Off the trans train

There is more treatment regret coming down the line, but how much?

Photo by Kenny Eliason on Unsplash

There are reasons to expect an increasing number of detransitioners to emerge in coming years, although nobody is systematically tracking how many adolescents regret medicalised gender change, according to a new journal article.

“Given the novelty of the gender-affirmation model and a ‘honeymoon’ period of up to 10 years, the full extent of regret and detransition in young people transitioning today, under vastly different circumstances than in the past, will not be known for many years,” says the author, Dr Sarah C. J. Jorgensen of Toronto University’s Institute of Medical Science.

Her open-access article in the journal Archives of Sexual Behavior argues that historically low rates of reported regret—arguably unreliable even at the time—are unlikely to apply to today’s transformed clinical situation.

These relatively recent changes include—

The explosion in atypical gender dysphoria among teenage females

The rise of the less cautious “gender-affirming” treatment approach

The resistance to full psychological screening before treatment as “pathologising”

The claim that mental health disorders are not necessarily a barrier to medicalised gender transition

Increasing evidence that mental health disorders may pre-date any gender issues and not be improved by medical transition

The reframing of medical interventions within a child-driven civil rights narrative

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Video: “No one ever explained to me that puberty would be a difficult time emotionally”—Jamie’s detransition story

“Reuters spoke to 17 people [in the United States] 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”—Reuters news report, “Why detransitioners are crucial to the science of gender care,” 22 December 2022

“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.”

Small percentage, big number

“Even if only a small percentage of people who transitioned as minors or young adults later take steps to detransition, a small percentage of a population that has grown exponentially in the last decade means many more detransitioners will emerge in the coming years,” Dr Jorgensen says in her new paper.

Although there is data suggesting more detransition and regret than reported in the early patient groups selected by the Dutch clinicians who pioneered paediatric gender medicine, she says there are no best practice guidelines for responding to the diverse experiences and needs of today’s emerging detransitioners.

“Some detransitioners might continue to have gender dysphoria or will have iatrogenic [or medically caused] dysphoria related to irreversible effects of hormones and surgery and will need non-medical ways to cope with it, as well as ongoing psychological support to manage possible anxiety, regret, and shame related to detransitioning,” Dr Jorgensen says.

“Moreover, research is urgently needed to determine the safest way to discontinue or change hormonal therapies, as well as reversal or reconstructive surgical options.”

The paper suggests a rise in detransition and regret was foreseeable.

“Decisions to transition are now being made by young people who might lack the cognitive and emotional maturity to fully appreciate the long-term repercussions of their decisions,” Dr Jorgensen says.

She cites a 2022 Dutch qualitative study of adolescents in gender clinics, with most of these patients saying they “believed certain aspects of medical transition—for example, loss of fertility and impact on future romantic relationships—simply cannot be understood and appreciated by young people below a certain age.”

The true extent of detransition is a contentious issue. There is no objective measure to tell at the outset which patients will persist with treatment and a transgender or non-binary identity.

“Only a small percentage of detransitioners (24 per cent) informed the clinicians and clinics that facilitated their transitions that they had detransitioned. Therefore, clinic rates of detransition are likely to be underestimated and gender transition specialists may be unaware of how many of their own patients have detransitioned, particularly for patients who are no longer under their care”—researcher Dr Lisa Littman, survey study of 100 detransitioners, 2021

Forgetting the brain?

In her paper, Dr Jorgensen highlights the fact that the adolescent brain is still developing and does not reach maturity until the mid-20s, with important executive functions the last to fully develop.

“Executive functions include the ability to plan, prioritize, and strategize to achieve long-term goals as well as the ability to thoughtfully weigh information to make decisions,” she says.

“In the adolescent brain, connections between the prefrontal cortex or decision-making center and the amygdala or emotional center are still evolving. Consequently, adolescents often prioritize feelings over facts when making decisions.

“Moreover, because corticostriatal connectivity is not fully developed until adulthood, adolescents do not assess risk like adults. An adolescent’s ability to judge the value of an outcome in the future, resulting from a decision made today, is often impaired, especially when the outcome is far in the future and outside their present experience.

“Peer influence is another uniquely powerful factor that impacts judgement and decision-making in adolescence. Neuroimaging studies have shown that peer pressure promotes high levels of activation in the amygdala (emotional center).

“This is not seen to the same extent during interactions with adults and may explain why adolescents value the opinions of their peers more than those of adults when assessing risk.”

“Detransition has become much more visible in recent years. However, it was only recently that the rates of detransition began to be quantified. According to recent United Kingdom and U.S. data, 10–30 per cent of recently transitioned individuals detransition a few years after they initiated transition”—journal article by Stephen Levine, E. Abbruzzese, Current Concerns About Gender-Affirming Therapy in Adolescents, April 2023

“Not all detransitioned individuals have expressed regret. Those who have, are often angry at themselves for their naïve adolescent certainty and disturbed about medical professionals’ unconcerned compliance with their requests. A growing number of malpractice lawsuits by regretful youth is likely in the future.”

