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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.

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‘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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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.

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

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Transgender regret? Research challenges narratives about gender-affirming surgeries

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Harry Barbee has received funding from the National Institute on Aging for their past work.

Bashar Hassan and Fan Liang do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

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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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eTable 1. Cross Tabulation of Self-Reported Current Gender and Gender at the Time of Surgery

eTable 2. Satisfaction With Decision and Decision Regret Scale Scores by Congruence of Gender at the Time of Surgery vs the Time of Survey Administration

eTable 3. Mental Health–Associated Medication Use at the Time of Surgery

Data Sharing Statement

• Low Rate of Regret After Gender-Affirming Mastectomy JAMA Surgery Invited Commentary October 1, 2023 Ian T. Nolan, MD; Brielle Weinstein, MD; Loren Schechter, MD

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Bruce L , Khouri AN , Bolze A, et al. Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy. JAMA Surg. 2023;158(10):1070–1077. doi:10.1001/jamasurg.2023.3352

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Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy

• 1 University of Michigan Medical School, Ann Arbor
• 2 Section of Plastic Surgery, University of Michigan, Ann Arbor
• 3 Michigan Institute for Clinical Health Research, Ann Arbor, Michigan
• 4 Institute for Healthcare Policy and Innovation, Ann Arbor
• 5 Seattle Children’s Hospital, Seattle, Washington
• Invited Commentary Low Rate of Regret After Gender-Affirming Mastectomy Ian T. Nolan, MD; Brielle Weinstein, MD; Loren Schechter, MD JAMA Surgery

Question   What is the rate of regret and satisfaction with decision after 2 years or more following gender-affirming mastectomy?

Findings   In this cross-sectional study of 139 survey respondents who underwent gender-affirming mastectomy, the median satisfaction score was 5 on a 5-point scale, with higher scores indicating higher satisfaction. The median decisional regret score was 0 on a 100-point scale, with lower scores indicating lower levels of regret.

Meaning   This study’s findings indicate low patient-reported long-term rates of regret and high satisfaction with the decision to undergo gender-affirming mastectomy, although the need exists for condition-specific instruments to assess satisfaction with decision and decisional regret for gender-affirming surgery.

Importance   There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments.

Objective   To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy.

Design, Setting, and Participants   For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020.

Exposure   Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy.

Main Outcomes and Measures   Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders.

Results   A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P  = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P  < .001) and anxiety (42 [44%] vs 97 [70%]; P  < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses.

Conclusions and Relevance   In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

An estimated 1.6% of US adults identify as transgender or nonbinary. 1 For many transgender or nonbinary individuals, medical and surgical affirmation is essential to treating gender dysphoria and ensuring social acceptance. A common concern for patients, physicians, and policy makers is the potential irreversibility of gender-affirming therapies, particularly surgery, and the possibility of regret following these procedures. Regret is a complex feeling with many theorized constructs combining negative emotion with the evaluation of past decisions and can occur for multiple reasons. 2 In the context of gender-affirming surgery, regret has previously been categorized into 3 etiologies, including social regret (eg, lack of social support), medical regret (eg, complications), and gender-related regret (eg, initially mistaken or later evolving transgender identity). 3

Although regret is often discussed as a serious concern surrounding gender-affirming surgery, evidence that supports this claim is limited. A recent systematic review reported a regret rate of 1% following transfeminine and transmasculine procedures; however, this analysis relied on secondary coding of studies with a variety of measures and a broad range of follow-up periods from 0.8 to 9 years. 4 Individual studies have also shown low rates of regret but have been limited by sample size and measurements that relied on chart review, ad hoc instruments, and use of changes in gender identity postoperatively as a proxy measure. 4 - 9 While prospective studies have shown high short-term satisfaction with decision, follow-up time has remained limited, ranging from months to 1 year. 10 , 11 The lack of data surrounding satisfaction with decision and decisional regret leaves clinicians unable to counsel patients on these important long-term outcome measures and legislators ill-equipped to draft evidence-based policy.

Gender-affirming mastectomy is the most common gender-affirming procedure in the US and is performed on transgender or nonbinary individuals who were assigned female sex at birth. 12 We aimed to measure long-term satisfaction with decision and decisional regret using previously validated instruments in individuals who had gender-affirming mastectomy more than 2 years ago in order to inform patients considering gender-affirming mastectomy and policy makers regulating these operations.

Participants were recruited from February 1 through July 31, 2022. Patients were eligible for this cross-sectional study if they underwent gender-affirming mastectomy at our institution (a tertiary referral center and the oldest continually operating gender-affirming surgical unit at a US academic center) between January 1, 1990, and February 29, 2020, were older than 18 years at the time of survey administration, and spoke English. All eligible patients were identified via medical record review. All patients met the World Professional Association for Transgender Health standards of care surgical requirements at the time of their operation prior to undergoing mastectomy. 13 A 3-pronged communication approach (email, telephone, and mail) was used to recruit participants for the study. The study was approved by the University of Michigan’s institutional review board (HUM00196040). Written consent was obtained for respondents, and a Health Insurance Portability and Accountability Act waiver was given for medical record review of nonresponders. The study is in accordance with the American Association for Public Opinion Research ( AAPOR ) reporting guideline.

Participants were administered a 1-time survey either electronically or by mail. The instruments included ad hoc demographic information, the Holmes-Rovner Satisfaction With Decision scale, and the Decision Regret Scale. Satisfaction with decision was measured using the revised Holmes-Rovner Satisfaction With Decision scale. 14 Originally published in 1996, this scale was validated for both postmenopausal hormone replacement therapy and antidepressant use in primary care patients. 14 , 15 The revised tool consists of 4 statements rated on a 5-point Likert scale. Responses are averaged for a score of 1 to 5, with a higher score corresponding to higher satisfaction. 16 The scale has high reliability (Cronbach α, 0.85-86) and has been applied to decisions regarding breast cancer, prostate cancer, and ovarian cancer. 16 , 17

Decisional regret was assessed using the Decision Regret Scale. 2 The scale contains 5 items that are rated on a 5-point Likert scale. Scores are converted to a 100-point scale, with higher scores corresponding to higher levels of regret. The instrument was validated originally in 4 patient populations: menopausal women considering hormone replacement therapy, men considering prostate cancer treatment, women considering breast cancer treatment, and women considering breast cancer adjuvant treatment. 2 , 18 It has high reliability (Cronbach α, 0.81-0.92) and is well correlated with decision satisfaction, decisional conflict, and overall rated quality of life. 2 , 18 The instrument has been used extensively for oncologic screening and treatment decisions as well as in nonclinical contexts. 19 - 22

Patient demographic characteristics, including age, recorded gender identity at last encounter in the medical record, hormonal therapy information, and preexisting medical and mental health comorbidities at the time of surgery, were collected from the electronic medical record for both responders and nonresponders. Surgical data were also collected, including the type of surgery performed (periareolar, double incision simple mastectomy, or another technique), complications, revision procedures, and any additional gender-affirming procedures. Furthermore, self-reported demographic, clinical, and surgical data were collected from respondents via an ad hoc survey. Specifically, self-reported sex assigned at birth; self-reported gender at the time of the surgery; and life partner status, education, and testosterone use at the time of the survey were collected. Self-reported race and ethnicity were recorded as a single item that asked, “How would you describe yourself?” Patients were able to select multiple classifications based on the US Office of Management and Budget race and ethnicity classification guidelines. 23 This information was recorded for the purpose of examining possible differences in patient-reported outcomes.

Descriptive statistics are presented for categorical data as counts and percentages and for continuous data as medians and IQRs. All univariable comparisons were performed using the Fisher exact test for categorical variables and Wilcoxon rank sum test for continuous variables. A 2-tailed P  < .05 was considered statistically significant. Scales were scored in accordance with the previous literature. 2 , 14 While previous cutoffs for both scales have been published, the clinical utility and rigor of establishing these cutoffs are not well described; thus, they were not used. 16 , 22 Thirteen individuals had strong discordance among their satisfaction with decision and decisional regret scores (9 with complete discordance, 3 with a Satisfaction With Decision scale score of 4.75 and a Decision Regret Scale score of 100, and 1 with a Satisfaction With Decision scale score of 5.00 and a Decision Regret Scale score of 95). As these scales are reverse scored from each other, there was concern that these individuals did not read the directions to these instruments. The Satisfaction With Decision scale was ordered first, and these 13 participants were noted to have high satisfaction and high regret, suggesting a possible error due to item order. This concern is further compounded by the established high correlation between satisfaction with decision and decisional regret. 2 For this reason, these individuals were excluded from the analysis. All analyses were performed using SAS, version 9.4 statistical software (SAS Institute Inc).

