full text of the remaining articles and selected those eligible according to the inclusion and exclusion criteria ( Fig. 1 ). If disagreements were encountered, a third reviewer (O.J.M.) moderated a discussion, and a joint decision between the 3 reviewers was made for a final determination. Inclusion criteria were all the articles that included patients aged 13 years or more who underwent GAS and report regret or de-transition rates, and observational or interventional studies in English or Spanish language. Exclusion criteria were letter to the editors, case series with <10 patients, case reports correspondences, and animal studies.

Data Extraction/Synthesis

After selecting the articles, we assessed study characteristics. We identified year of publication, country in which the study was conducted, population size, and number of transmasculine and transfemenine patients with their respective mean age (expressed with SD, range, or interquartile range if included in the study). In addition, we extracted information of the method of data collection (interviews versus questionnaires), number of regrets following GAS, as well as the type of surgery, time of follow-up, and de-transition procedures. We classified the type of regret based on the patient’s reasons for regret if they were mentioned in the studies. We used the Pfäfflin and Kuiper and Cohen-Kettenis classifications of regret ( Table 1 ). 20 , 23

Quality Assessment

To assess the risk of bias within each study, the National Institute of Health (NIH) quality assessment tool was used. 24 This tool ranks each article as “good,” “fair,” or “poor,” and with this, we categorized each article into “low risk,” “moderate risk,” or “high risk” of bias, respectively.

Our primary outcome of interest was the prevalence of regret of transgender patients who underwent any type of GAS. Secondary outcomes of interest were discriminating the prevalence of regrets by type gender transition (transfemenine and transmasculine), and type of surgery.

Data Analysis and Synthesis

The binominal data were analyzed, and the pooled prevalence of regret was estimated using proportion meta-analysis with Stata Software/IC (version 16.1). 25 Given the heterogeneity between studies, we conducted a logistic-normal-random-effect model. The study-specific proportions with 95% exact CIs and overall pooled estimates with 95% Wald CIs with Freeman-Turkey double arcsine transformation were used. The effect size and percentage of weight were presented for each individual study. 25 , 26

To evaluate heterogeneity, I 2 statistics was used. If P < 0.05 or I 2 > 50%, significant heterogeneity was considered. A univariate meta-regression analysis was performed to assess the significance in country of origin, tools of measurement, and quality of the studies.

To assess publication bias, we used funnel plot graphic and the Egger test. If this test showed us no statistical significance ( P > 0.05), we assumed that the publication bias had a low impact on the results of our metanalysis. To assess the impact of the publication bias on our missing studies, we used the trim-and-fill method.

A sensitivity analysis was conducted to assess the influence of certain characteristics in the magnitude and precision of the overall prevalence of regret. The following characteristics were excluded: <10 participants included, and the presence of a high risk of bias.

A total of 74 articles were identified in the search, and 2 additional records were identified through other sources. After the first-step screening process, 39 articles were relevant based on the information provided in their titles and abstracts. After the second-step process, a total of 27 articles were included in the systematic review and metanalysis ( Fig. 1 ).

Based on the NIH quality assessment tool, the majority of article ranged between “poor” and “fair” categories. 24 ( See Supplemental Digital Content 2, which displays the score of each reviewed study. https://links.lww.com/PRSGO/B599 .)

Study Characteristics

In total, the included studies pooled 7928 cases of transgender individuals who underwent any type of GAS. A total of 2578 (33%) underwent transmasculine procedures, 5136 (67%) underwent transfemenine surgeries, and 1 non-binary patient underwent surgery. In Table 2 characteristics of studies are listed. Without discriminating type of surgical technique, from all transfemenine surgeries included, 772 (39.3%) were vaginoplasty, 260 (13.3%) were clitoroplasty, 107 (5.5%) were breast augmentation, 72 (3.7%) were labioplasty and vulvoplasty, and a small minority were facial feminization surgery, vocal cord surgery, thyroid cartilage reduction, and oophorectomy surgery. The rest did not specify type of surgery. In regard to transmasculine surgeries, 297 (12.4%) were mastectomies, 61 (2.6%) were phalloplasties, and 51 (2.1%) hysterectomies ( Table 3 and 4 ). Overall, follow-up time from surgery to the time of regret assessment ranged from 0.8 to 9 years ( Table 2 ).

Regrets and De-transition

Almost all studies conducted non-validated questionnaires to assess regret due to the lack of standardized questionnaires available in this topic. 15 , 19–33 Most of the questions evaluating regret used options such as, “ yes,” “sometimes,” “no” or “ all the time,” “sometimes,” “never,” or “most certainly, ” “very likely,” “maybe,” “rather not,” or “definitely not.” 14 , 18 , 19 , 23 , 27–38 Other studies used semi-structured interviews. 34 , 37 , 39–43 However, in both circumstances, some studies provided further specific information on reasons for regret. 14 , 20 , 23 , 29 , 32 , 36 , 41 , 44–46 Of the 7928 patients, 77 expressed regret (12 transmen, 57 transwomen, 8 not specified), understood by those who had “sometimes” or “always” felt it.

Reasons for Regret

The most prevalent reason for regret was the difficulty/dissatisfaction/acceptance in life with the new gender role. 23 , 29 , 32 , 36 , 44 Other less prevalent reasons were “failure” of surgery to achieve their surgical goals in an aesthetic level and psychological level. 29 , 32 , 36 , 47 Based on the reasons presented, we classified the types of regrets according to Pfäfflin’s types of regret and Kuiper and Cohen-Kettenis classification. According to Pfäfflin’s types, 28 patients had minor regret, and 34 patients had major regret. 14 , 20 , 23 , 29 , 32 , 36 , 41 , 44 , 45 Based on the Kuiper and Cohen-Kettenis regret classification, 35 patients had clear regret, 26 uncertain regret, 1 regret, and none presented with regret assumed by others. 23 In Table 5 and 6 , the reasons and classifications are shown.

Prevalence of Regret

The pooled prevalence of regret among the TGNB population after GAS was 1% (95% Confidence interval [CI] <1%–2%; I 2 = 75.1%) ( Fig. 2 ). The prevalence for transmasculine surgeries was <1% (CI <1%–<1%, I 2 = 28.8%), and for transfemenine surgeries, it was 1% (CI <1%–2%, I 2 = 75.5%) ( Fig. 3 ). The prevalence of regret after vaginoplasty was of 2% (CI <1%–4%, I 2 = 41.5%) and that after mastectomy was <1% (CI <1–<1%, I 2 = 21.8%) ( Fig. 4 ).

Meta-regression and Publication Bias

No covariates analyzed affected the pooled endpoint in this metanalysis. The Funnel Plot shows asymmetry between studies ( Fig. 5 ). The Egger test resulted in a P value of 0.0271, which suggests statistical significance for publication bias. The Trim & Fill method imputed 14 approximated studies, with limited impact of the adjusted results. The change in effect size was from 0.010 to 0.005 with no statistical significance ( Fig. 6 ).

Sensitivity Analysis

When excluding studies with sample sizes less than 10 and high-risk biased studies, the pooled prevalence was similar 1% (CI <1%–3%) compared with the pooled prevalence when those studies were included 1% (CI <1%–2%).

The prevalence of regret in the TGNB population after GAS was of 1% (CI <1%–2%). The prevalence of regret for transfemenine surgeries was 1% (CI <1%–2%), and the prevalence for transmasculine surgeries was <1% (CI <1%–<1%). Traditionally, the landmark reference of regret prevalence after GAS has been based on the study by Pfäfflin in 1993, who reported a regret rate of 1%–1.5%. In this study, the author estimated the regret prevalence by analyzing two sources: studies from the previous 30 years in the medical literature and the author’s own clinical practice. 20 In the former, the author compiled a total of approximately 1000–1600 transfemenine, and 400–550 transmasculine. In the latter, the author included a total of 196 transfemenine, and 99 transmasculine patients. 20 In 1998, Kuiper et al followed 1100 transgender subjects that underwent GAS using social media and snowball sampling. 23 Ten experienced regret (9 transmasculine and 1 transfemenine). The overall prevalence of regret after GAS in this study was of 0.9%, and 3% for transmasculine and <0.12% for transfemenine. 23 Because these studies were conducted several years ago and were limited to specific countries, these estimations may not be generalizable to the entire TGNB population. However, a clear trend towards low prevalences of regret can be appreciated.

