Over half of people who believed they were transgender, transitioned to the opposite sex, but then regretted it and transitioned back — known as detransitioners — felt they did not receive adequate evaluation from a doctor or mental health professional before starting transition, new research indicates.
In what is thought to be the first study to ask whether detransitioners informed their original clinicians of their regret at transitioning, clonidine drug class only 24 of the 100 surveyed said they had done so.
This strongly suggests that records on detransition may understate the real numbers, says Lisa Littman, MD, MPH, president of The Institute for Comprehensive Gender Dysphoria Research (ICGDR), who is the sole author of the study, published in Archives of Sexual Behavior.
She stresses that the findings illustrate the complexity surrounding gender dysphoria. “We need to recognize that there are many different types of experiences around gender dysphoria, transition, and detransition,” she told Medscape Medical News.
She also said there is some resistance among certain healthcare professionals, and in society in general, to the idea that transitioning is not always successful.
“We Need to Understand Why This Is Happening”
“Detransition exists and we need to understand why this is happening,” Littman emphasized.
She also observed that some supporters of “rapid transition” do not want to accept that transitioning helps some individuals but harms others.
“In the end, our goals should be providing the right treatment for the right patient, and without a thorough evaluation, clinicians are at serious risk of giving patients the wrong treatment,” she urged.
She also noted that despite some individuals feeling better after transition these people still felt inclined to detransition due to discrimination and pressure.
“Individuals should not be pressured to detransition, nor should they be pressured to transition. Both types of pressure were reported by respondents.”
The recently recognized shift from mostly natal males to natal females seeking to transition was also borne out by her study data, with the proportion of natal girls who detransitioned at 69%.
“Shedding Light“ on Often Ignored Population
Asked to comment on the study, Laura Edwards-Leeper, PhD, a clinical psychologist who specializes in gender diverse and transgender children from Beaverton, Oregon, welcomed Littman’s study.
It is, said Edwards-Leeper, a “critical preliminary step toward shedding light on this often ignored and dismissed population of individuals who deserve support, compassion, and sometimes medical intervention from healthcare providers.”
She added that multiple online reports attest to detransitioners feeling they had not received adequate evaluation prior to medically transitioning, as well as many who expressed feeling too ashamed or angry to return to their same clinicians to detransition.
“Littman’s study provides quantitative support for both of these reported experiences, further emphasizing the importance of the field taking a closer look at the processes currently in place for those experiencing gender dysphoria,” said Edwards-Leeper.
And Miroslav L. Djordjevic, MD, PhD, professor of surgery/urology, University of Belgrade, Serbia, who is a specialist in urogenital reconstructive surgery and has performed over 2000 gender reassignment surgeries in transgender individuals, has recently seen many cases of regret after such surgeries, with requests for reversal operations.
“Despite the fact that medical detransition is relatively safe and without severe consequences, surgical detransition presents one of the most difficult issues in transgender medicine,” Djordjevic told Medscape Medical News.
Commending Littman on her study, he drew attention to some of the bioethical questions that arise relating to those who detransition.
“I ask what happened in the period before medical transitioning? Was there proper psychological care during medical transitioning?
“Who confirmed their desire for detransition — the same professionals who did the transition?” or someone else, he continued.
“And who accepted these individuals for gender-affirming surgery and what were the criteria for this decision?”
Substantial Study of Reasons for Both Transitioning and Detransitioning
In her article, Littman describes a 100-strong population of individuals (66 Americans, nine British, nine Canadian, four Australians, and 12 from “other” nations), ranging from 18 years to over 60 years of age with a mean age of 29.2 years, who had experienced gender dysphoria, chosen to undergo medical and/or surgical transition, and then detransitioned by discontinuing medications, having reversal surgery, or both.
Participants completed a 115-question survey providing data including age at first experience of gender dysphoria, when participants first sought transitioning care and from whom, and whether they felt pressured to do so. Friendship group dynamics were also explored.
Various narratives of participants’ transitioning-detransitioning experiences were gathered and grouped, for example, those related to discrimination pressures; experiences of trauma or mental health conditions prior to transition; and reports of internalized homophobia.
Edwards-Leeper observed that the study offers a more extensive assessment of reasons for detransitioning than any other prior research in the field, which has been sparse.
Another survey published in the summer also found that detransitioners report significant unmet medical and psychological needs, and a lack of compassion and help from medical and mental health practitioners.
But another 2021 study concluded most detransitioners only reverted to their birth sex due to societal or family pressure, discrimination, or shift to a nonbinary identity.
“However, Littman’s study found that only a small percentage actually detransitioned for that reason [23%], whereas the majority detransitioned because of a change in how the individual understood being a male or female, resulting in becoming comfortable in their assigned gender (60%),” notes Edwards-Leeper.