Old data

Dr Jorgensen documents the flaws in historically low reported rates of regret—rates still relied on by today’s gender-affirming clinicians who fail to explain the shortcomings, uncertainties or narrow definitions of regret in these seemingly reassuring statistics.

She analyses the 2018 Dutch long-term study of Dr Chantal Wiepjes and colleagues. Its headline regret rates of 0.3 per cent for transmen and 0.6 per cent for transwomen are commonly used to dismiss concerns about the future of current adolescent patients.

Dr Jorgensen highlights crucial elements of the Wiepjes study which are rarely mentioned in mainstream media, including—

The study involved almost 7,000 patients who sought hormonal therapy and surgery from 1972 to 2015, placing it in the period pre-dating the dominance of the more radical gender-affirming treatment model

The Dutch clinicians carried out extensive mental health evaluations before selecting patients for treatment

In total, 70 per cent of the patients were started on hormonal therapy and 78 per cent of this group went on to have their ovaries or testes removed

The 0.3-0.6 per cent regret rates apply only to those patients who underwent genital surgery as adults

Regret in those who did not undergo this surgery was not reported

Regret was determined by a retrospective review of medical documents, a method open to non-response bias

A significant number of former patients—36 per cent—were ‘lost to follow-up’, meaning there is a serious question whether the true, overall risk of regret was higher than 0.3-0.6 per cent

Recycling regret statistics

American psychiatrist Dr Jack Turban, frequently quoted in mainstream media as an expert on youth gender medicine, has cited the Wiepjes study and its impressively low regret rates.

In The Washington Post, beneath the headline “Texas officials are spreading blatant falsehoods about medical care for transgender kids”, Turban writes: “Studies of gender-affirming surgeries show regret rates between 0.3 and 0.6 percent.”

The term “gender-affirming”, suggesting today’s less careful approaches to treatment, arguably does not apply to the Dutch patient group.

Another media favourite, Australian paediatrician Dr Michelle Telfer cites the same study by Wiepjes et al in a profile article that declared she had “won the gender clinic battle” against critics who highlighted the risks of medical intervention.

Dr Telfer also references the headline regret rates of the Wiepjes study in an Australian parliamentary submission, saying: “The reality is that there is no evidence of increasing rates of regret or of people detransitioning... International research on regret rates, including a large cohort study from the Netherlands from 1972 to 2015 showed regret rates have been consistently low at 0.3-0.6 per cent.”

And that anachronistic Wiepjes study surfaced again in another media profile of Dr Telfer, this time the Australian Story program of the public broadcaster the ABC, in which she says:

“From the research, when they look at long-term regret rate, it’s actually very small and it’s somewhere in the range of 0.3-0.6 per cent. If you are to avoid providing care to everyone to try and get that regret rate down to zero, it means you’re denying 99.5 per cent of all people who come to you the benefits of treatment.”

“Those who insist that a young person has the right to receive any medical intervention they desire now, and the right to regret that intervention later, privilege autonomy above all else. The ‘patient autonomy’ argument is compromised by the very young age of the many affected patients, and a common tendency among gender-affirming providers to exaggerate the benefits of the practice, while downplaying the risks and uncertainties”—journal article by Stephen Levine, E. Abbruzzese, Current Concerns About Gender-Affirming Therapy in Adolescents, April 2023

Trending up

Dr Jorgensen’s paper points to recent data tending to cast doubt on the gender-affirming mantra that it is vanishingly rare for young people to regret medical transition. While acknowledging a range of ideas about what constitutes detransition or regret, she cites studies including—

• A retrospective review of 175 patients who medically transitioned at an adult clinic in the U.K. reported that 6.9 per cent of patients detransitioned within 16 months of starting transition

• A further 22 per cent disengaged from care and were discharged from the clinic without completing their planned treatment

• A second study from a U.K. primary care practice that included 41 trans-identifying patients (with a median age of 22 years) found that 12 per cent of those who had started hormonal treatments detransitioned or documented regret after an average of five years

• In addition, 7.3 per cent of this group stopped hormonal therapy for medical or unknown reasons

• An analysis of 1,089 young people referred to paediatric endocrine clinics in England between 2008 and 2021 reported that 5.3 per cent stopped treatment with puberty blockers or cross-sex hormones and re-identified with their birth sex before age 18

• A study that included 952 trans-identifying adolescents and adults in the U.S. military healthcare system found 29 per cent discontinued hormonal therapies within four years

Note: GCN sought comment from Dr Turban and Dr Telfer. GCN does not dispute that gender-affirming clinicians genuinely believe their treatment approach helps vulnerable youth