The causes and types of regrets reported in the studies are specified and shown in Table 5 and 6 . Overall, the most common reason for regret was psychosocial circumstances, particularly due to difficulties generated by return to society with the new gender in both social and family enviroments. 23 , 29 , 32 , 33 , 36 , 44 In fact, some patients opted to reverse their gender role to achieve social acceptance, receive better salaries, and preserve relatives and friends relationships. These findings are in line with other studies. Laden et al performed a logistic regression analysis to assess potential risk factors for regret in this population. 46 They found that the two most important risk factors predicting regret were “poor support from the family” and “belonging to the non-core group of transsexuals.” 46 In addition, a study in Italy hypothesized that the high percentage of regret was attributed to social experience when they return after the surgery. 33

Another factor associated with regret (although less prevalent) was poor surgical outcomes. 20 , 23 , 36 Loss of clitoral sensation and postoperative chronic abdominal pain were the most common reported factors associated with surgical outcomes. 14 , 36 In addition, aesthetic outcomes played an important role in regret. Two studies mentioned concerns with aesthetic outcomes. 14 , 47 Only one of them quoted a patient inconformity: “body doesn’t meet the feminine ideal.” 14 Interestingly, Lawrence et al demonstrated in their study that physical results of surgery are by far the most influential in determining satisfaction or regret after GAS than any preoperative factor. 36 Concordantly, previous studies have shown absence of regret if sensation in clitoris and vaginal is achieved and if satisfaction with vaginal width is present. 36

Other factors associated to regret were identified. Blanchard et al in 1989 noted a strong positive correlation between heterosexual preference and postoperative regret. 32 All patients in this study who experienced regret were heterosexual transmen. 32 On the contrary, Lawrence et al in 2003 did not find such correlation and attributed their findings to the increase in social tolerance in North American and Western European societies. 36 Bodlund et al found that clinically evident personality disorder was a negative prognostic factor for regret in patients undergoing GAS. 48 On the other hand, Blanchard et al did not find a correlation among patient’s education, age at surgery, and gender assigned at birth. 32

In the present review, nearly half of the patients experienced major regret (based on Pfäfflin classification), meaning that they underwent or desire de-transition surgery, that will never pass through the same process again, and/or experience increase of gender dysphoria from the new gender. One study found that 10 of 14 patients with regret underwent de-transition surgeries (8 mastectomies, 2 vaginectomies, 2 phalloplasties, 2 testicular implants removal, and 1 breast augmentation) for reasons of social regret, true regret or feeling non-binary. 23 On the other hand, based on the Kuiper and Cohen Kettenis’ classification, half of the patients in this review had clear regret and uncertain regret . This means that they freely expressed their regret toward the procedure, but some had role reversal to the former gender and others did not. Interestingly, Pfäfflin concluded that from a clinical standpoint, trangender patients suffered from many forms of minor regrets after GAS, all of which have a temporary course. 20 This is an important consideration meaning that the actual true regret rate will always remain uncertain, as temporarity and types of regret can bring a huge challenge for assessment.

Regret after GAS may result from the ongoing discrimination that afflicts the TGNB population, affecting their freely expression of gender identity and, consequently feeling regretful from having had surgery. 15 Poor social and group support, late-onset gender transition, poor sexual functioning, and mental health problems are factors associated with regret. 15 Hence, assessing all these potential factors preoperatively and controlling them if possible could reduce regret rates even more and increase postoperative patient satisfaction.

Regarding transfemenine surgery, vaginoplasty was the most prevalent. 14 , 19 , 23 , 30–33 , 35 , 36 , 44 , 45 Interesintgly, regret rates were higher in vaginoplasties. 14 , 36 , 44 In this study, we estimated that the overall prevalence of regret after vaginoplasty was 2% (from 11 studies reviewed). This result is slightly higher than a metanalysis of 9 studies from 2017 that reported a prevalence of 1%. 13 Moreover, vaginoplasty has shown to increase the quality of life in these patients. 13 Mastectomy was the most prevalent transmasculine surgery. Also, it showed a very low prevalence of regret after mastectomy (<1%). Olson-Kennedy et al demonstrated that chest surgery decreases chest dysphoria in both minors and young adults, which might be the major reason behind our findings. 38

In the current study, we identified a total of 7928 cases from 14 different countries. To the best of our knowledge, this is the largest attempt to compile the information on regret rates in this population. However, limitations such as significant heterogeneity among studies and among instruments used to assess regret rates, and moderate-to-high risk of bias in some studies represent a big barrier for generalization of the results of this study. The lack of validated questionnaires to evaluate regret in this population is a significant limiting factor. In addition, bias can occur because patients might restrain from expressing regrets due to fear of being judged by the interviewer. Moreover, the temporarity of the feeling of regret in some patients and the variable definition of regret may underestimate the real prevalence of “true” regret.

Based on this meta-analysis, the prevalence of regret is 1%. We believe this reflects and corroborates the increased in accuracy of patient selection criteria for GAS. Efforts should be directed toward the individualization of the patient based on their goals and identification of risk factors for regrets. Surgeons should continue to rigorously follow the current Standard of Care guidelines of the World Professional Association for Transgender Health (WATH). 49

CONCLUSIONS

Our study has shown a very low percentage of regret in TGNB population after GAS. We consider that this is a reflection on the improvements in the selection criteria for surgery. However, further studies should be conducted to assess types of regret as well as association with different types of surgical procedure.

Acknowledgments

All the authors have completed the ICMJE uniform disclosure form. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Why Gender Reassignment Surgery Isn’t a Cure-all for Many Trans People

Imagine coming to the realization that you are in the wrong body. Inside you feel a certain way, but your appearance reflects something different. How do you cope with this dichotomy? Can you? If you’re transgendered, one approach is sexual reassignment surgery. Correct the outside appearance, and the symmetry should allay any conflict. However, a new meta-analysis conducted by UK researchers finds that some patients are just as distressed after the operation as before . Researchers reviewed 100 studies of post-operative transsexuals from around the globe to draw their conclusions.

British newspaper The Guardian was the motivating force behind this study. It interviewed several people who had gone through such an operation and regretted it. In the meta-analysis, researchers found zero evidence that undergoing such a procedure had any value to the patient. Researchers at the University of Birmingham’s aggressive research intelligence facility (Arif) conducted the study.

The director of Arif, Chris Hyde, expressed doubt on whether gender reassignment surgery was beneficial. “There’s still a large number of people who have the surgery but remain traumatized,” he said. “Often to the point of committing suicide.” Unfortunately, in their final analysis, Arif investigators determined that the lion’s share of the research on this topic so far was poorly designed and executed.

Though things have been tough for the transgendered, acceptance is beginning to take root.

Between 100 and 500 of these procedures occur in the US in any given year, according to the Surgery Encyclopedia , although a separate report indicates that, in terms of male-to-female transitions (MF) alone, between 800 and 1,000 occur annually .

According to some accounts, those who undergo a sex change sometimes feel the hormone therapy, which they must undergo for a year prior to surgery, “pushes” them into it. Others say they will never be accepted in their new body, and so would rather go back to the old one. In one of the studies, over half of the participant pool disappeared. The reason was unknown.

This may reflect the disdain for their new body or worse, according to Dr. Hyde. Though the majority of patients do well, Dr. Hyde contends, those who do not are woefully unprepared for how bad they feel. Some say that losing half of the participants in such a study reflects how little regard the transgendered receive in society.

A recent study out of the University of California, San Diego proves that many trans people feel at odds with their own physical gender . The ability to identify this may someday work to help trans children understand who they are. After puberty, transitioning becomes more difficult, medically speaking. This neurological discovery could help clear up questions of whether a transition should occur or not, as brain imaging data is objective. It could also help to tell whether a person will take well to sexual reassignment.

New study uses brain imaging to show neurological differences between transgendered and cisgendered.

Laura Case at UC San Diego wanted to see if she could use brain imaging to detect an incongruity between the brain and the body, in terms of gender identity. Eight trans men, or those who are female biologically but identify as male, were tested, along with eight cisgender women—used as a control group.