A total of 235 patients were eligible for the study, of whom 139 responded (59% response rate). There were no significant differences in median age at the time of surgery (responders, 27.1 [IQR, 23.0-33.4] years; nonresponders, 26.4 [IQR, 23.1-32.7] years), surgical technique, complication rate within 30 days, or reoperation rate ( Table 1 ). Nonresponders (n = 96) had a longer postoperative period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] years vs 3.6 [IQR, 2.7-5.3] years; P  = .002). Nonresponders also had lower rates than responders of diagnoses of depression (42 [44%] vs 94 [68%]; P  < .001) and anxiety (42 [44%] vs 97 [70%]; P  < .001) in the past medical history section of the medical record at the time of surgery ( Table 1 ). However, the rates of medication use associated with anxiety and depression at the time of surgery did not differ between respondent groups (eTable 3 in Supplement 1 ). Approximately one-quarter of responders (35 [25%]) and nonresponders (22 [23%]) underwent an additional gender-affirming procedure following mastectomy ( Table 1 ). No individuals in this study presented with or underwent a reversal procedure (ie, breast reconstruction) at our institution following mastectomy.

Postoperative time for respondents ranged from 2.0 to 23.6 years. Regarding self-reported gender identity at the time of survey completion, 88 (63%) identified as male, 17 (12%) identified as nonbinary, and 29 (21%) identified with multiple gender identities ( Table 2 ). There were 27 individuals (19%) who had incongruent self-reported gender identity at the time of surgery compared with current self-reported gender identity. Thirteen self-reported as male at the time of surgery and currently self-report their identity as other, multiple, or no identified gender (eTable 1 in Supplement 1 ). The majority of the respondents in the cohort were White (105 [76%] vs 4 Asian [3%], 7 Black or African American [5%], 5 Hispanic or Latinx [4%], and 17 multiracial or other [12%]) and had a college degree or higher ( Table 2 ). Well over three-quarters of respondents took testosterone at the time of surgery (123 of 138 [89%] [1 participant did not respond]) and were taking hormone therapy at the time of survey completion (117 of 139 [84%]) ( Table 2 ). No participants self-reported reversal procedures (ie, breast reconstruction following mastectomy).

Regarding satisfaction with decision, the median Holmes-Rovner Satisfaction With Decision score was 5.0 (IQR, 5.0-5.0) (mean [SD], 4.8 [0.6]) ( Table 3 ; Figure ). Regarding decisional regret, the median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) (mean [SD], 4.2 [12.1]) ( Table 3 ; Figure ). Individuals who had incongruent gender identities at the time of surgery and survey administration (n = 27) had a median Satisfaction With Decision score of 5.0 (IQR, 5.0-5.0) and decisional regret score of 0 (IQR, 0.0-5.0) (eTable 2 in Supplement 1 ).

In this cross-sectional survey study of participants who underwent gender-affirming mastectomy 2.0 to 23.6 years ago, respondents had a high level of satisfaction with their decision and low rates of decisional regret. The median Satisfaction With Decision score was 5 on a 5-point scale, and the median decisional regret score was 0 on a 100-point scale. This extremely low level of regret and dissatisfaction and lack of variance in scores impeded the ability to determine meaningful associations among these results, clinical outcomes, and demographic information.

The results are overwhelmingly positive compared with other medical and nonmedical decisions. Participants had a mean (SD) decisional regret score of 4.2 (12.1) on a 100-point scale. In a systematic review of 44 studies of multiple conditions using the Decision Regret Scale, including breast cancer treatment and reconstruction, only 1 study of urinary incontinence had a lower level of decisional regret (mean score, 2.5). 22 With regard to satisfaction with decision, the mean (SD) score was 4.8 (0.6) on a 5-point scale, which is higher than reported scores of mastectomy with reconstruction (mean, 3.97). 17 Placed in context with other procedures assessed by the same instruments, there was low long-term decisional regret and high satisfaction with decision following gender-affirming mastectomy. Beyond the scales, approximately one-quarter of both responders and nonresponders had an additional gender-affirming procedure following mastectomy. These results suggest sustained intent and consistency in decision-making.

Previous qualitative work suggested that the notion of regret, requests for reversal, and changes in gender identity have a nuanced, diverse association with one another, and patients presenting with concerns in any of these domains deserve multidisciplinary care. 5 , 24 Our reversal rate was 0% and consistent with recent reports of 0.3% in a larger single-center cohort. 5 With regard to changes in gender identity, 19% of our cohort had a different self-reported gender identity at the time of surgery compared with the time of survey administration. This finding could represent continued gender exploration or could additionally represent the pressures nonbinary patients face to conform to gender binaries in medical settings. 25 Individuals with different gender identities had instrument scores similar to those of individuals with concordant gender identities (eTable 2 in Supplement 1 ). These findings support the notion that ongoing gender exploration should not be used as a proxy measure for regret. 24 We did not observe any individuals presenting for surgical reversal, and individuals with changing gender identities had high levels of satisfaction and low regret.

While our findings show substantially low levels of decisional regret, they suggest the need for instruments calibrated specifically to the experience of undergoing gender-affirming surgery. Although a strength of this study is the use of validated instruments that can be compared with other surgical conditions, our findings suggest the need for condition-specific instruments and validation in the transgender population. Floor and ceiling effects limited our ability to perform statistical analysis to establish cutoffs specific to our cohort and identify characteristics associated with regret and satisfaction that could aid patient counseling in the future. While there are established cutoffs for both instruments, the establishment of said cutoffs is not well described, and the actual clinical utility is not clear. 16 , 22 Furthermore, these instruments do not capture the dimensions of regret unique to gender-affirming surgery. It is not known whether the individuals expressing dissatisfaction and regret in our cohort were experiencing these in relation to gender identity or experiencing other forms of regret known to follow gender-affirming surgery, such as social regret associated with increased stigma and discrimination or medical regret associated with complications and outcomes. 3 This finding supports the urgent need for condition-specific instruments for gender-affirming surgery, which is currently under development by the GENDER-Q team. 25

This study had several limitations. Although this study includes robust long-term data surrounding regret and satisfaction with decision following gender-affirming mastectomy, the cross-sectional nature of this study and variation in follow-up time among participants pose the possibility of recall bias. The association of time elapsed with regret specifically is unclear, with systematic review suggesting that regret may increase over time. 22 There were also 13 individuals with completely discordant regret and satisfaction scores, which may represent difficulty with following survey instructions, as these instruments are reverse coded from each other. These individuals were not included in the analysis given this concern. Unaccounted responder bias may also skew results. Interestingly, the only significant differences between responders and nonresponders were time since surgery and the rates of depression and anxiety diagnoses at the time of surgery in the medical record, with responders having higher diagnosis rates. While the rates of diagnoses differed between groups, the rates of medication use associated with anxiety and depression at the time of surgery did not (eTable 3 in Supplement 1 ). This discrepancy suggests that variation in documentation may contribute to this difference between responders and nonresponders. Furthermore, we were unable to determine procedures performed outside of our institution, which might have led to an underestimation of procedures following mastectomy. Clinician-level factors, such as patient counseling, were not collected and have been shown to be associated with regret and satisfaction with decision. 16 , 17 , 22 Finally, participants were recruited from a single academic center with a uniform approval process to undergo surgery and may not be representative of other sites. A multicenter study with multiple practice types is needed to ensure the generalizability of these results and to examine subpopulations.

In this cross-sectional study of individuals who underwent gender-affirming mastectomy 2.0 to 23.6 years ago, we observed long-term low levels of decisional regret and high satisfaction with decision using available validated instruments. The lack of variation in scores impeded the ability to perform a statistical analysis to establish characteristics associated with satisfaction with decision and regret. There were no individuals who underwent reversal procedures. While prospective, multicenter work is needed, these results are consistent with previous ad hoc studies and affirm the overwhelmingly low levels of regret following gender-affirming surgery.

Accepted for Publication: May 25, 2023.

Published Online: August 9, 2023. doi:10.1001/jamasurg.2023.3352

Corresponding Author: Megan Lane, MD, MS, North Campus Research Center, University of Michigan, 2800 Plymouth Rd, Ann Arbor, MI 48109 ( [email protected] ).

Author Contributions: Dr Lane had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ms Bruce and Dr Khouri contributed equally as co–first authors. Drs Morrison and Lane contributed equally as co–senior authors.

Concept and design: Khouri, Bruce, Khalatbari, Hamill, Wilkins, Morrison, Lane, Hsu.

Acquisition, analysis, or interpretation of data: Bruce, Khouri, Bolze, Ibarra, Richards, Khalatbari, Blasdel, Hamill, Morrison, Lane.

Drafting of the manuscript: Bruce, Khouri, Bolze, Richards, Wilkins, Morrison, Lane.

Critical review of the manuscript for important intellectual content: Khouri, Bolze, Ibarra, Richards, Khalatbari, Hamill, Morrison, Lane, Hsu, Blasdel.

Statistical analysis: Richards, Khalatbari.

Obtained funding: Bruce, Khouri, Morrison.

Administrative, technical, or material support: Bolze, Ibarra, Hamill, Morrison.

Supervision: Bolze, Hamill, Hsu, Wilkins, Morrison, Lane.

Conflict of Interest Disclosures: Ms Bruce and Dr Morrison reported receiving grants from The Plastic Surgery Foundation during the conduct of the study. Dr Lane reported receiving salary support via an F32 training grant (F32HS028748-01) from the Agency for Healthcare Research and Quality outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by a pilot grant (923995) from The Plastic Surgery Foundation (Drs Khouri, Ms Bruce, and Dr Morrison). Biostatistical support was provided by funding from the National Center for Advancing Translational Sciences (grant UM1TR004404) for the Michigan Institute for Clinical and Health Research.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; the collection, management, analysis, or interpretation of the data; the preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Information: The University of Michigan institutional review board requested that the authors also disclose their participation in the performance of gender-affirming surgery in their practice (Drs Hsu, Wilkins, and Morrison) and assistance with these procedures during their surgical residency (Drs Khouri and Lane).