Reasons for Detransitioning
Asked to expand upon the motives for detransition identified in her study, Littman told Medscape Medical News: “We found remarkable breadth in the reasons given for detransitioning.”
“I believe that we were able to capture the diversity of experiences around detransition because we reached out to communities that were strongly ‘pro-transition’ — like the World Professional Association for Transgender Health [WPATH] — and communities where individuals might be more sceptical about transition being universally beneficial, like detransition forums,” she said.
Speaking to the complexity of the experiences, 87% selected more than one reason for detransitioning.
The most common reason (60%) was becoming more comfortable identifying with their birth sex, followed by having concerns about potential medical complications from transitioning (49.0%).
Regarding those who became more comfortable with their natal sex, Littman noted that the finding adds “further support that gender dysphoria is not always permanent.”
She also noted that “because most gender dysphoric youth who are allowed to go through puberty grow up to be lesbian, gay, or bisexual (LGB) nontransgender adults, intervening too soon with medical treatments risks derailing their development as LGB individuals.”
Internalized homophobia or difficulty accepting themselves as lesbian, gay, or bisexual was reported by 23% of participants as a reason for transition and subsequent detransition.
“For these people, transitioning could be interpreted as an attempt to escape the reality of being same-sex attracted and detransitioning was part of accepting themselves as homosexual or bisexual,” explained Littman.
“Exploring their distress and discomfort around sexual orientation issues may have been more helpful to them than medical and surgical transition or at least an important part of exploration,” she adds in the article.
Societal Pressure, Friends, and Social Media Also Play a Role
The latest first-hand reports also support prior work by Littman, as reported by Medscape Medical News, when she first identified the concept she termed rapid-onset gender dysphoria (ROGD) to describe a sudden transgender identification, usually in the early teenage years, and with no prior indication of any gender questioning.
ROGD, Littman believes, is strongly related to psychosocial factors, such as trauma, mental health problems, or social influence contributing to the development of gender dysphoria.
The current study found that 58% of respondents expressed the belief that the cause of their gender dysphoria was something specific, such as trauma, abuse, or a mental health condition, with respondents suggesting that transitioning prevented, or delayed, them from addressing their underlying mental health conditions.
One participant is quoted as saying: “I was deeply uncomfortable with my secondary sex characteristics, which I now understand was a result of childhood trauma and associating my secondary sex characteristics with those events.”
Reflecting on their previous identification as transgender, more than a third of respondents reported that someone else told them their feelings meant they were transgender, and they believed them.
“This speaks to the effect social influence can have on people’s interpretation of their own feelings and their development of a transgender identity,” Littman remarked.
“Participants also listed several social media sources that encouraged them to believe that transitioning would help them,” she added.
Several friendship group dynamics suggestive of social influence were reported by a subset of respondents, including the fact that their friendship groups mocked people who were not transgender and their popularity increased when they announced they were going to transition.
Pendulum Has Swung Too Far the Other Way
Natal females, who in recent years have made up most referrals, were younger than natal males when they sought transition and decided to detransition; and they stayed “transitioned” for a shorter period than natal males. They were also more likely to have experienced a trauma less than 1 year before the onset of gender dysphoria and were more likely to have felt pressured to transition.
“Because the females in the study transitioned more recently than the males, they may have experienced a culture where there is more of a ‘push’ to transition,” Littman pointed out.
She added that, “20 years ago, gender dysphoric patients were most likely to be underdiagnosed and undertreated. Now, the pendulum has swung the other way and patients are, in my opinion, more likely to be over-diagnosed and over-treated. I think we need to aim for somewhere between these two extremes and prioritize people getting the right treatment for the right reason for their distress.”
Djordjevic added that, with colleagues from Belgrade and the Netherlands, he has published accounts of the experiences of seven individuals who showed regret after gender-affirming surgery.
All of them were born male, “and we confirmed the very poor evaluation and transition process they underwent. We conclude that clinicians should be aware that not everyone with gender identity disorders need or want all elements of hormonal or surgical therapy,” he told Medscape Medical News.
Edwards-Leeper concluded that more long-term longitudinal studies are needed that follow individuals who undergo transition under different models of care.
“My prediction is that those who first engage in supportive, gender exploratory therapy, followed by comprehensive assessment, will have the best outcomes, perhaps even if they ultimately detransition, as these individuals will know that they did not jump into irreversible interventions too quickly and had time to make the best decision for themselves at the time,” she concluded.
Arch Sex Behav. Published online October 19, 2021. Full text
Littman, Edwards-Leeper, and Djordjevic have reported no relevant financial relationships.
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