Using magnetoencephalography and an MRI, researchers found that trans men had less activity in a region of the brain known as the supramarginal gyrus. This area gives us a sense of our body parts belonging to us. It may mean that that sense is less pronounced in the transgendered than in cisgendered or traditionally gendered people. Whether this feeling came first and caused a biological response, or the biological manifestation shaped the psychology of the person, is not yet known. One previous study found that white matter in four regions of the brain of trans men closely resembled that of cisgender men.

More research is planned, which will look into the neurobiology of the transgendered, and the impact of sexual assignment surgery on them. For many of us, gender is something we take for granted. Unfortunately, trans people must try to find their way in a dichotomous world where the true diversity of humanity is often ignored, overlooked, ridiculed, or shunned.

The supramarginal gyrus. Image y Gray, vectorized by Mysid, colourd by was_a_bee. (File:Gray726.svg) [Public domain], via Wikimedia Commons.

The truth is that many more people are born with ambiguous sex organs than we think. Oftentimes in the past, doctors at the time of birth decided arbitrarily which gender the child was going to be, simply by which sex organ was easier to fashion. Those born with ambiguous genatalia are known as “intersex.” This occurs in about one in 1,500 or 2,000 births or 1.7% of the world population . Due to this, for many, identifying as gender fluid may make more sense.

By all accounts, intersex babies are just as healthy as their cisgender counterparts. Unfortunately, our society’s focus on labels makes the lives of those who are trans difficult. Perhaps instead we should love them for who they really are, regardless of what they have in their pants.

The other important notion is that it’s human nature to think, “If only _____ were true, I’d be content.” But no matter the physical situation, contentment cannot come from without, no matter how we think the outcome might transform us. Though in some cases, it seems gender reassignment surgery can be life changing, contentment itself, no matter your gender, be it strict or fluid, can only come from within.

To hear one person’s story click here: 

A Reuters Special Report

Why detransitioners are crucial to the science of gender care.

UNDONE: Max Lazzara lived as a transgender man for eight years before detransitioning in 2020. She says she now realizes that gender-affirming medical treatment was not appropriate for her and that it took a toll on her physical and mental health. REUTERS/Matt Mills McKnight

USA-TRANSYOUTH/OUTCOMES

Understanding the reasons some transgender people quit treatment is key to improving it, especially for the rising number of minors seeking to medically transition, experts say. But for many researchers, detransitioning and regret have long been untouchable subjects.

By ROBIN RESPAUT , CHAD TERHUNE and MICHELLE CONLIN

Filed Dec. 22, 2022, noon GMT

For years, Dr Kinnon MacKinnon, like many people in the transgender community, considered the word “regret” to be taboo.

MacKinnon, a 37-year-old transgender man and assistant professor of social work at York University here, thought it was offensive to talk about people who transitioned, later regretted their decision, and detransitioned. They were too few in number, he figured, and any attention they got reinforced to the public the false impression that transgender people were incapable of making sound decisions about their treatment.

“This doesn’t even really happen,” MacKinnon recalled thinking as he listened to an academic presentation on detransitioners in 2017. “We’re not supposed to be talking about this.”

MacKinnon, whose academic career has focused on sexual and gender minority health, assumed that nearly everyone who detransitioned did so because they lacked family support or couldn’t bear the discrimination and hostility they encountered – nothing to do with their own regret. To learn more about this group for a new study, he started interviewing people.

In the past year, MacKinnon and his team of researchers have talked to 40 detransitioners in the United States, Canada and Europe, many of them having first received gender-affirming medical treatment in their 20s or younger. Their stories have upended his assumptions.

Many have said their gender identity remained fluid well after the start of treatment, and a third of them expressed regret about their decision to transition from the gender they were assigned at birth. Some said they avoided telling their doctors about detransitioning out of embarrassment or shame. Others said their doctors were ill-equipped to help them with the process. Most often, they talked about how transitioning did not address their mental health problems.

In his continuing search for detransitioners, MacKinnon spent hours scrolling through TikTok and sifting through online forums where people shared their experiences and found comfort from each other. These forays opened his eyes to the online abuse detransitioners receive – not just the usual anti-transgender attacks, but members of the transgender community telling them to “shut up” and even sending death threats.

“I can’t think of any other examples where you’re not allowed to speak about your own healthcare experiences if you didn’t have a good outcome,” MacKinnon told Reuters.

The stories he heard convinced him that doctors need to provide detransitioners the same supportive care they give to young people to transition, and that they need to inform their patients, especially minors, that detransitioning can occur because gender identity may change. A few months ago, he decided to organize a symposium to share his findings and new perspective with other researchers, clinicians, and patients and their families.

Not everyone was willing to join the discussion. A Canadian health provider said it couldn’t participate, citing recent threats to hospitals offering youth gender care. An LGBTQ advocacy group refused to promote the event. MacKinnon declined to identify either, telling Reuters he didn’t want to single them out. Later, after he shared his findings on Twitter, a transgender person denounced his work as “transphobia.”

He expected his research would be a hard sell even to many of the 100 or so people from Canada, the United States and elsewhere who accepted his invitation. “I need your help,” he told the crowd that assembled in November in a York University conference room for the daylong session. “My perspectives have changed significantly. But I recognize that for many of you, you may find yourselves feeling much like I did back in 2017 – challenged, apprehensive, maybe fearful.”

Fighting words

In the world of gender-affirming care, as well as in the broader transgender community, few words cause more discomfort and outright anger than “detransition” and “regret.” That’s particularly true among medical practitioners in the United States and other countries who provide treatment to rising numbers of minors seeking to transition.

They insist, as MacKinnon once did, that detransitioning is too rare to warrant much attention, citing their own experiences with patients and extant research to support their view. When someone does detransition, they say, it’s almost never because of regret, but rather, a response to the hardship of living in a society where transphobia still runs rampant.

“These patients are not returning in droves” to detransition, said Dr Marci Bowers, a transgender woman, gender surgeon and president of the World Professional Association for Transgender Health (WPATH), an international group that sets guidelines for transgender care. Patients with regret “are very rare,” she told Reuters. “Highest you’ll find is 1% or 1.5% of any kind of regret.”

Doctors and many transgender people say that focusing on isolated cases of detransitioning and regret endangers hard-won gains for broader recognition of transgender identity and a rapid increase in the availability of gender care that has helped thousands of minors. They argue that as youth gender care has become highly politicized in the United States and other countries, opponents of that care are able to weaponize rare cases of detransition in their efforts to limit or end it altogether, even though major medical groups deem it safe and potentially life-saving.

“Stories with people who have a lot of anger and regret” about transitioning are over-represented in the media, and they don’t reflect “what we are seeing in the clinics,” said Dr Jason Rafferty, a pediatrician and child psychiatrist at Hasbro Children’s Hospital in Providence, Rhode Island. He also helped write the American Academy of Pediatrics’ policy statement in support of gender-affirming care. Detransitioning is a “very invalidating term for a lot of people who are trans and gender-diverse,” Rafferty said.

Some people do detransition, however, and some do so because of regret. The incidence of regret could be as low as clinicians like Bowers say, or it could be much higher. But as Reuters found, hard evidence on long-term outcomes for the rising numbers of people who received gender treatment as minors is very weak.

Dr Laura Edwards-Leeper, a clinical psychologist in Oregon who treats transgender youths and a co-author of WPATH’s new Standards of Care for adolescents and children, said MacKinnon’s work represents some of the most extensive research to date on the reasons for detransitioning and the obstacles patients face. She said the vitriol he has encountered illustrates one reason so few clinicians and researchers are willing to broach the subject.

“People are terrified to do this research,” she said.

For this article, Reuters spoke to 17 people who began medical transition as minors and said they now regretted some or all of their transition. Many said they realized only after transitioning that they were homosexual, or they always knew they were lesbian or gay but felt, as adolescents, that it was safer or more desirable to transition to a gender that made them heterosexual. Others said sexual abuse or assault made them want to leave the gender associated with that trauma. Many also said they had autism or mental health issues such as bipolar disorder that complicated their search for identity as teenagers.