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The Gender Reassignment Controversy

When people opt for surgery, are they satisfied with the outcome.

Posted March 16, 2018 | Reviewed by Ekua Hagan

In an age of increasing gender fluidity, it is surprising that so many find it difficult to accept the gender of their birth and take the drastic step of changing it through surgery. What are their motives? Are they satisfied with the outcome?

Gender may be the most important dimension of human variation, whether that is either desirable, or inevitable. In every society, male and female children are raised differently and acquire different expectations, and aspirations, for their work lives, emotional experiences, and leisure pursuits.

These differences may be shaped by how children are raised but gender reassignment, even early in life, is difficult, and problematic. Reassignment in adulthood is even more difficult.

Such efforts are of interest not just for medical reasons but also for the light they shed on gender differences.

The first effort at reassignment, by John Money, involved David Reimer whose penis was accidentally damaged at eight months due to a botched circumcision.

The Money Perspective

Money believed that while children are mostly born with unambiguous genitalia, their gender identity is neutral. He felt that which gender a child identifies with is determined primarily by how parents treat it and that parental views are shaped by the appearance of the genitals.

Accordingly, Money advised the parents to have the child surgically altered to resemble a female and raise it as “Brenda.” For many years, Money claimed that the reassignment had been a complete success. Such was his influence as a well-known Johns Hopkins gender researcher that his views came to be widely accepted by scholars and the general public.

Unfortunately for Brenda, the outcome was far from happy. When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1).

Money's ideas about gender identity were forcefully challenged by Paul McHugh (2), a leading psychiatrist at the same institution as Money. The brunt of this challenge came from an analysis of gender reassignment cases in terms of both motivation and outcomes.

Adult Reassignment Surgery Motivation

Why do people (predominantly men) seek surgical reassignment (as a woman)? In a controversial take, McHugh argued that there are two main motives.

In one category fall homosexual men who are morally uncomfortable about their orientation and see reassignment as a way of solving the problem. If they are actually women, sexual interactions with men get redefined as heterosexual.

McHugh argued that many of the others seeking reassignment are cross-dressers. These are heterosexual men who derive sexual pleasure from wearing women's clothing. According to McHugh, surgery is the logical extreme of identifying with a female identity through cross-dressing.

If his thesis is correct, McHugh denies that reassignment surgery is ever either medically necessary or ethically defensible. He feels that the surgeon is merely cooperating with delusional thinking. It is analogous to providing liposuction treatment for an anorexic who is extremely slender but believes themselves to be overweight.

To bolster his case, McHugh looked at the clinical outcomes for gender reassignment surgeries.

Adult Reassignment Results

Anecdotally, the first hurdle for reassignment is how the result is perceived by others. This problem is familiar to anyone who looked at Dustin Hoffman's depiction of a woman ( Tootsie ). Diligent as the actor was in his preparation, his character looked masculine.

For male-to-female transsexuals, the toughest audience to convince is women. As McHugh reported, one of his female colleagues said: “Gals know gals, and that's a guy.”

According to McHugh, although transsexuals did not regret their surgery, there were little or no psychological benefits:

“They had much the same problems with relationships, work, and emotions, as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled (2)”.

Thanks to McHugh's influence, gender reassignment surgeries were halted at Johns Hopkins. The surgeries were resumed, however, and are now carried out in many hospitals here and around the world.

What changed? One likely influence was the rise of the gay rights movement that now includes transgender people under its umbrella and has made many political strides in work and family.

McHugh's views are associated with the religious right-wing that has lost ground in this area.

Transgender surgery is now covered by medical insurance reflecting more positive views of the psychological benefits.

Aspirational Surgery

Why do people who are born as males want to be women? Why do females want to be men? There seems to be no easy biological explanation for the transgender phenomenon (2).

Transgender people commonly report a lifelong sense that they feel different from their biological category and express satisfaction after surgery (now called gender affirmation) that permits them to be who they really are.

The motivation for surgical change is thus aspirational rather than medical, as is true of most cosmetic surgery also. Following surgery, patients report lower gender dysphoria and improved sexual relationships (3).

All surgeries have potential costs, however. According to a Swedish study of 324 patients (3, 41 percent of whom were born female) surgery was associated with “considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

1 Blumberg, M. S. (2005). Basic instinct: The genesis of behavior. New York: Thunder's Mouth Press.

2 McHugh, P. R. (1995). Witches, multiple personalities, and other psychiatric artifacts. Nature Medicine, 1, 110-114.

3 Dhejne, S., Lichtenstein, P., Boman, M., et al. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study of Sweden . Plos One.

Nigel Barber, Ph.D., is an evolutionary psychologist as well as the author of Why Parents Matter and The Science of Romance , among other books.

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

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.

Study Characteristics

H, High; He, Heterosexual; Ho, Homosexual; IQR, Interquartile Range; I, Interview; L, Low; M, Moderate; Me, Median; NA, Not applicable; NS: Not specified, Q: Questionnaire; RAP: Radial Arterial Forearm-Flap Phalloplasty without or with cutaneous nerve to clitoral nerve anastomosis; SP: Suprapubic Pedicle-Flap Phalloplasty.

a Reflects the mean of both transmasculine and transfeminine.

b Includes both scheduled and completed surgery.

c Reflects the mean of both transmasculine and transfeminine for 10 patients who reported regret.

d Includes both surgery and no surgery patients.

Studies Differentiating Type of Surgery among Transfeminine Patients

GAS, Gender affirmation surgery.

Studies Differentiating Type of Surgery among Transmasculine Patients

GAS, Gender affirmation surgery

Type of Regret

N, no; NS, not specified; Y, Yes.

a 8 mastectomies, 2 vaginectomies, 2 phalloplasties, 2 testicular implants removal, and 1 breast augmentation

Causes of Regret

GAS, Gender affirmation surgery; NS, not specified

Pooled prevalence of regret among TGNB individuals after gender affirmation surgery. Heterogeneity chi 2 = 73.25 (d.f. = 26) p = 0.00, I 2 [variation in effect size (ES) attributable to heterogeneity] = 64.51%, Estimate of between-study variance Tau 2 = 0.01, Test of ES=0 : z= 4.46 p = 0.00

Subgroup analysis of the prevalence of regret among TGNB individuals after gender affirmation surgery based on gender. ES, effect size.

Subgroup analysis of the prevalence of regret among TGNB individuals after gender affirmation surgery based on the type of surgery. ES, effect size.

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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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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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A phrase we hear all too often in today’s world is “you do you.” In essence, what people imply by this is that people should do whatever they want – as long as it doesn’t hurt anyone else. This mentality flies in the face of love for our fellow human beings, for it doesn’t take into account the hurt that people can inflict upon themselves. This is all too clear in the recent transgender movement .

Politicians, organizations, and activists teach that people should be able to do what they want with their bodies. This includes changing their sex by either living as the opposite sex or by ingesting hormones to suppress the natural functioning of their bodies. But what happens when a person has transitioned and wants to change his or her mind? As we see below, the regret is real.

Real-life stories

A June 2022  New York Post story tells the devastating story of Chloe. It states:

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.

Chloe, who has since detransitioned, states, “I was failed by the system. I literally lost organs.” And now she wants people to know her story, so they don’t make the same mistake she did.

Eva is a woman who lived as a transgender male as a teenager. Though she did not medically transition, she determined – as an adult – that she no longer wanted to live as a man. She states that she felt “misled” by both family members and doctors. According to an article about her, “Eva, now 24, is part of a controversial cohort known as detransitionsers and desisters, transgender people who come to rethink their decision, often having already undergone drug and surgical treatments.”

In October 2020, Eva began a group called Detrans Canada, which she hopes can help people who feel “ostracized” for their decision to detransition. According to the site , the group’s “objectives are to examine how individuals experience changes to how they experience their sex and gender, transition and detransition processes (social, legal, medical), and to identify detransition-related healthcare and social support needs. We also aim to develop better guidance for care providers who work with trans, nonbinary, gender-fluid, detrans/retrans, and other gender diverse populations who change the direction of their transitions.”

In a similar story, Charlie Evans , a woman in the UK who detransitioned and stopped taking hormone therapy, has said that “hundreds” of people have contacted her since she made it public that she was detransitioning. According to Charlie, “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. They don’t know what their options are now.”

The article states:

The number of young people seeking gender transition is at an all-time high but we hear very little, if anything, about those who may come to regret their decision. There is currently no data to reflect the number who may be unhappy in their new gender or who may opt to detransition to their biological sex. Charlie detransitioned and went public with her story last year – and said she was stunned by the number of people she discovered in a similar position.

Sky News tells the story of a woman named Ruby (pseudonym) who had undergone testosterone therapy and lived as a male, first identifying as male at 13. However, she changed her mind about transitioning to a male before she was scheduled to have a double mastectomy. Ruby states: “I didn’t think any change was going to be enough in the end and I thought it was better to work on changing how I felt about myself, than changing my body…I’ve seen similarities in the way I experience gender dysphoria, in the way I experience other body image issues.”

