Regretting Transition for Gender Dysphoria

Supporters of gender-affirming therapy (GAT)—transition affirmation—are doubling down on claims that regret and detransition are rare. From state-level bills in my home state of California to national policy initiatives from the federal administration, the assertion that transitioning for gender dysphoria is all but regret free is used as a promotional tool for the proposed mandating of GAT essentially on request. However, the sales pitch does not hold up to inspection.

Studies and surveys commonly cited to prove that regret after transition (GAT) for gender dysphoria is exceedingly rare remarkably often demonstrate the same fatal flaws:

• Impressively high rates of loss to follow up, from over 20 percent to over 60 percent, which invalidate the findings.[1] Were those lost patients helped, hurt or even still alive?[2]
• Exceedingly strict definitions for regret, e.g. requiring formal application to change their legal documents back to the original sex.[3]
• Insufficient periods of follow up, usually only six months to two years post-transition, despite the existing evidence that post-surgical regret is known to manifest eight years or so post-transition.[4]^,[5]
• Sampling usually taken from gender clinics, to which those with regret repeatedly report they do not return. Dr. Littman’s 2021 survey of 100 detransitioners found that only 24 percent had informed their clinician of their detransition, thus 76 percent did not.[6]
• Data is gleaned from in-house satisfaction surveys lacking clear and uniform definitions, metrics and follow up. This low-quality data then gets pooled to create low quality, unreliable results.

A 2022 review by Boyd et al., of a modest but at least population-based UK sample (n=68) noted that 20 percent of the sampled patients quit hormone treatment, with half reporting “regret” or “detransition” as why.[7] That would mean a 10 percent rate of regret or detransition, except that regretters often don’t return to gender clinics or even inform their healthcare professionals of their progress. A 2021 single-clinic review by Hall et al

found a 6.9 percent detransition rate, but the same caveat applies, namely that those with regret avoid the gender clinics.[8] The obvious implication is that the rate of regret is higher than reported.

An oft-cited study from 2021 by Bustos et al., of regret after gender-affirming surgery pooled 27 studies comprising a reported 7,928 “transgender patients,” resulting in a “pooled prevalence” rate of regret of 1 percent.[9] Though the authors did offer a caution that “there is high subjectivity in the assessment of regret and lack of standardized questionnaires…,” rebuttal letters were more revealing.

One such letter by Exposito-Campos et al., reported three levels of error in the Bustos study.[10] First, flawed methods were seen in the excluding of several highly relevant studies, along with the fact that the sample from the largest included study (Wiepjes 2018 Amsterdam Cohort study) was exaggerated to 4,863 from 2,627, an 85 percent bump up.

Next listed was flawed data: (1) inadequate follow up period, only one or two years post-surgery for many of the included studies; (2) 36 percent loss to follow up in the Amsterdam Cohort study alone, which supplied nearly half of the Bustos study’s participants; (3) 23 of 27 studies with “moderate-to-high risk of bias”; (4) “The majority of included studies ranged between ‘poor’ and ‘fair’ quality…”; and (5) even in the five included studies with higher quality ratings, the loss to follow up was 28 to over 40 percent and included “loss through death from complications or suicide, negative outcomes potentially associated with regret.” Third and finally, Exposito-Campos et al., noted flawed sample selection in that the cohorts represented in the pooled studies met a different standard than those with gender dysphoria today due to the current loose criteria in determining clearance for gender-affirming surgery. The authors diplomatically specified that Bustos’ conclusions were “unsupported and potentially inaccurate.”

Dr. Lisa Littman’s previously mentioned 2021 paper titled “Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners” found, unsurprisingly, there was no solitary reason or experience leading to detransition.[11] Among the most common motivations given were 60 percent who developed more comfort identifying with their natal sex, 55 percent saying they had received inadequate evaluation from medical or mental health professionals prior to transitioning, 49 percent concerned about potential medical complications of the transition and 30 percent who began to see their gender dysphoria as caused by trauma, abuse or mental health issues. And to reiterate, 76 percent failed to inform their clinician of their detransition.

Further evidence regarding regret is not hard to find. A 2021 paper by Entwistle examined testimonies of detransitioners.[12] A 2019 story in the British News.sky.com discussed the establishment of The Detransition Advocacy Network necessitated, as the title of the article stipulated, by “‘Hundreds’ of young trans people seeking help to return to original sex.”[13] The Reddit.com group r/detrans has more than 34,000 members. Walt Heyer’s sexchangeregret.com site contains numerous accounts and more information on the topic. Walt informed me that of the many thousands of people with post-transition regret he has counselled, not one of them had ever been approached to participate in a regret study, including Walt. A series of five-minute mini-documentaries with regretters of transition is on Facebook under the “His Name is Money” project.

Post-transition regret in patients with gender dysphoria is not rare. The studies claiming regret to be extremely uncommon are usually fatally flawed by high rates of loss to follow up, excessively rigid definitions of regret, insufficient length of follow up, sampling bias and low-quality data, which can then get pooled into larger amounts of low-quality data. We will be hearing more from those with transition regret, and so shall the courts.

[1] D’Angelo, R., Syrulnik, E., Ayad, S. et al. One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Arch Sex Behav (2020). https://doi.org/10.1007/s10508-020-01844-2

Citing: D’Angelo R. Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry. 2018;26(5):460-463. doi:10.1177/1039856218775216

[2] D’Angelo R. Psychiatry’s ethical involvement in gender-affirming care. Australasian Psychiatry. 2018;26(5):460-463. doi:10.1177/1039856218775216

[3] D’Angelo, R., Syrulnik, E., Ayad, S. et al. One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Arch Sex Behav (2020). https://doi.org/10.1007/s10508-020-01844-2

[4] Dhejne C, Öberg K, Arver S, et al. An analysis of all applications for sex reassignment surgery in Sweden, 1960–2010: prevalence, incidence, and regrets. Arch Sex Behav. 2014;43:1535–1545.

[5] Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam cohort of gender dysphoria study (1972–2015): Trends in prevalence, treatment, and regrets. J Sex Med. 2018;15:582–590.

[6] Littman, L. Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Arch Sex Behav 50, 3353–3369 (2021). https://doi.org/10.1007/s10508-021-02163-w

[7] Boyd I, Hackett T, Bewley S. Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare (Basel). 2022 Jan 7;10(1):121. doi: 10.3390/healthcare10010121. PMID: 35052285; PMCID: PMC8775415.

[8] Hall, R.; Mitchell, L.; Sachdeva, J. Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: Retrospective case-note review. BJPsych Open 2021, 7, e184.

[9] Bustos VP, Bustos SS, Mascaro A, et al. Regret after gender-affirmation surgery: a systematic review and meta-analysis of prevalence. Plast Reconstr Surg Glob Open. 2021;9:e3477.

[10] Expósito-Campos, Pablo MA^*; D’Angelo, Roberto PsyD^†,‡ Letter to the Editor: Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence, Plastic and Reconstructive Surgery – Global Open: November 2021 – Volume 9 – Issue 11 – p e3951 doi: 10.1097/GOX.0000000000003951

[11] Littman, L. Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Arch Sex Behav 50, 3353–3369 (2021). https://doi.org/10.1007/s10508-021-02163-w

[12] Entwistle K. Debate: Reality check – Detransitioner’s testimonies require us to rethink gender dysphoria. Child Adolesc Ment Health. 2021;26(1):15-16. doi:10.1111/camh.12380

[13] UK Story: ‘Hundreds’ of young trans people seeking help to return to original sex,” News.sky.com, 05 Oct 2019.