Echoing what MacKinnon has found in his work, nearly all of these young people told Reuters that they wished their doctors or therapists had more fully discussed these complicating factors before allowing them to medically transition.

No large-scale studies have tracked people who received gender care as adolescents to determine how many remained satisfied with their treatment as they aged and how many eventually regretted transitioning. The studies that have been done have yielded a wide range of findings, and even the most rigorous of them have severe limitations. Some focus on people who began treatment as adults, not adolescents. Some follow patients for only a short period of time, while others lose track of a significant number of patients.

“There’s a real need for more long-term studies that track patients for five years or longer,” MacKinnon said. “Many detransitioners talk about feeling good during the first few years of their transition. After that, they may experience regret.”

In October, Dutch researchers reported results of what they billed as the largest study to date of continuation of care among transgender youths. In a review of prescription drug records, they found that 704, or 98%, of 720 adolescents who started on puberty blockers before taking hormones had continued with treatment after four years on average. The researchers couldn’t tell from the records why the 16 had discontinued treatment.

Gender-care professionals and transgender-rights advocates hailed the 98% figure as evidence that regret is rare. However, the authors cautioned that the result may not be replicated elsewhere because the adolescents studied had undergone comprehensive assessments, lasting a year on average, before being recommended for treatment. This slower, methodical approach is uncommon at many U.S. gender clinics, where patient evaluations are typically done much faster and any delay in treatment, or “gatekeeping,” is often believed to put youth at risk of self-harm because of their distress from gender dysphoria.

Dr Marianne van der Loos, the Dutch study’s lead author, is a physician at Amsterdam University Medical Center’s Center for Expertise on Gender Dysphoria, a pioneer in gender care for adolescents. “It’s important to have evidence-based medicine instead of expert opinion or just opinion at all,” van der Loos said.

Reliable evidence of the frequency of detransition and regret is important because, as MacKinnon, van der Loos and other researchers say, it could be used to help ensure that adolescent patients receive the best possible care.

“We cannot carry on in this field that involves permanently changing young people’s bodies if we don’t fully understand what we’re doing and learn from those we fail.” Dr Laura Edwards-Leeper, clinical psychologist and co-author of WPATH treatment guidelines for adolescents

A basic tenet of modern medical science is to examine outcomes, identify potential mistakes, and, when deemed necessary, adjust treatment protocols to improve results for patients. For example, only after large international studies analyzing outcomes for thousands of patients did researchers establish that implanted coronary artery stents were no better than medication for treating most cases of heart disease.

Stronger data on outcomes, including the circumstances that make regret more likely, would also help transgender teens and their parents make better-informed decisions as they weigh the benefits and risks of treatments with potentially irreversible effects.

“We cannot carry on in this field that involves permanently changing young people’s bodies if we don’t fully understand what we’re doing and learn from those we fail,” said Edwards-Leeper, the clinical psychologist and WPATH member. “We need to take responsibility as a medical and mental-health community to see all the outcomes,” she said in an interview.

As Reuters reported in October , thousands of families in the U.S. have been weighing these difficult choices amid soaring numbers of children diagnosed with gender dysphoria, the distress experienced when a person’s gender identity doesn’t align with their gender assigned at birth. They have had to do so based on scant scientific evidence of the long-term safety and efficacy of gender-affirming treatment for minors.

Concern about how to cope with the growing waiting lists at gender clinics that treat minors has divided experts. Some urge caution to ensure that only adolescents deemed well-suited to treatment after thorough evaluation receive it. Others argue that any delay in treatment prolongs a child’s distress and puts them at risk of self-harm.

Detransition defined

Detransitioning can mean many things. For those who transitioned socially, it may entail another change in name, preferred pronouns, and dress and other forms of identity expression. For those who also received medical treatment, detransitioning typically includes halting the hormone therapy they otherwise would receive for years.

Nor do all people who stop treatment regret transitioning, according to interviews with detransitioners, doctors and researchers. Some end hormone therapy when they have achieved physical changes with which they are comfortable. Some are unhappy with the side effects of hormones, such as male pattern baldness, acne or weight gain. And some are unable to cope with the longstanding social stigma and discrimination of being transgender.

Doctors and detransitioners also described the challenging physical and emotional consequences of the process. For example, patients who had their ovaries or testes removed no longer produce the hormones that match their gender assigned at birth, risking bone-density loss and other effects unless they take those hormones the rest of their lives. Some may undergo years of painful and expensive procedures to undo changes to their bodies caused by the hormones they took to transition. Those who had mastectomies may later undergo breast reconstruction surgery. As parents, they may regret losing the ability to lactate. Detransitioners also may need counseling to cope with the process and any lingering regret.

The impact can be social, too. In a study published last year in the Journal of Homosexuality, a researcher in Germany surveyed 237 people who had socially or medically transitioned and later detransitioned, half of them having transitioned as minors. Many respondents reported a loss of support from the LGBTQ community and friends, negative experiences with medical professionals, difficulty in finding a therapist familiar with detransition and the overall isolation after detransition.

“Many respondents described experiences of outright rejection from LGBT+ spaces due to their decision to detransition,” wrote Elie Vandenbussche, the study’s author, a detransitioner and at the time a student at Rhine-Waal University of Applied Sciences. “It seems reasonable to suspect that this loss of support experienced by detransitioners must have serious implications on their psychological well-being.”

In its new Standards of Care, released in September, WPATH cited Vandenbussche’s paper and a few others on detransitioning and continuation of care among younger patients. “Some adolescents may regret the steps they have taken,” the WPATH guidelines say. “Therefore, it is important to present the full range of possible outcomes when assisting transgender adolescents.”

However, Bowers, WPATH’s president, is among several gender-care specialists who say patients are ultimately responsible for choices they make about treatment, even as minors. They should not be “blaming the clinician or the people who helped guide them,” she said. “They need to own that final step.”

WPATH’s guidelines acknowledge the lack of research on long-term outcomes for youth who didn’t undergo comprehensive assessments, saying that the “emerging evidence base indicates a general improvement in the lives of transgender adolescents” who receive treatment after careful evaluation. “Further, rates of reported regret during the study monitoring periods are low,” the guidelines say.

Specific treatment protocols for detransitioning are hard to find. WPATH’s guidelines don’t provide detailed advice to clinicians on treating patients who detransition. The Endocrine Society’s guidelines for gender-affirming care, published in 2017, don’t address the issue, either. The “question of discontinuing hormone treatment is beyond the scope covered by the current guideline,” an Endocrine Society spokeswoman said.

Some doctors think they – and patients – would benefit from more guidance. “We have guidelines to guide us in providing transition-related care, initiating hormones and managing them long-term. Equally as important would be having guidelines in deprescribing hormones in the safest way possible,” said Dr Mari-Lynne Sinnott, a doctor who attended MacKinnon’s symposium. She runs one of the only family medical practices in Newfoundland focused on gender-diverse people, who make up about half of her 1,500 patients.

“Sure of my identity”

Max Lazzara’s childhood in Minneapolis, Minnesota, was chaotic, with divorce, “moving around a lot, some emotionally abusive stuff at home,” she said. Her mother worked full-time, so Lazzara did most of the cooking, cleaning and caring for her little brother. She began to cut and burn herself as a means of coping and had tried to commit suicide three times before she entered high school, according to Lazzara and her medical records, which cite a history of bipolar disorder.

“The life of a woman was bleak to me,” Lazzara told Reuters. “I worried that I would have to get married to a man someday and have a baby. I wanted to run far away from that.”

In early 2011, when Lazzara was 14, she started questioning her gender identity. After discovering forums on Tumblr where young people described their transitions, she felt like something snapped into place. “I thought, ‘Wow, this could explain why my whole life felt wrong.’”

During the summer of that year, Lazzara changed her name and began experimenting with presenting as more masculine. It felt good to cut her hair and wear gender-neutral or men’s clothing. She took medications and received therapy to treat bipolar disorder. But it wasn’t enough to alleviate her distress. In April 2012, Lazzara was admitted to the hospital at the University of Minnesota after a fourth suicide attempt.