The Statistics

A transgender survey was conducted in 2022 , but the results have not been published yet (set for late 2023). So, we must look to the 2015 U.S. Transgender Survey (page 111) for the most updated statistics. The survey claims that 11% of female respondents reverted back to their original sex. Transgender men had a reversion rate of 4%.

Those who chose to revert cited a variety of reasons. Five percent of those who detransitioned realized that a gender transition was not what they wanted. Other people cited family pressure and difficulty getting a job as reasons to detransition.

Authors of a 2021 article in  Plastic and Reconstructive Surgery conducted a systematic review of several databases to determine the rate of regret for those who had undergone surgery. According to the article, “7928 transgender patients who underwent any type of [gender-affirmation surgeries] were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%-2%).” However, the article goes on to state that there was “high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.”

Despite these low numbers and any possible issues with the format of the questionnaire, those who have lived life as a transgender male or female and who have detransitioned claim that the numbers are much higher  and that people are afraid to speak out.

That’s why the people discussed above want others to hear their stories – and they want them to hear the stories before they transition .

Those who do transition and who want to detransition and live as their biological sex need help and support. There are loving and compassionate groups who can help.

Support is Available

The Rainbow Redemption Project is a Christian group that helps people who want to detransition. Its mission is to provide “resources for detransitioners, with the ultimate goal of fully redeeming their lives through the transformative power of Jesus Christ.”

Sex Change Regret offers personal testimonies, resources, and guidance for those who are regretting changing their sex and who want to detransition.

Focus on the Family offers articles and resources for counseling on its site.

Catholic Charities and local parishes will also offer resources.

Help is out there. There are so many people who want to help those who are confused about their sexuality, confused about who they are, and confused about who they want to be.

And as stewards of our brothers and sisters in Christ, it is our job to treat all people with empathy, understanding, and compassion. It is our job to help them see the inherent dignity in themselves. And in both love and charity, it is our job to assist them as they seek help in moving forward.

This article was most recently updated July 2023 by Susan Ciancio.

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Susan Ciancio

Susan Ciancio has a BA in psychology and a BA in sociology from the University of Notre Dame, with an MA in liberal studies from Indiana University. Since 2003, she has worked as a professional editor and writer, editing both fiction and nonfiction books, magazine articles, blogs, educational lessons, professional materials, and website content. Fourteen of those years have been in the pro-life sector. Currently Susan writes weekly for HLI, edits for American Life League, and is the editor of its Celebrate Life Magazine. She also serves as executive editor for the Culture of Life Studies Program, an educational nonprofit program for k-12 students.

75 Comments

Unfortunately our current media for that last few years is promoting this insanity of pretending to be someone you are not and mutilating ones body to continue pretending. This article brings out the other side that the media does not tell us. The regret of having this done. Thank you Susan for writing this and giving helpful resources along with the truth. Thank you!!!

Pray for our children! E 908-239-8990

The regret is real. The psychological issues are real. And by the way, the pronoun thing, I hate to inform you, but you are 1 not 2 as in they, them. There is no plural to one person, man, woman, man/woman. Give me a break, deal with your mental issues, whatever they may be. Please stop with the plural reference, you sound like an idiot.

Actually, the pronoun “they” can be used as a singular term. Sometimes, when speaking about someone, you won’t mention their gender identity. So, I could say, “I met someone at the store.” The word “someone” is a gender-neutral word, so it doesn’t tell you the gender of the person. It would be grammatically correct for you to respond with “What was their name?” because you do not know their gender identity, and it would be rude to assume. If this is grammatically correct, why would it not be grammatically correct to use these pronouns with people we know the gender identity of? Plus, the pronoun “they” is in multiple dictionaries as a singular pronoun. If you understand the English language, it is not hard to understand pronouns, so please be respectful of others’ pronouns.

Really hope those reading this biased article would also consider reading the survey it cites from 2015:

“Respondents who had de-transitioned cited a range of reasons, though only 5% of those who had de-transitioned reported that they had done so because they realized that gender transition was not for them, representing 0.4% of the overall sample.”

Most of the reasons for detransition were pressure from an external source, which some may see as a good thing (religious peeps) but the larger world would consider this very negative. We should be aiming for a world of compassion, where trans people can have access to transition and be accepted by all for who they are… love thy neighbour and all. There are very few treatments that have as large of a satisfaction as HRT (consider your BP meds, diabetes meds, etc., wouldn’t you rather be off them?). We have created a world that makes trans people feel hated, and then point at them when they stop being who they are because they feel horrible. What is your motive for reading these articles? To justify your religious position? Consider meeting/ reading accounts from transgender people and consider developing some empathy that you claim to have because of your faith.

“The LORD bless you and keep you, the LORD make His face shine on you and be gracious to you, the LORD turn His face toward you and give you, EJS, peace.”Peace I leave you,My peace I give unto you..let not your heart be troubled.

I am writing to you on behalf of a group of detransitioned women regarding Dr Jack Turban. We are deeply concerned with Dr Turban’s disparagement of psychiatric intervention and exploratory psychotherapy, his singular endorsement of affirmative therapies for people with gender dysphoria, and his dismissive and derogatory treatment of those of us who detransitioned due to transition regret.

We are but a few of many that have been the victims of this type of cavalier attitude. We all suffered from gender dysphoria at one point (and some still do), and were led to believe that our best chance of treating our dysphoria was to medically transition. As it turned out, this was not the case. As a result, we now have to live with bodies and voices that have been irreversibly changed (and in some cases damaged) by hormones and surgeries, when what we needed was a compassionate and thoughtful exploration of our gender distress through talk therapy. Some of us will now never be able to have children and many of us live with great distress and regret every day.

Not only did physicians like Dr Turban fail us by sending us down a singular path of transition, they are now letting us down once again by disparaging our experiences and even our existence, when they should be providing us with support to help us heal from our unnecessary medical transitions. The fact that Dr Turban is a psychiatrist at Stanford and uses his credentials to promote his reckless approach is especially troubling, as he has been granted a large and influential media platform. As we see more and more distressed young people following in our footsteps of a rushed medical gender transition, in a few years, we fear the consequences of Dr Turban’s activism will be catastrophic and visible to all.

Dr Turban does not hide his disregard for the role of psychotherapy in treating gender distress, and his singular belief in medical and surgical approaches to treating gender dysphoria, whatever its cause may be. Appearing on the GenderGP Podcast episode ‘Exploring Detransition with Dr Jack Turban’ (2021), hosted by Dr Helen Webberley, a UK physician criminally-convicted for running an illegal clinic, Dr Turban says:

“There’s no psychiatric intervention for gender dysphoria. There are medical interventions for gender dysphoria, if you will. And it’s not the rule like right, how the psychiatrist’s going to treat gender dysphoria, they’re not like they’re not going to make that go away. …. The only way that it’s ever been proposed that psychiatry can do that was through conversion therapy, which obviously doesn’t work:” As you will read later in this letter, many detransitioners report that they strongly wish they had received exploratory psychotherapy rather than affirmation, thus Dr Turban’s insinuation that this would be tantamount to conversion therapy is highly disturbing.

Dr Turban describes detransition, in the GenderGP podcast, as having “become this really awful word… I feel like 90% of the time when you read it, it’s really being weaponized.” The claim that discussing detransition is problematic due to the topic being “weaponized” has been used to shame and silence detransitioners who try to tell our stories. This bullying of a very vulnerable group is unacceptable, and we find it incredibly worrying that Dr Turban would participate in the accusation that detransition is “being weaponized,” furthering the bullying of detransitioned individuals. This is not only a matter of rhetoric. Many of us are unable to receive any meaningful support from the mental health community. Instead of helping us heal, many mental health professionals informed by the likes of Dr. Turban continue to steer us toward medical transition, unable to accept our lived experience. There are more and more people like us sharing their stories of transition regret openly online, and we implore you to look these up.

Dr Turban goes on to say:

“when you say detransition people usually think that means like transition regret. It brings up this idea that somebody transitioned, then realize like, oh my god, that was a huge mistake. I’m actually cisgender, I regret every domain of gender affirmation I’ve ever had. And as I’m sure you know, that’s not the reality of the situation.” Dr Turban is, again, completely dismissing those of us who have experienced transition regret. As detransitioned woman, we are deeply hurt that Dr Turban would find it appropriate to suggest that our pain and distress is not a reality. We do, in fact, regret every domain of gender affirmation we ever had and the irreversible changes that medical transition did to us that we must now live with for the rest of our lives. It is, therefore, highly unprofessional and deeply offensive to see comments like this from a fellow at Stanford.

At the same time as Dr Turban dismisses our existence, he also claims to represent us in research, but his bias is clear: the goal is to minimize detransition because it contradicts Dr. Turban’s professional aspirations to promote transgender medical and surgical interventions. In the GenderGP podcast he also says:

“We have a paper that hopefully is coming out soon, where we took the data from the 2015 US Transgender Survey. So this was a survey of over 27,000 transgender adults in the United States. And we found that of those who had transitioned in some way, don’t quote me on that exact number, but it’s something like 13% of them said that at some point in their life, they had detransitioned. And when we looked at why they did that, the vast majority of them, like close to 90%, I think, had detransitioned due to some external factor.” We bring to your attention that the 2015 USTS survey that Dr Turban repeatedly uses for his research is an online convenience survey that was promoted by transition advocacy sites. We believe in and support transgender rights and trans people, but respectfully submit that this survey, subtitled “Injustice at Every Turn,” which is full of biased questions that promote a political agenda, serves as a poor base for respectable research. Dr Turban previously attempted to use this survey to claim that psychotherapy leads to suicide; his problematic analysis and conclusions were thoroughly outlined in a rebuttal by Roberto D’Angelo et al. in ‘One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria’ (2020), to which Dr.Turban never replied, even through he had the chance to do so. Instead, he attacked the researchers on Twitter. Dr Turban also used the same survey to attempt to show that puberty blockers saved lives. Another rebuttal showed just how flawed that piece of research was (‘Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria’ (2020) by Michael Biggs). Dr Turban failed to respond to that critique in the scientific area, but did go on media circuit to promote his deeply flawed conclusions.

Most recently, Dr Turban misused this problematic sample to discredit detransition experiences in his research, ‘Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis’ (2021). Dr. Turban did not seem troubled by the fact that 100% of the respondents were transgender-identified and did not identify as detransitioners. This is an expert from his study:

These [detransition due to internal factors] experiences did not necessarily reflect regret regarding past gender affirmation, and were presumably temporary, as all of these respondents subsequently identified as TGD, an eligibility requirement for study participation. Dr. Turban’s conclusions were that detransition is largely a temporary phenomenon, happens in response to external pressures, and does not really represent a problem for those who detransitioned. These conclusions are highly flawed and ignore those of us who have detransitioned due to transition regret, and who were excluded from the survey for no longer being transgender-identified.

In comparison, recent detransition research conducted within the actual detransition community (‘Detransition-Related Needs and Support: A Cross-Sectional Online Survey’ (2021) by Elie Vandenbussche) found very different results: that most of us detransition due to the internal realization that transition was not what we needed, that transition did not help and can actually make things worse for us, and that we found other non-invasive ways to alleviate our dysphoria. Further, the research showed that detransitioners expressed the need to find alternative treatments to deal with their gender dysphoria, but reported that it was nearly impossible to talk about it within LGBT+ spaces and in the medical sphere.

Vandenbussche found that most detransitioners currently are in dire need of psychological support on matters such as gender dysphoria, co-morbid conditions, feelings of regret, social/physical changes and internalized homophobic or sexist prejudices. The research confirmed that detransitionres experience prejudice when working with medical and mental health systems, which Dr. Turban’s vocal activism directly emboldens and reinforces.

We feel it important to add that in May 2021, the Karolinska Hospital in Sweden issued a new policy statement regarding the treatment of gender-dysphoric minors. This policy has ended the practice of prescribing puberty blockers and cross-sex hormones to gender-dysphoric patients under the age of 18. Finland also revised its treatment guidelines in June 2020, prioritizing psychological interventions and support over medical interventions. Major changes are also underway in the UK, as the NHS has convened a “Cass Review” to examine the practice of transition for young people and the evidence that underlies it.

Thus, it seems evident that there is a growing concern over the proliferation of medical interventions that have a low certainty of benefits, while carrying a significant potential for medical harm. It is worrying that Dr Turban does not seem to demonstrate the professional curiosity to rethink his endorsement of medical transition for minors and his dismay at psychotherapy and its role in the care of gender dysphoric individuals of all ages.

We are also deeply concerned by Dr Turban’s activism to suppress the debate on the proper care for gender dysphoria in the public arena. On May 25, 2021, Dr Turban tweeted the following:

“When I spoke with @60Minutes about their “detransition” story and asked where they found the people to profile – they refused to tell me and became defensive. We still don’t know if they searched for people on TERF forums, and transparency would be appreciated.” We bring to your attention that “TERF” (an acronym for “trans-exclusionary radical feminist”) is a pejorative term, and that Dr Turban’s use of it to smear and dismiss the experiences of the detransitioners who appeared on 60 Minutes is incredibly hurtful. That a fellow at Stanford would criticise 60 Minutes for having a brief segment featuring detransitioners has many of us very concerned that, should one of his patients experience transition regret and subsequently decide to detransition, Dr Turban would be unfit to help them due to his hostility towards the subject.

Therefore, we are deeply concerned with how Dr Turban may practice as a clinician, specifically how he may treat a transgender person struggling with transition regret or a detransitioner seeking to discuss their regret or reverse their transition. His comments on the GenderGP podcast, his flawed use of the USTS, and his hostility towards any discussion of transition regret are all highly problematic and in need of addressing. We ask Stanford to speak out for more thoughtful approaches because, as it stands now, Stanford appears to be silently endorsing Dr Turban’s harmful claims that exploratory psychotherapy is tantamount to conversion therapy and that hormones and surgeries are the only appropriate treatment for people with gender dysphoria.

I received affirmative care at my gender clinic. I received no exploratory talk therapy. I injected myself with cross-sex hormones and underwent a double mastectomy. I now suffer from transition regret, and have detransitioned as a result. The distress and harm that I have endured because of the knee-jerk affirmative approach that people like Dr Turban advocates for has been immense. I implore you, on behalf of the detransitioned women who co-signed this letter and myself, to please consider its contents carefully – we wish only to help the many others like us.

Thank you for your brave reply!

The term “TERF” was coined BY Trans-Exclusionary Radical Feminists, who used it for decades to describe themselves. Then, all of a sudden, it became a “slur” . . . ?

Thank you so much for your research!

Though I d like to get my GRA surgery, some scary thoughts of regretting it come to my mind from time to time

Thank you for this excellent article!

“The Hill recently reported on a 2020 survey that polled more than 15,000 American citizens aged 18 years or older. According to the survey, ‘Within Generation Z, the youngest adult demographic who are aged between 18 to 23 in 2020 … two percent identified as gay, lesbian, or transgender.'”

That is clearly incorrect. I don’t know why pollsters can’t figure this out, but when you ask people outright if they are gay, they almost always say ‘no’. No one wants to admit it in person. This may be doubly true for the younger generation because kids have been using the word “gay” to mean “stupid” for a couple decades now, so young gay people don’t want to be associated with that word.

My estimate is that the percentage of the population which is exclusively gay is somewhere between 6% and 8%, and that another 5% to 10% of straight men will allow themselves to be gratified by a man (less for straight women).

Human Life International: DON’T put me on your mailing list.

Thank you so much for your wonderful information! Please keep up your good work. Please pray for me.

Thank you for this excellent article. We are all being deluged with the misinformation and lies of the media and our poor children are being indoctrinated in school about this “gender dysphoria”. Why so, when this type of mental illness affects such a small percentage of our population? The true statistics of the heightened future problems of those who transition either pharmaceutically or surgically need to be widely circulated to the entire population. People must begin to realize that the lies they are being fed are NOT the truth, and that we do need to love these affected people, as God loves them. We, as a nation as well as a world need to come up with a better plan to help our brothers and sisters. And the media and the governments need to realize that we are not the hateful people they have made us out to be. May God show us the way!

You know you won’t make it to your 20th birthday without removing your breasts? Stop and think for a moment, does this sound like a statement made of someone with sound mind? This article is far from bigoted. This article shows far more compassion for people with your struggle than the mainstream narrative. I truly hope you find your peace. You’re perfect just the way you are.

Very wsll said!

I stopped reading after you said “god given sex”. You can’t even prove a god or gods exist, let alone make a ridiculous assertion like this. What a nonsensical article. You’re a joke.

God is not real and science should not be political.

And not to mention the fact that 62% of all of those people transition back again. So cut these by 2/3 and you have the real number.

I think that is a very good point Daniel!

Thank you for your website! Please keep me informed. My work needs your help and needs this very important information.

Thank you, Li. If you have specific questions or need additional information, please reach out to us at [email protected] and we’ll make sure your question gets to our Director of Research for an answer.

Thank you so much for your work! I support you 100%

Lord Jesus, please help me turn away from my sin of transgender lies. I want to follow you. You are the way, the truth and the life. Please pray for me.

How do you get in touch with the person who is having an organization helping detransitioned persons?

Jesus please help me stop believing lies in transgender.

Thank you for your website. I fully support your work. Please pray I change how I best help my patients.

Thank you for your website information. This is very valuable for our organization.

You have given us very important information. Thank you for speaking out the truth. May the truth set us free from the lie and bondage of transgender. Our hope is in Jesus Christ

Because of my study in this area, your article provides very important information. We all need to learn more about it. Thank you.

Jesus answered, “I am the way and the truth and the life. No one comes to the Father except through me.” Lord Jesus please help me to follow YOU the giver of the true life. I want to turn away from my way of transgender to YOUR way.

Thank you for your information. I wish to turn my ideas, my researchs, and all my works to better understand this issue that I am struggling with.

I am doing lots of research on gender issues. Thank you for your helpful information! Take courage and keep up your good work. Don’t mind all the negative comments.