“I felt so strongly. I thought nothing would change my mind.” Max Lazzara, on her decision to medically transition at age 16

Three weeks later, she sought care at the university’s Center for Sexual Health, where she was diagnosed with gender identity disorder. Lazzara told the clinic she was “sure of my identity,” according to her medical records. She wanted hormones and surgeries, the records show, including a mastectomy, a hysterectomy, and liposuction to slim her legs and hips. She was horrified at her body, could not look down in the shower and felt “absolute dread at the time of menstrual cycle,” the records note.

“I felt so strongly. I thought nothing would change my mind,” Lazzara told Reuters.

Clinicians at the university warned families that their children were suicidal “because they are born in the wrong bodies,” Lazzara’s mother, Lisa Lind, told Reuters. “I thought, ‘I’ll do whatever it takes, so she doesn’t kill herself.’”

Lazzara started taking testosterone in the fall of 2012, at age 16. She was still binding her breasts – so tightly, she said, that her ribs deformed. After a man groped her on the street, she decided to have breast-removal surgery, tapping the college fund her grandmother had left for her to cover the nearly $10,000 cost.

Initially, Lazzara was happy with her transition. She liked the changes from taking testosterone – the redistribution of fat away from her hips, the lower voice, the facial hair – and she was spared the sexist cat-calling that her female friends endured. “I felt like I was growing into something I wanted to be,” Lazzara said.

But her mental health continued to deteriorate. She attempted suicide twice more, at ages 17 and 20, landing in the hospital both times. Her depression worsened after a friend sexually abused her. She became dependent on prescription anti-anxiety medication and developed a severe eating disorder.

During the summer of 2020, Lazzara was spiraling. She realized she no longer believed in her gender identity, but “I didn’t see a way forward.”

That October, Lazzara was working as a janitor in an office building in the Seattle area when she caught her reflection in a bathroom mirror. For the first time, she said, she saw herself as a woman. “I had not allowed myself to have that thought before,” she said. It was shocking but also clarifying, she said, and “a peaceful feeling came over me.”

Then she began to ponder her sexuality. In middle school, she had crushes on girls. After her transition, she identified as a transgender man who was bisexual. Now, she realized, she was a lesbian.

Lazzara stopped taking testosterone. She later asked her doctor in the Seattle area for advice, but he seemed unsure about how to proceed. She found a new doctor and recently sought laser hair removal on her face.

Lazzara told Reuters she now realizes that gender treatment was not appropriate for her and that it took a toll on her physical and mental health. “I do wish my doctors had said to me, ‘It’s OK to feel disconnected from your body. It’s OK to like girls. It’s OK to be gender non-conforming.’”

Since Max Lazzara detransitioned, many in the online transgender community who embraced her a decade ago have distanced themselves from her, and she has received hateful messages on social media.

Her original gender-care providers at the University of Minnesota declined to comment. In a statement, the university’s medical school said “gender-affirming care involves a carefully thought-out care plan between a patient and their multidisciplinary team of providers.”

Lazzara recently found the before-and-after pictures of her torso on the website of the surgeon who performed her mastectomy in 2013. She had given him permission to post the images because he was proud of the outcome. Seeing her body as it once was stunned her. “I saw my breasts before I got them removed. That’s my 16-year-old body,” she said. “I had no ability at that age to be in my own body in my own way.”

Since revealing she detransitioned, Lazzara said, many in the online transgender community who embraced her a decade ago have distanced themselves from her, and she has received hateful messages on social media. Now, when she sees someone come out online as detransitioned, she sends them a private message of support. “I know how lonely and alienating it can be,” she said.

“Shut up,” detransitioner

Transgender people are frequently subjected to harassment, abuse and threats online. And as Lazzara’s experience shows, so are detransitioners. In recent posts on TikTok, users took turns telling detransitioners to “shut up,” and mocked, attacked and blamed them for perpetuating harm on the transgender community.

Diana Salameh, a transgender woman, film director and comedian from Mississippi, posted a TikTok video on Oct. 1 to “all the so-called transgender detransitioners out there.” Detransitioners “are just giving fuel to the fire to the people who think that no trans person should exist,” she said in the video. “You people who jumped the gun, made wrong decisions that you should actually feel embarrassed for, but you want to blame somebody else.” In closing, she said, “I think you all need to sit down and shut the fuck up!”

Salameh told Reuters she posted the video because detransitioners spread the false idea “that nobody can be happy after transition,” and right-wing opponents of youth gender care are using their stories “to fuel their agendas.”

Earlier this year, K.C. Miller, a 22-year-old in Pennsylvania who was assigned female at birth, began wrestling with how she felt about her medical transition.

Miller initially sought treatment for gender dysphoria when she was 16 from the adolescent gender clinic at Children’s Hospital of Philadelphia. In September 2017, Miller met with Dr Linda Hawkins, a counselor and co-founder of the hospital’s gender clinic, for the first of two 90-minute visits. During that session, Miller told Hawkins she had wanted to be a Boy Scout as a kid and “always felt like a tomboy,” according to Hawkins’ notes in Miller’s medical records, reviewed by Reuters. Miller also told Reuters that as a young girl she was attracted to other girls, but didn’t feel she could pursue those relationships because her family’s church didn’t accept homosexuality.

Miller’s case had further complications. Hawkins noted that Miller had an extensive history of sexual abuse by a family member starting at age 4, and that as a result, Miller had already been diagnosed with anxiety and post-traumatic stress disorder. Miller had been admitted to a psychiatric hospital for 10 days because of suicidal thoughts in late 2016.

While in the hospital, Miller told her mother she wished she wasn’t a girl “because then the abuse would not have happened,” Hawkins wrote. Elsewhere in the records, Hawkins noted that “Mom expresses concern that the desire to be male and not female may be a trauma response.”

Miller, her mother and Hawkins met again seven weeks later. Miller had continued to have suicidal thoughts. She had taken medication for depression and anxiety and was working with a therapist, Hawkins noted. By the end of that second visit, Hawkins concluded that, “in spite of” Miller’s trauma from abuse, the 16-year-old “has been insistent, persistent and consistent” in thinking of herself as male.

Hawkins referred Miller to a local gender clinic to receive testosterone. Miller got a mastectomy about six months later.

But medical treatment didn’t offer the relief she sought. Her body started to change due to the hormones, yet Miller didn’t feel better. Instead, she cycled through bouts of depression. She passed as a young man, but “something felt off. It felt like I was putting on an act.”

Then Miller began reading the stories posted online by young detransitioners. Parts of their experiences resonated with her. “I absolutely would not have done this if I could go back and do it again,” Miller told Reuters. “I would have worked through therapy and would be living my life as a lesbian.”

Miller said Hawkins should have done a more thorough evaluation of all of Miller’s mental health issues and shouldn’t have recommended treatment so quickly.

Her mother, who asked not to be identified to protect her privacy, told Reuters that providers assured her that Miller’s distress was related to her gender identity and that gender-affirming care would reduce the risk of suicide.

A spokesman for Children’s Hospital of Philadelphia declined to comment, citing patient privacy.

Sitting in her car in early October, Miller let out years of frustration in a video posted on Twitter. She told viewers she felt she looked too masculine to detransition. She described how testosterone thinned her hair. “I don’t see me personally being able to come back from what’s happened,” she said in the video.

The video went viral, registering nearly four million views within days and igniting an avalanche of comments. Two days after Miller’s post, Alejandra Caraballo, a transgender woman, LGBTQ-rights advocate and clinical instructor at Harvard Law School’s Cyberlaw Clinic, wrote on Twitter: “The detransition grift where you complain about transitioning not making you look like a greek god but you also aren’t actually detransitioning yet because you don’t feel like your birth gender and you follow a bunch of anti-trans reactionaries that want all trans people gone.”

Caraballo told Reuters she reacted to Miller’s video because those types of detransition stories are “outlier examples being used by many on the anti-trans side to undermine access to gender-affirming care. They aren’t representative of detransitioners on the whole.”

In other posts and direct messages, some transgender people Miller had once idolized made fun of her appearance and criticized her decisions. One person made a death threat.

A few weeks later, Miller said she stopped taking testosterone, began to feel suicidal and sought psychiatric care. She uses female pronouns among friends, but still presents as a man in public.