Your article provides very important information for my work. Thank you!

Thank you for your valuable information!

Totally agree!

Simple biology of chromosomes don’t determine sex assigned at birth. Hormones play a large role.

I’m so glad that you mentioned the alarmingly high rates of suicide that trans people face. As Catholics I’m sure you greatly value the human life, and wish to preserve it in any way you can. Although I’m not religious, I completely agree that we should work towards lowering these confronting statistics. Perhaps a way that this could be done is by allowing trans people to exist freely without pitting them against “gods will” and making them feel like they are abominations. It seems strange to me that you focus on the plight of the 4-11% of people who regret there transition, as opposed to the 40% of people who are suicidal. Surely if you were wishing to improve the quality of life for people and ease their suffering- the larger proportion would be the starting point?

I’m a guy in 30’s with gender dysphoria since the age of 3, always felt something wrong with me. I honestly doubt that many would want to revert back to their gender. If you truly have this problem, you would never really want to change back. Well perhaps some would… maybe less than 1% want to change back. If you don’t have this problem, you cannot imagine how agonizing and mentally painful it is. I have not changed my gender only due to the cost and my tall manly outlooks 6.3 ~191 cm tall. Deep inside I know I’m a woman and feel very sad about this. Hate absolutely everything about masculinity, manly things, doing manly things, being put into wrong roles. I think…act..am into all the things a woman would be. I see it’s a religious website so I might as well say that I spend many hours a day reading scriptues and in prayer, it’s the only thing that has kept me somewhat sane. Still every single day of my life, I wish the same thing… if only I could change my gender, not be so tall, look feminine and be a girl.

Thank you for writing this. I feel deep pain from your statements. I also believe you are doing the right thing turning to read the Scriptures and be in prayer. I regret the agonizing and mental pain that you are suffering. I know that Paul asked the Lord to take away an issue that he was dealing with, and the Lords answer was “my grace is sufficient”. The Lord never did take away whatever was ailing Paul, but Paul‘s behavior shows us the right attitude. And I would like to praise your right attitude.I will pray for you Helena that you may find some peace which ever way you decide to go.

I think that our society puts too much emphasis on the way we look. Too bad! There are so many narcissists out there. I think most people do not understand the LGBTQ community. May God give them more insight and therefore tolerance of people that are different from them.

People in the LGBTQ community are misunderstood. My God help others be more understanding and tolerant.

Why cant you still, even without surgery, let go of traditional male roles? In reality, you can be and do whatever you want. Many men and women have rejected traditional roles and live life accordingly. I have to say, I’m not a huge fan of surgery…then again, that’s not my call. Good luck to you! <3

Shame on you!! After all your education you resort to ‘we as christian’ You need help!

This article is not transphobic at all. The article does not hate transgenders purely because of who they are. Stop throwing the word „transphobic“ around. You don’t even know what it means.

Aw, to be 17 and the most intelligent person in the room….

Yes but just it also said out of the 8% overall that switched back, 62% only reverted temporarily so presumably didn’t regret it for long. And “only 5% of those who had de-transitioned reported that they had done so because they realized that gender transition was not for them, representing 0.4%” overall. The rest of the 8% was due to pressure or harassment from family, spouses or employers.

I’m a transgender woman, and I feel truly sorry for you. Your an ignorant bigot who ignores the scientific literature to cling to your Bronze Age mythology. As a writer and researcher I cannot believe you would put your name on such trashy articles. You need to look at the unbiased research that is available.

Paul R. McHugh M.D. has been discredited by John Hopkins University as well as the whole of the scientific community. Walt Heyer has been on a campaign of misinformation to attack the transgender community. .

Nah bro, you’re still and will forever be a dude

I noticed a pattern! As you pointed out, Paul R. McHugh M.D. has been discredited. The scientist who claimed that vaccines cause autism was also discredited. A lot of the scientists people use to support these kinds of views aren’t legitimate scientists. Btw you are a perfectly real and valid woman no matter what anyone on this site says.

You can never change your DNA. You are still a man… Sorry but you can look like a woman but your DNA is XY.

XY vs XX is not how sex is determined. If someone is XY but missing the SRY gene they develop as a woman, look like a woman, mensturate, and can have children.

Who knows how many other toggles there are in our genes.

You think she is still a man, but she knows that she is a woman. Who is right? She is much more intelligent than you!

“Bronze Age mythology” I’m sorry. I didn’t realize the truth had an expiration date.

No, but apparently brains do as is the case with you.

How can you respond this way to a respectful article, that is aiming for nothing but the best solution for people identifying as transgender? Your response is extremely demeaning. No one should be called an ignorant bigot for stating what they believe in. What I don’t understand is how people who claim to be a victim of disrespect, can be so utterly disrespectful and even aggressive to others themselves.

It is incredibly ironic that you are calling this individual disrespectful when the article itself is disrespectful to the individual, and then being disrespectful to the individual yourself.

Invalidation of someone’s identity that is the opposite of what reputable studies and medical advice say (hint: none of which is represented well in the article)? Oh, that’s okay. But call someone a bigot? Oh no, that crosses the line!

what if you stated that you believed in bigoted ideas? could you be called an ignorant bigot then?

I share this view of the issue.

Hey Kitty Kay I see what you said!

“God given sex”….. I didn’t realize this was a satirical website.

Great points all, Maureen!

I have a teenage daughter who came home from school proclaiming there are now seven officially recognized “genders”. Her best fried is a male to female transgender. He “came out” to her first because he felt secure in their friendship and indeed she has been readily accepting of his dysphoric nature and refuses to consider that it may be more harmful in the long-run to encourage his rejection of his God given anatomy. She (like many young people today) see it as cruel and homophobic to not be supportive of the idea of gender fluidity. We don’t as a society normally encourage people iwith psychological disorders to embrace that disorder as some kind of evolutionary development. I think in time society will look to the current social hysteria as a time of group insanity. I absolutely believe it is more harmful to dismiss the idea of gender dysphoria as a dis-order,and discourage psychiatric treatment while we applaud the notion that we can simply choose to transition via dangerous experimental surgeries and toxic chemical therapies. That is truly social insanity. I must wonder then what forces are behind this whole movement and to what end? I cannot accept that homosexual behavior is biblically endorsed yet I likewise do not think that homosexuality itself is some treatable disease. I believe that people are born with a wide variety of illnesses and disabilities both physical and psychological in nature. I leave judgement of the soul to the only entity with the authority to judge. I am certain there will be practicing homosexuals accepted into heaven as there will be self appointed judges who honestly believe that cruelty and rejection are acceptable means of treatment for those they deem unworthy of love. The Christian ideal of loving one’s fellow man, of having compassion for the suffering of others and rejecting violence is what our Messiah is ALL about. My daughters best friend is a gender-dysphoric boy who we have all come to love. At first I wanted to make Jacob feel accepted and loved the way he is so I went along with calling him the female name he prefers (Joanna) and allowing him to dress up as a woman. I still want to do what is best by him because he is a sweet young man that I have come to love dearly. Then I listened to a web chat about the issue of gender dysphoria by a man who transitioned decades ago but later regretted the descisionandnow runs an organization dedicated to helping people with regrets over transitioning. I also listened to a variety of people on the whole issue of our new social embrace of same sex marriage, same sex married couples raising children. I have a niece who married another woman a couple years ago. They now have a daughter due to artificial insemination. I did not attend the wedding because that would be hypocritical of me. I did recently attend the child’s first birthday party because children however conceived are gifts from our Creator. There were a couple folks who spoke out against same sex parents, they later felt they didn’t have a “whole”family and felt pressured as children to say nothing critical about their home environments. We have all been sheparded into this new social construct where all things are okay and dissention is not tolerated. There is no room for expressing criticism, even acknowledging the blatant errors in our new social order. The bullying of any and all critics of the far left LGBTQ agenda is akin to the past bullying of LGBTQ people. Thanks to our uber politically correct social order, tolerance has been confused with endorsement. We are bullied into silence and required to express only endorsement of the new agenda. Well we can’t say we weren’t warned. There is a final book in our scriptures that spoke of such a time.

I think a lot of the transgender problems are societies binary attitude for gender behavior. If it becomes known that a boy likes to wear girls clothes he will be ostracized by his family, friends and possible be beat to a pulp by the alpha males in his life. If boys who demonstrated classically female behavior were not so savagely attacked by friends, family and acquaintances they would not feel that they needed to change sex.

We just sat in on a trial for a young boy whose mother claims he is transgender. The psychiatrist and endocrinologists claim it is a mental issue, not medical.

I personally believe that, since there are about 500+ differences in the Helixical structure of the DNA strands, as well, as how men and women process thoughts; men are concerned with practicality, generally, whereas women are concerned with how it feels, how they feel, what feelings will ensue, etc. Though any individual all along this spectrum may tend to lean more in one direction or another, generally, these descriptions apply to men, and women.What, I believe is fluid, is not sex/gender; but, instead sexual preference. I’ve read of stories about how, a boy dated only girls, as a teen; but, as an adult, dated only other men. This, in popular lingo is known as “coming out of the closet,” or shortened, “coming out.” What I disagree with is this idea, that you are different as a child, than as an adult. But, what is obviously different is the sexual preference you choose, as you age, mature, and investigate a lifestyle alternative to the one you used to. Some adults even desire sex with men, and women, or some other version, different from the experiences they preferred as teens. So, though I don’t accept gender fluidity, I do accept a diversity of sexual preferences, in just one lifetime, based upon desires to explore one you might never have tried, or, only tried once. I do believe you reinforce the choice, every tme you choose to re-experience that variety of sexual expression; and, that this continual same selection can open you up further to pursuing that particular lifestyle, responding only to that stimulation, and abandoning any other option. Conversely, you can see that choice as just one of several options, like bisexuals do. I don’t think true love comes as a result of anything but a “sacred” marriage between a man and a woman. Any other combination is NOT sacred. It is, first sexual, then emotional, then intellectual, and then anatomical, or physical. It is an inauthentic copy of a sacred marriage, duplicating a true sacred relationship, vowing to each other before God, and witnesses, being pronounced by an attendant minster, priest, rabbi, or imam. I hace always believed there are only two sexes, male and female, and, there are no permutations of either, though some try to claim an unnatural, unprovable, untenable variation, for which there still is no scientific evidence in any confirmative method employed by researchers. These claimers of such always quote Alfred E. Kinsey, from the 1950’s who actually had no researcher’s credentials, and was a botanist, and an entomolgist; that is a plant, and insect scientist, whose theories have long since, been discredited, when it was found that his samples were very small, and he used himself as a subject. No reputable scientist ever does that. So, that is where most of the ideas, moderns who embrace them, came from originally; from a non-medical(not even an MD) amateur researcher without credentials as such, got these ideas from. He also created the idea that babies are sexually aroused, can have orgasms, and a whole lot of other nonsense, for which his conclusions are invalid, for the same reasons already stated. This tries to justify pedophilia. This will be the next step in the abbreviation of these folks, LGBTQ+P, and all the other now, affiliations, that are constantly being added to. Watch out folks, God is watching.

Sorry, lots of inaccuracies here. Sex and Gender are NOT interchangeable. Sex is physical. Gender is mental. As is sometimes crudely stated, sex is between your legs and gender is between your ears.

The correct reference is sexual orientation, not preference. Preference suggests that there is some question, but the reality it that there isn’t.

Whatever people do sexually as young people compared to what they do as older people sounds like an answer looking for a question. Remember that there is A LOT of societal pressure to conform to what society sees as the “proper” arrangement of sexuality and gender identity. Obviously you have never felt that as a cisgender heterosexual male. But, just because YOU have not experienced this does not mean that it doesn’t exist.

If you read what gay and trans people have written about their lives, it is clear that they knew something was different about them from very early ages. At the time, they had no vocabulary and no sense of what it meant. In many cases, they were punished severely, but that didn’t really change anything. All it did was cause them to suppress their true selves.

True love only between a man and a woman? No. I know gay men and gay women who have take care of their seriously ill partners tirelessly for years. Conversely, there are many heterosexual couples where one person abandons the relationship due to the serious illness of the other person. I have read many accounts of this kind of abandonment. Obviously you have not.

If you believe that there are only 2 sexes, then how you you explain intersex people?

Personally I have to laugh when people always want to trot out Walt Heyer. Statistically he is irrelevant. Where is the army of people to prove the point? Also, you have to understand that he mislead his therapist and he has admitted that.

Finally, if Anderson and Dr. McHugh were correct, doesn’t it stand to reason that there would be a high degree of agreement among doctors, psychiatrists and psychologists? The truth is the Anderson and McHugh are outliers without much support.

Your logic of the highlighted cases being outliers and statistically irrelevant is ironic considering that all trans folk put together are rarer outliers when compared to non-trans folk than people living with transitioning-regret (or detransitioned) are when compared to people who have transitioned successfully. And this is not even considering the attacks anyone even considering detransitioning face. There is so much effort put towards preventing people from detransitioning when compared to getting people to transition.

Oppressed people always have mental, emotional and addictive behavior issues. I’m glad you said to approach people experiencing dysphoria with love and compassion.

Maybe god wants us to learn from people who don’t fit the gender binary. Otherwise, assuming no errors, god wouldn’t create intersex individuals–it may be only one in every 2000 people, but that’s something.

My personal belief is that all the chemicals in our environment are affecting us and our gender. For example, we use oxybenzone in sunscreens. It’s a synthetic estrogen. Another synthetic estrogen, DES, was widely touted until it was used long enough that we found female offspring would require hysterectomies in their 20s. I have to add that the transwomen and transmen who I know are pretty happy with their transition…but generally they have undergone a lot of therapy to determine if gender dysphoria or other issues are at the root of their discomfort and unhappiness.

“[A]ssuming no errors, god wouldn’t create intersex individuals–it may be only one in every 2000 people, but that’s something.” You could use this logic to state that all sorts of issues and abnormalities people are born with (from the merely irregular to the horrific and painful) are simply “how God made them,” but that’s a common misunderstanding of God’s will. Things are not as they should be, due to the disorder of sin on the cosmos; in the mystery of His will God apparently permits and works through all of it, but we need not say He actively wills it as simply a normal diversity in the species. At the same time He desires our well-being, and that normally through the medium of the sciences (medicine, therapy, etc.)

“pretty happy with their transition” v “our hearts are restless until they rest in thee’. I think judging the happiness of others is in God’s perspective not our superficial experience of others.

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Adolescent Gender Dysphoria Is a Temporary Diagnosis for Most Teens

New evidence underscores that a GD diagnosis in adolescence is an unreliable basis for medical interventions.

It is widely recognized that most children with gender dysphoria (GD) will come to terms with their sex and not live as transgender adults. Transition advocates contend, however, that administering irreversible endocrine and surgical interventions to adolescents is not a problem because, unlike childhood-onset GD, adolescent GD almost never remits.

This view is encapsulated in a quote from Stephen Rosenthal, a notable U.S. gender physician, in an article for Nature Reviews Endocrinology , one of the highest-ranked peer-reviewed medical journals: “Longitudinal studies have indicated that the emergence or worsening of gender dysphoria with pubertal onset is associated with a very high likelihood of being a transgender adult. This observation is central to the rationale for medical intervention in eligible transgender adolescents ” (emphasis added).  

Like many assertions in youth gender medicine, the claim about the near-permanence of adolescent gender dysphoria (GD) has never been properly tested. (How these studies are designed makes them incapable of answering this question, which is probably why Rosenthal uses the vague word “indicate[s].”) So we decided to test it ourselves. Our findings, from an ongoing Manhattan Institute analysis of an all-payer, all-claims national insurance database, challenge this “central” belief underpinning youth gender medicine. In fact, the rate of persistence of the gender dysphoria diagnosis for youth over seven years is 42.2 percent to 49.9 percent, with the trend line suggesting likely future declines.  

Our findings are highly significant for the debate over youth gender medicine. Treatments with permanent effects, and that include negative impacts on health and functioning, should not be offered to patients—especially not minors—with a diagnosis likely to disappear after a few years.

L ike our prior analysis of the number of mastectomies performed on minors , this analysis is based on a comprehensive database of insurance health claims in the United States containing health-care encounter data for about 85 percent of the insured U.S. population. Since American insurance rates are high (about 90 percent of the U.S. population overall, and 95 percent of children, are insured), this is probably one of the most comprehensive resources for health care-related inquires.

In the first part of our analysis, we estimated the number of U.S. minors (age 17.5 and younger) who have had a gender-related diagnosis between 2017 and 2023. Our data show between 272,181 and 342,476 such cases. The smaller number in this range comes from only using the International Classification of Diseases (ICD) diagnostic category F64, which captures the diagnoses of “gender identity disorders” (see Table 1a below). F64 is also used to capture “gender dysphoria” and “gender incongruence.” For simplicity, we will refer to this group as the “GD” group. The bigger number comes from adding two more ICD diagnoses commonly used to signal gender-related concerns: E34.9 (“endocrine disorder, unspecified”) and Z87.890 (“personal history of sex reassignment”). For simplicity, we will refer to this group as “GD+”. Further accounting for the estimated 15 percent missing claims in our database, we get a range of roughly 320,000 to 400,000 minors who were diagnosed with GD/GD+ at some point between 2017–2023.

Table 1a: F64 “gender identity disorder” diagnosis for youth (<18 years)

Table 1b: F64 “gender identity disorder” and related diagnoses (GD+) for youth (<18 years)

*The 2023 data contain around 90 percent of total expected claim volume for that year due to the known issue of “claim runout”—claims for services incurred at the end of the calendar year are not always submitted in a timely manner, leading to an undercounting of such claims. However, since patients with GD have, on average, four-five diagnoses per year, while 2023 may represent a slight undercount, it is much likely to be less than 10 percent, as most patients would have already presented with the diagnoses earlier in the year and would have been captured in our data.

**It appears that the number of GD-related diagnoses in 2023 have dropped substantially. We are undertaking a separate analysis of this preliminary finding. Our current analysis suggests that though states that imposed age limits on medical transition had the highest drops in the diagnosed prevalence of GD, all the states, including those that became “sanctuary” states for minor transition, seem to have experienced notable declines in 2023.