In its Standards of Care, WPATH says many detransitioners “expressed difficulties finding help during their detransition process and reported their detransition was an isolating experience during which they did not receive either sufficient or appropriate support.”

In May, Dr Jamison Green, a transgender man, author and former president of WPATH, said he was encouraged when about 30 medical professionals attended an online WPATH seminar he and other gender-care specialists helped lead. The session was intended to help providers better serve detransitioners and other patients with an evolving gender identity.

“I wish people in the transgender community would be less judgmental about people who change their mind,” Green said. “Transgender people, especially when they are newer to the community, can be really brutal to people for not conforming. I really think it’s harmful for everybody.”

Word search pitfalls

Ever since the first clinic to offer gender care to minors in the United States opened in Boston 15 years ago, none of the leading providers have published any systematic, long-term studies tracking outcomes for all patients.

In 2015, the National Institutes of Health funded a study to examine outcomes for about 400 transgender youth treated at four U.S. children’s hospitals, including the gender clinic at Boston Children’s Hospital. Researchers have said they are looking at “continuation of care.” However, long-term results are years away.

That has left a small assortment of studies to guide clinicians in this emerging field of medicine. The results of these studies suggest a wide range of possibilities for rates of detransitioning, from less than 1% to 25%. The research provides even less certainty about the incidence of regret among patients who received medical treatment as minors. And the studies have serious drawbacks.

Two of the largest ones, which found that 2% or less of people who transitioned experienced regret, focused on Europeans who primarily initiated treatment as adults. Experts caution that the results, because of the differences in maturity and life experiences between adults and adolescents, may have limited relevance as an indicator of outcomes for minors.

Researchers acknowledge that studies that follow patients for only a short time may underestimate detransition and regret because evidence indicates some people may not reach that point until as long as a decade after treatment began. Some studies also lose track of patients – a recurring challenge as minors age out of pediatric clinics and have to seek care elsewhere.

Even the choice of search terms can trip up researchers, as apparently happened in a study published in May by Kaiser Permanente, a large integrated health system based in Oakland, California.

That study examined 209 patients who underwent gender-affirming mastectomies as minors between 2013 and 2020 in Kaiser’s northern California region. Its authors searched the patients’ medical records for words such as “regret,” “dissatisfaction,” “unsatisfied” and “unhappy” as indicators of regret. They didn’t look for the term “detransition,” according to the study.

Their search yielded two patients who had expressed regret, or less than 1% of the group studied. The two patients, identified as nonbinary, had top surgery at age 16, and expressed regret within a year and a half.

Reuters found two other patients in the region covered by the study who don’t match those characteristics and whom the Kaiser researchers apparently missed. Both have been outspoken about their detransitions.

One is Max Robinson, who was 16 when she sought gender care at Kaiser in 2012. Her pediatric endocrinologist prescribed a puberty blocker and later testosterone.

The doctor monitored Robinson’s hormone levels, wrote numerous letters to help Robinson change her legal gender from female to male, and recommended a plastic surgeon in San Francisco, Robinson’s medical records show. “I have no reservations recommending Max as a well adjusted candidate for breast reduction,” the Kaiser endocrinologist wrote to the surgeon in May 2013. Max had the surgery six weeks later, when she was 17.

After the surgery, Robinson felt better. But within a year, her mental health issues, including anxiety and depression, had escalated, medical records show.

In November 2015, three years after starting testosterone and two years after her surgery, Robinson told the Kaiser physician she was now seeing that she wasn’t interested in taking hormones any longer. “I’m no longer going to be using testosterone, so I don’t need further appointments or for those prescriptions to be active,” she wrote to the doctor. Two months later, she asked Kaiser to provide a letter confirming her detransition so she could change her legal records back to female. Kaiser obliged.

“The whole experience alienated me from my doctors,” she told Reuters.

Robinson began to speak publicly about her decision to detransition and in 2021 published “Detransition: Beyond Before and After,” a book in which she details her own process of medical transition and detransition.

The other patient was Chloe Cole. According to a letter of intent to sue that her lawyers sent to Kaiser in November, Cole was 13 when a Kaiser doctor in 2018 put her on a puberty blocker, followed a few weeks later by testosterone, for her gender-affirming treatment.

At 15, Cole told Reuters, she also wanted top surgery. In an interview, she and her father said the doctors at Kaiser readily agreed, though he wanted to wait until she was older.

“They were so adamant,” he said. He recalled the doctors telling him: “‘At this age, they definitely know what their gender is.’” The father asked not to be named out of concern that speaking publicly might jeopardize his employment. Detransition, he said, “wasn’t really discussed as a possibility.”

In June 2020, a Kaiser surgeon performed a mastectomy on Cole, according to the letter of intent to sue. That was a month before her 16th birthday. Less than a year later, Cole said, she began to realize she regretted her surgery and medically transitioning in general after a discussion in school about breastfeeding and pregnancy.

Cole said that when she discussed her decision to detransition with her gender-care specialist at Kaiser, “I could tell that I made her upset that I was so regretful,” Cole said in an interview. Eventually, the doctor offered to recommend a surgeon for breast reconstruction, Cole said, “but that’s something I’ve decided to not go through with.”

Cole has begun speaking out publicly in support of measures to end gender-affirming care for minors, appearing often on conservative media and with politicians who back such bans.

In the letter of intent, Cole’s lawyers said Kaiser’s treatment “represents gross negligence and an egregious breach of the standard of care.”

Steve Shivinsky, a spokesman for Kaiser Permanente, declined to comment on the care provided to Cole and Robinson or whether they were included in the study, citing patient privacy.

In a statement, he said Kaiser’s “clinicians are deeply interested in the outcomes of the care we provide and the individual’s state of health and wellbeing before, during and beyond their gender transition.” For adolescents seeking gender-affirming care, he said, “the decision always rests with the patient and their parents and, in every case, we respect the patients’ and their families’ informed decision to choose one form of care over another.”

The Kaiser researchers followed up with patients in their study an average of 2.1 years after surgery. “The time to develop postoperative regret and/or dissatisfaction remains unknown and may be difficult to discern given that regret is quite rare,” the researchers wrote.

A change of perspective

MacKinnon, the assistant professor of social work, grew up as what he calls “a gender-nonconforming tomboy” in a small Nova Scotia town. After getting his degree in social work, he medically transitioned at 24 when he started taking testosterone. “It was a very slow build,” MacKinnon said of his transition. He didn’t identify as transgender as a child.

As a young researcher in Toronto, MacKinnon was drawn to work that exposed the barriers transgender people face in getting medical care and navigating daily life, interviewing clinicians and patients about their experiences. More recently, he turned his attention to detransition and regret.

In August 2021, MacKinnon published a paper in which he and his co-authors wrote that there was “scant evidence that detransition is a negative phenomenon” for patients that would justify limiting access to gender-affirming treatment. That conclusion angered many of the detransitioners he would later need to win over.

Michelle Alleva, a 34-year-old detransitioner in Canada, criticized MacKinnon’s study in a blog post as another effort by gender-care supporters to whitewash the pain of regret and assuage clinicians’ fears of malpractice lawsuits. Another detransitioner complained on Twitter that the word “regret” was put in quotes in the paper, undermining its legitimacy in her opinion.

Still skeptical that regret was a significant issue, MacKinnon in the autumn of 2021 embarked on his latest study and began talking to more people about their decisions to detransition. In July, he published a paper based on formal interviews with 28 of the more than 200 detransitioners he and his colleagues have found.

A third expressed either strong or partial regret about their transition. Some said their transitions should have proceeded more slowly, with more therapy. Others expressed regret about the lasting impact on their bodies. Some said their mental health needs weren’t adequately addressed before transitioning. “They felt like their consent wasn’t informed because they didn’t initially understand what was going on that might have explained their feelings and suffering,” MacKinnon told Reuters.

The patients’ stories brought MacKinnon round to the view that the gender-care community needs to address regret, adjust treatment to reduce its incidence, and provide better support for detransitioners. “Some of what I’ve learned about detransitioners is identifying cracks in the gender-affirming care system, particularly for young people,” he said.

In September, MacKinnon presented his findings to a small but attentive crowd at WPATH’s annual conference in Montreal. A few weeks later, he shared his research more widely on Twitter. “We need to listen to and learn from the experiences of detransitioners, not silence them,” he wrote.

Some people applauded his work. Others criticized it. Robyn D., who identified as “quietly trans,” replied on Twitter: “Transphobia disguised as academic opinion is the most poisonous of them all.” She didn’t respond to requests for comment from Reuters.

At his November symposium, MacKinnon didn’t encounter the blowback from clinicians that he had expected. In fact, he accepted an invitation from one to speak about detransition at her medical practice.

Alleva, who had criticized MacKinnon’s earlier study, was also there, one of the scores of detransitioners MacKinnon and his colleagues have talked to. She medically transitioned 12 years ago and then detransitioned in 2020 after a mastectomy, a hysterectomy and years of testosterone. She had refused to participate in his research because she didn’t trust MacKinnon, but over the summer, they began talking.

“He reminded me of my old trans friends who I don’t speak with anymore,” Alleva said. “He actually listened to me.”

Few answers: A survey of the science on gender-care outcomes for youths

No large-scale, long-term studies have tracked the incidence of detransition and regret among patients who received gender-affirming treatment as minors. Studies that are available yield a wide range of results for various definitions of detransition, regret or continuation of care. Due to their limitations, the studies lack definitive answers. Here is an overview of frequently cited research:

Research institutions

Karolinska Institute, Karolinska University Hospital, Sahlgrenska University Hospital

The study’s authors said they found a 2.2% regret rate  among patients who had gender reassignment surgeries in Sweden from 1960 to 2010. The researchers found 681 people who filed a government application for a legal change in gender and received surgery, which was available only to patients 18 and older. Among that group, 15 people later reversed their decisions and filed a “regret application” with a national health board.

Limitations

The authors said the regret rate for patients in the last decade reviewed, from 2001 to 2010, may have increased over time. “The last period is still undecided since the median time lag until applying for a reversal was 8 years,” according to the study.

Far fewer adolescents received gender-affirming medical care prior to 2010. Also, the assessment phase for patients in the study was much longer than what Reuters found most youth gender clinics in the U.S. offer today. The gender-care specialists in Sweden did approximately one year of evaluation before recommending any treatment, according to the study.

10.1007/s10508-014-0300-8

Netherlands

Research institution

Amsterdam University Medical Center

February 2018

This study found a rate of regret of less than 1%  among transgender men and women “who underwent gonadectomy,” or removal of the testes or ovaries, from 1972 to 2015 in the Netherlands.

The authors found 14 cases of regret out of 2,627 patient cases reviewed. The earliest any of the 14 started hormone treatment was 25. Until 2014, transgender people in the Netherlands had to undergo gonadectomy to change the gender on their birth certificate. For surgery, patients were required to be at least 18 and on hormone therapy for at least a year.

The study didn’t report regret among patients who didn’t undergo surgery. Thirty-six percent of patients overall didn’t return to the clinic after several years of treatment and were lost to follow-up.

People treated in the last decade of the study may report regret later. “In our population the average time to regret was 130 months, so it might be too early to examine regret rates in people who started with (hormone therapy) in the past 10 years,” the authors wrote.

https://www.jsm.jsexmed.org/article/S1743-6095(18)30057-2/fulltext

October 2022

Researchers found that 98% of 720 adolescents who started on puberty blockers before taking hormones had continued with treatment after four years on average. The authors used a nationwide prescription drug registry in the Netherlands to track whether patients were still taking hormones.

The researchers didn’t identify the reasons why 2% of patients had stopped treatment . The adolescents in the Netherlands also went through a lengthy assessment process, a year on average, before being recommended for medical treatment. For that reason, the Dutch researchers say, their results may not be applicable more broadly.

“There might be a difference because of that diagnostic phase,” said Dr Marianne van der Loos, the study’s lead author and a physician at Amsterdam University Medical Center’s Center for Expertise on Gender Dysphoria. “If you don’t have that, maybe more people will start treatment and reconsider it later on because they didn’t get help during that phase by a mental health professional.”

https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(22)00254-1/fulltext

United States

Children’s Mercy Kansas City, Uniformed Services University, U.S. Department of Defense

The authors said that more than a quarter of patients  who started gender-affirming hormones before age 18 stopped getting refills  for their medication within four years. The study examined 372 children of active duty and retired service members in the U.S. military insurance system, known as TRICARE.

It’s unclear why patients stopped their medication because the study only examined pharmacy records. The researchers said the number of patients who stopped hormones is likely an overestimate because they couldn’t rule out that some patients got hormones outside of the military system, perhaps at college or with different health insurance.

The follow-up period for many patients was relatively short. The researchers examined patients enrolled from 2009 to 2018, but 58% of the patients started hormones in the last 22 months of the study.

https://doi.org/10.1210/clinem/dgac251

United Kingdom

University College London Hospitals, Leeds Teaching Hospitals, Tavistock and Portman clinic – National Health Service Trust

Researchers found that 90 patients, or 8.3% , of 1,089 adolescents referred for gender-affirming care at endocrinology clinics no longer identified as gender-diverse , either before or after starting on puberty blockers or hormones. The review spanned patients who were treated from 2008 through 2021.

The authors noted the 8.3% figure may be an underestimate because 62 additional patients, or 5.4% of all participants, moved away or didn’t follow up with the clinics.

https://adc.bmj.com/content/107/11/1018

Fenway Institute, Massachusetts General Hospital

Drawing on the 2015 U.S. Transgender Survey, the authors found that 13.1%  of 17,151 respondents had detransitioned  for some period of time.

Some of the common reasons respondents provided were pressure from a parent (35.6%), pressure from their community or societal stigma (32.5%), or difficulty finding a job (26.9%). Nearly 16% of respondents cited at least one “internal driving factor, including fluctuations in or uncertainty regarding gender identity,” according to the study. Half of the people who reported detransitioning had taken gender-affirming hormones.

By design, the authors said, all respondents identified as transgender at the time of survey completion, and the survey wasn’t intended to capture people who detransitioned and no longer identified as transgender.

https://www.liebertpub.com/doi/10.1089/lgbt.2020.0437

Youth in Transition

By Robin Respaut, Chad Terhune and Michelle Conlin

Photo editing: Corinne Perkins

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

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Media's 'detransition' narrative is fueling misconceptions, trans advocates say

In early October, the United Kingdom's SkyNews ran a story about the “Detransition Advocacy Network,” a new charity founded by Charlie Evans, a former transgender man who detransitioned in 2018. Evans told SkyNews that “hundreds” of young trans people were seeking her help to return to their sex assigned at birth, and she said more resources are urgently needed for people experiencing post-transition regret.

"I'm in communication with 19- and 20-year-olds who have had full gender reassignment surgery who wish they hadn't, and their dysphoria hasn't been relieved, they don't feel better for it," Evans told SkyNews. "They don't know what their options are now.”

Following SkyNews’ interview with Evans, news outlets across the U.K. and the United States covered the phenomenon of detransitioning . The BBC dedicated an hour to the topic on two of its flagship programs in late November, and right-wing outlets such as The Daily Wire and Breitbart covered the topic with an explicitly transphobic spin. New York magazine published a piece last month about another advocacy group for ex-trans people where one interviewee expressed concern that "many teenage women ... have been convinced too quickly that the only solution is to change their sex."

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No one disputes that transition regret does exist and that there are trans people who return to the sex they were assigned at birth. However, trans advocates say some of the recent coverage around the topic portrays detransitioning as much more common than it actually is, fueling misconceptions about the gender transition process and painting trans people as just temporarily confused or suffering from a misdiagnosed psychological disorder. This misleading information, they say, can have serious real-world consequences, from misguided policy proposals to social stigma.

“I think the reason why detransition stories are popular in this given time is because it neatly fits into this idea that young people especially are being made to be trans,” Lui Asquith, a legal counselor for U.K.-based LGBTQ group Mermaids, told NBC News. “The media are conjuring up a panic about trans lives, and the first victims of that panic are the young people who are indirectly being told that they're a phase."

How common is 'transition regret'?