*** The numbers in the year columns represent the diagnostic prevalence (unique count of patients with the diagnosis) for that year. The number in the “Total” column is the total number of unique patients for each diagnosis for the years 2017 to 2023. The number in the “Total” column is thus less than the sum of the individual columns.

Having established the size of the population of youth with GD and GD+ in our dataset to be between 272,181 (320,000) and 342,476 (400,000) cases, we focused next on the key question: What is the evidence that gender dysphoria in adolescents is so persistent as to be regarded in clinical settings as permanent? A high rate of persistence would suggest that adolescents with GD are, in fact, “transgender adolescents,” meaning they will go on to live their lives as adults who feel severe discomfort with their sex.

To estimate the diagnostic persistence rate of GD, we created a baseline cohort of minors who had the diagnosis of GD (“F64”) in 2017 and who were continuously present in the dataset for the entire seven years through 2023, as evidenced by medical professionals billing for any health-care service for each of these patients, in every year. We then estimated the persistence of the diagnosis using various scenarios in order to test the robustness of our findings.

*GD consists of all F64 codes

 **Related diagnoses (GD+) consist of all F64 (gender identity disorders) codes, as well as F651 (transvestic fetishism); E34.9 (endocrine disorder, unspecified); Z87.890 (personal history of sex reassignment); and Z90.970 (acquired absence of other genital organ(s))

Table 2a: persistence of GD and GD+ in minors over 7 years, cohort-based analysis, unique patients

Table 2b: persistence of GD and GD+ in minors over 7 years, cohort-based analysis,  percent

For the lower end of the estimate, we coded individuals as diagnostically persistent only if they had an F64 (“gender identity disorders”) claim in the follow-up period (in addition to baseline). We recorded this as “GD.” For the upper range of the estimate of persistence, we allowed for any GD-related claim (F64, F651, Z87.890, Z90.79, E34.9) to be counted as “persistence” (but only F64 at baseline). We recorded this as “GD+.”

For HIPAA reasons, the data use agreement allowed us to conduct analysis based on five-year brackets, which limited our analysis for youth to 7.5–12.5-year-olds and 12.5–17.5-year-olds. We analyzed the entire 7.5–17.5 cohort of youth, but we also ran a separate analysis for the 12.5–17.5 subgroup. Our rationale was that while eight- and nine-year-olds could be candidates for hormonal suppression under the current protocols, the 12.5+ group is much more likely to be treated medically, and they may also have a different diagnostic-persistence rate. Our criteria produced 9,144 unique patients at baseline for the 7.5-to-17.5-year-old cohort and 6,616 for the 12.5-to-17.5-year-old cohort. Both denominators are sufficiently large to analyze diagnostic persistence.

Our analysis found that in the 12.5–17.5 age category, 43.7 percent–46.2 percent of those who had a GD diagnosis in 2017 retained a gender-related diagnosis by 2023. In the combined 7.5–17.5 age groups category, the diagnostic persistence rate was slightly lower, at 42.2 percent–44.5 percent.

As the diagnostic-persistence chart shows, across all age groups, there was a steeper drop-off between the first and second years (2017 to 2018) as compared with subsequent years. We considered different explanations for this. We ran several other analyses, starting our cohorts at other years, and continued to observe the effect of having a sharper drop-off after year one, with a flatter but ongoing reduction in subsequent years. 

To account for the possibility of false positive diagnoses in the baseline year, we ran another analysis, this time requiring that the baseline cohort have at least two gender-related claims (one F64, and the other F64 or other GD-related codes) within a six-month period. Applying this approach to the older adolescent group of 12.5-to-17.5-year-olds, we saw that the diagnostic persistence rate over seven years rose only slightly, to 49.9 percent.

Finally, we ran a sub-analysis which ensured that the patients in the initial cohort were diagnosed with GD for the first time in 2018 and had no prior GD diagnosis in 2017. This truncated our follow-up period to six years (2018–2023) and resulted in even lower persistence rates (around 40 percent) in just six rather than seven years. Incidentally, this sub-analysis also resulted in a drop-off after the first year that was less sharp than in the main analysis, but still sharper than in subsequent years. These interesting findings may reflect a more robust way to analyze the data and are worth exploring further.

S o, what is the takeaway from this analysis? The single biggest observation is that, contrary to what has been asserted by advocates of youth transition, most adolescents with a GD diagnosis will not have this diagnosis within as few as seven years, during the period of rapid identity development. The single most important implication is that there is no empirical basis for assuming that most adolescents presenting with GD are destined to live as gender-transitioned adults. This further suggests that the GD diagnosis presents a dubious basis for offering teens life-altering interventions with permanent impacts on health and functioning.

One should consider alternative interpretations of our findings, which are preliminary and conservative, and for which we welcome feedback. First, perhaps non-accepting parents are not allowing young people to seek medical services related to their gender distress after an initial health-care encounter, and these minors delay transition until adulthood as a result. The problem with this explanation is that, by the end of our analysis, more than half of the original cohort—5,962 out of 9,144 individuals—were nearly 18 or older, with the oldest participants approaching 25. 

Another alternative explanation is that young people are getting their gender-related treatments without insurance (e.g., buying hormones off the street or paying out of pocket). This is possible, especially if an individual’s insurance carrier does not cover transition-related procedures. However, it is unlikely to explain the full extent of the drop, especially since insurers tend to cover gender-transition treatments and online providers tend not to serve patients under 18.

Further, even when age-restriction laws were enacted in some states in 2023, services related to GD treatment such as blood work or psychological care remained legal in these states and would presumably still be covered by insurance. Since these services would likely be billed with the GD diagnosis, the diagnosis would have shown up in the data. From an insurance perspective, the absence of a GD-related diagnosis on insurance claims is a reliable (if not perfect) proxy for non-pursuit of medical interventions related to GD, including medical gender transition.

A third possibility (though not technically an alternative explanation) is that some continue to identify as transgender but stop the pursuit of medical interventions of any kind, including therapy, related to their identification. This is indeed possible: young gender dysphoric people may not pursue medicalization for several reasons, including shifting identities and shifting “embodiment goals.” Notably, however, this explanation does not help those making the case for using an adolescent GD diagnosis as a basis for medical interventions with lifelong impacts on health and functioning.

Our data analysis has several limitations. First, given when we acquired our database, the 2023 data have about 90 percent of the total expected claims for the year. However, we think this has a limited impact on our analysis of diagnostic persistence, since most patients with claims related to GD have four to five or more such claims per year, according to our data. It is possible that with more complete data, the 2023 numbers would increase. Yet even if we inflate our current 2023 patient count by 10 percent, 2023 is still on track to show a decline in diagnostic prevalence, relative to 2022.

Another limitation is the inability to account for data from Kaiser Permanente, which are absent from our database because Kaiser’s is a closed billing system. Kaiser is a Top Five insurer, with a market share of about 7 percent . It may thus capture around 7 percent of transitioning youth. If the persistence rates of Kaiser patients are different, we are unable to account for it.

To summarize our key findings, the number of young people who have received a GD diagnosis in recent years is much higher than previously reported. By our conservative estimate, over 300,000 minors in the U.S. had a GD diagnosis between 2017 and 2023, which means that the condition is not rare. Even more important is that among adolescents with a GD diagnosis in 2017, over half lost their gender-related diagnoses by 2023, with future ongoing declines likely, as suggested by the trend. There is also some evidence of a sharper than usual 2023 decline, though future data would need to confirm this trend.

W e are not the first to present findings that challenge the conventional wisdom among gender clinicians on the persistence of adolescent GD. A recent study from the Netherlands on “gender non-contentedness” (“unhappiness with being the gender aligned with one’s sex”) found that unhappiness with gender plummeted from 11 percent among young adolescents to 4 percent 14 years later. A German study published earlier this year and using national insurance data reported that over 60 percent of young people diagnosed with GD no longer had that diagnosis five years later. Almost three-quarters of adolescent girls aged 15 to 19—the prime demographic of rapid-onset gender dysphoria—lost their diagnosis. According to the German researchers, this means that gender dysphoria has “low diagnostic persistence.” Another data analysis , combining U.S. and other countries’ data, showed similar trends, concluding that “GD is not a permanent diagnosis.” A landmark 2022 U.S. study of military health-care records found that one quarter of adolescents who started on hormones discontinued their treatment at the four-year mark.

Doubts about the predictive value of a GD diagnosis even following comprehensive assessment also inform the Cass Review . “Although a diagnosis of gender dysphoria has been seen as necessary for initiating medical treatment,” physician Hilary Cass writes in her report to the National Health Service of England, “it is not reliably predictive of whether that young person will have longstanding gender incongruence in the future, or whether medical intervention will be the best option for them.” The Cass Review’s conclusions were informed by seven new systematic reviews of evidence, including one on care pathways.

In sum, while our analysis is the first comprehensive effort to track diagnostic persistence of GD in the U.S., our findings add to a growing international body of evidence that adolescent GD is not a permanent condition and that, given the stakes, it is irresponsible to view adolescents with GD as “transgender adolescents.”

Leor Sapir  is a fellow at the Manhattan Institute.

Photo by Vladimir Vladimirov/Getty Images

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