There are an estimated 1.4 million transgender adults in the U.S., according to the Williams Institute at the UCLA School of Law, and the U.K.’s Government Equalities Office “tentatively” estimates there are between 200,000 and 500,000 trans people in Britain and Northern Ireland.

While the information regarding how many trans people detransition is sparse, those who work with the trans community say it is uncommon. “The actual numbers around them are significantly low,” Asquith said.

"Are there risks to getting gender affirming care? Maybe. But are there risks for not getting gender affirming care? Definitely. And the risks of the latter usually outweigh the former."

Dr. Jack Turban

The information that does exist appears to corroborate Asquith’s claim. In a 2015 survey of nearly 28,000 people conducted by the U.S.-based National Center for Transgender Equality, only 8 percent of respondents reported detransitioning, and 62 percent of those people said they only detransitioned temporarily. The most common reason for detransitioning, according to the survey, was pressure from a parent, while only 0.4 percent of respondents said they detransitioned after realizing transitioning wasn’t right for them.

The results of a 50-year survey published in 2010 of a cohort of 767 transgender people in Sweden found that about 2 percent of participants expressed regret after undergoing gender-affirming surgery.

The numbers are even lower for nonsurgical transition methods, like taking puberty blockers. According to a 2018 study of a cohort of transgender young adults at the largest gender-identity clinic in the Netherlands, 1.9 percent of adolescents who started puberty suppressants did not go on to pursue hormone therapy, typically the next step in the transition process.

Misinformation about the transition process

Stories about detransitioning often include misinformation not only about the prevalence of transition regret, but also about transitioning itself, according to transgender health experts and LGBTQ advocates. They say misconceptions about the gender transition process — including at what age different procedures are even considered — are widespread.

"We have people that are using media to educate themselves, and media is picking and mixing what they want to highlight and what they want to conflate or exaggerate," Asquith said. "It's incredibly unhelpful."

Dr. Stephen Rosenthal, medical director for the University of California, San Francisco, Child and Adolescent Gender Center, said before the onset of puberty, there’s “ no role ” for medical intervention in a person who might be transgender, something that is not always made clear in media coverage .

For a child who has not yet reached puberty, trans health experts recommend seeking mental health support, because even prior to disclosing a gender identity that is different than the one they were assigned at birth, trans youth can experience symptoms including depression, social isolation and suicidal ideation. While medical guidelines advise that prepubescent children do not undergo hormone interventions, they state that allowing trans youth to “socially transition,” which can include taking on a new name and wearing a different style of clothing, can greatly benefit a child.

“It’s letting your child be themselves and loving them for who they are,” transgender advocate Gillian Branstetter said of the guidelines regarding children who haven't reached puberty.

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Once the child starts to experience puberty, health experts — including those at the U.K.’s National Health Service and the American Academy of Pediatrics — recommend a puberty blocker, as experiencing puberty when suffering from gender dysphoria can be traumatic for trans youth. With age, gender-expansive youth can explore other options such as gender-affirming hormones and surgery.

The World Professional Association of Transgender Health (WPATH) Standards of Care recommends deferring genital surgery until a person is at least 18 years old. But even then, only 25 percent of trans and gender-noncomforming adults in the U.S. reported undergoing some form of transition-related surgery, according to a 2015 U.S. Transgender Survey .

There have also been misconceptions surrounding the safety and lasting impact of nonsurgical transitioning steps, like puberty blockers. In September, a false news story linking the use of puberty blockers to “thousands of deaths” went viral , thanks in no small part to the signal boosting of right-wing media outlets like The Daily Wire.

Dr. Jack Turban, a resident physician in psychiatry at Massachusetts General Hospital who researches the mental health of trans youth, told NBC News that puberty blockers are actually a pretty low-risk way to provide care for gender dysphoric youth.

“Puberty blockers put puberty on hold so that adolescents have more time to decide what they want to do next. This is important because, while pubertal blockade is reversible, puberty itself is not,” he said. “It’s much more common to regret not getting puberty blockers than it is to regret getting puberty blockers.”

“With any intervention there are risks and benefits,” Turban said. “Are there risks to getting gender affirming care? Maybe. But are there risks for not getting gender affirming care? Definitely. And the risks of the latter usually outweigh the former.”

The consequences of misleading coverage

Advocates say that media coverage around transgender issues, and the public discourse it generates, can have a real-life impact on the lives of transgender people.

Branstetter, who as the former spokesperson for the National Center for Transgender Equality spent years speaking to the press and following coverage about transgender issues, said the media too often focuses on the “debate” over trans people’s validity, and does not pay enough attention to the struggles and joys of the trans experience.

“Decisions about newsworthiness are too often pinned to skepticism about trans people, or an assumption that your readers are more interested in whether trans people exist and not the actual experiences of trans people,” she said.

Asquith said coverage that questions the existence of trans identities can be particularly harmful to trans youth, an already vulnerable group that has an alarmingly high rate of attempted suicide and is subjected to disproportionately high rates of bullying and harassment. According to a 2017 National School Climate Survey by GLSEN, 44 percent of LGBTQ students reported feeling unsafe at school because of their gender expression.

“If one's gender identity is different than that assigned at birth, if parents are being made to feel like that's wrong,” Asquith said, “that is not OK."

“The media need to take responsibility for that,” she added.

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Misleading coverage has also provoked misguided policy proposals and political maneuvers disguised as genuine concerns for children’s health, according to LGBTQ advocates. Branstetter pointed to recent coverage about two Texas parents involved in a bitter divorce who disagreed over whether their 7-year-old is transgender. Following claims by the father that the child’s mother, a pediatrician, was trying to “chemically castrate” their child, Republican lawmakers in the state inserted themselves into the matter Gov. Greg Abbott ordered an investigation into the family, and Sen. Ted Cruz, R-Texas, went so far as to call parents who support their trans children “ child abusers .”

Branstetter said that media coverage is tied to the bigotry that transgender people face in their daily lives. She pointed to the recently proposed bills in Texas, Georgia and Kentucky that would ban access to trans health care for minors, such as puberty blockers and hormone replacement therapy, and said that media coverage has played a large role in making anti-trans proposals like them politically fruitful.

“Those very proposals, should they be enacted into law, have a body count,” she said. “It would be restricting health care as prescribed by doctors, it would be people crossing state lines in order to get the health care they need. It would not merely destroy lives, it would end lives. And all of that is based on false myths about who trans people are and what our health care entails.”

'Wedge issues'

Some advocates say the burst of detransition stories is just the latest in a cycle of media narratives that, intentionally or not, fuel misconceptions and stir up anti-trans sentiment.

Tea Uglow, creative director for Google’s Australia-based Creative Lab, is one of those advocates. Earlier this year, she debuted a project titled “ Yours Sincerely, The Fourth Estate ,” an archive of headlines and articles containing the word “transgender” from various U.K. and Australian news outlets between August 2018 and August 2019. Uglow told NBC News that stories about detransitioning and transition regret are the latest example of a broader trend.

“What is very obvious over the last few years is how there have been different wedge issues at different points, like the bathroom debates and then this very interesting thing about trans women in sports ,” Uglow said. “It's a pernicious cycle.”

In 2016, following North Carolina’s reversal of a Charlotte city ordinance permitting transgender people to use bathrooms that align with their gender identity, the debate over which restroom trans people should use was covered widely, with some of the coverage veering transphobic. As recently as November 2018, the trans bathroom debate was still being used in political ads . More recently, a slew of national victories by transgender athletes prompted a call for trans women to be banned from participating in women's sporting events over concerns that they would make the playing field uneven .

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Less than one-quarter (24 percent) of Americans report having a close friend or family member who is transgender , according to the Public Research Religion Institute. This means for most people in the U.S. — and likely beyond — media coverage is the primary way they’re receiving information about the community. This is part of the reason Asquith said media outlets should be more aware of the impact their coverage could have on the trans community.

“It's about media taking responsibility for the repercussions of the rhetoric that is out there,” Asquith said. “It is fueling hate.”

Turban has a prescription for those disseminating misleading information about trans people: Talk to the experts.

"What would be useful is if journalists and politicians reach out to transgender people and the physicians and researchers who actually study this topic, rather than cisgender political pundits and people who don’t care for trans youth," he said.

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