Detransition needs further understanding, not controversy

Abstract

Kinnon MacKinnon and colleagues call for robust, sensitive research to inform comprehensive gender care services for people who detransition

In recent years, public discourse has drawn attention to research and clinical practice regarding gender affirming care for transgender, non-binary, and gender diverse (trans) populations. In particular, the phenomenon of gender detransition—discontinuing or reversing gender affirming medical or surgical interventions—has been thrust into the spotlight through a highly publicised legal case in the UK, brought by someone who detransitioned, that challenges the ability of people younger than 16 years to give informed consent to start medical gender affirming treatment.¹ At the same time politically driven efforts across the United States are seeking to restrict those under the age of 18 from receiving gender affirming care, citing that limited long term evidence contraindicates gender affirming care for children and adolescents.^{2 3}

The flurry of media attention has highlighted the complexity underlying the science of gender care and the reality that, for some trans people, gender identity and care needs may change over time. Yet media stories about detransition often disproportionately feature those who want to limit access to treatments for gender dysphoria. Understanding the full range of experiences and perspectives of people who detransition—who may be referred to as detransitioners or detrans people—is crucial to advancing the field of gender care (box 1).

Box 1. Glossary of key concepts relevant to research and practice.

• Detransition—The process of discontinuing or reversing a gender transition, often in connection with a change in how the individual identifies or conceptualises their sex or gender since initiating transition

• Detrans—A term claimed by some people with an experience of detransition. This term is rarely thought of as a gender identity and is often used alongside another personal descriptor, such as detrans lesbian, detrans male, or detrans non-binary. Some people prefer the term detransitioner. These are all self-applied labels that should not be used to describe someone unless they use it themselves

• Gender dysphoria—A feeling of discomfort with your primary or secondary sex characteristics. This term is used in psychiatric and medical settings to identify a clinical rationale for gender care, and it is often used to describe feelings of discomfort with birth assigned sex. Many trans and detrans people also use this word to describe their feelings of gender related distress. Gender dysphoria may also encompass iatrogenic, “reverse dysphoria”—that is, discomfort with primary or secondary sex characteristics following gender affirming medical or surgical interventions

• Questioning—The process of questioning your gender identity. Questioning can occur not only before initiating a gender transition but after transition, related to social, legal, or medical interventions. Before detransitioning, individuals may feel regret about their transition and question their identity or their decision to transition

• Re-identifying—A shift in how someone identifies and understands their sex, gender, or sexuality, often referring to a change from one identity to another. Some people re-identify as lesbian, gay, bisexual, or heterosexual after a period of affirming a trans identity and engaging in a gender transition

• Retransition—Resuming a gender transition following detransition. Some detrans people may use this term to indicate restarting hormone therapy for medical reasons but without re-identifying as transgender. Others may apply this word to refer to re-identifying since initiating a gender transition such as moving from a binary transgender identity to non-binary. Some people prefer retransition to describe stopping or reversing transition.

• Transgender—An umbrella term inclusive of those who identify with a gender different from the one assigned to them at birth. Trans people may affirm a binary gender identity (woman or man) or an identity outside of the gender binary such as non-binary, genderfluid, or genderqueer. Some transgender people detransition because of stigma, social pressure, or discrimination in employment settings.

Limited research

All gender care patients—irrespective of their individual outcomes—deserve high quality research and care that is sensitive to their experiences and needs. An analysis of US private and public health insurance data commissioned by Reuters found that, between 2017 and 2021, gender dysphoria diagnoses nearly tripled in the US, with over 14 000 young people aged 17 and younger starting to take gender affirming hormones.⁴ Around 64% of gender dysphoria diagnoses are made in patients assigned female at birth.⁵

However, existing research, clinical guidance, and services largely focus on initiating rather than discontinuing or reversing interventions for the treatment of gender dysphoria.⁶ The World Professional Association of Transgender Health⁷ and the Association of Clinical Psychologists United Kingdom (ACPUK),⁸ for instance, both recognise the need for care for people who detransition. ACPUK states that people require a “broad range of specialist services as they navigate the detransition process.”⁸ With no clinical guidelines to advise care providers, people undergoing detransition may have unmet care needs while making medically uncertain decisions.⁶ Little is known about this group or their care needs owing to oversights in research that contribute to low quality evidence and pervasive stigma surrounding detransition—the same phenomena trans communities have identified as contributing to their erasure, discrimination, and lack of attention in care settings.⁹

Limited attention to detransition in academic research may partly be a defence against the stigmatised, transantagonistic, and erroneous belief about the transience of trans identity. Although shifts in identity and detransition do occur following transition, these outcomes are unlikely to represent the majority.¹⁰ Research is also affected by the ongoing public discourse and legal battles surrounding gender care that have weaponised detransition and decisional regret.¹¹ Some authors even caution against applying the concept of detransition,¹² which is an understandable response to sociopolitical environments that continue to delegitimise trans people and threaten contemporary gender care. However, this position dismisses the fact that individuals use the words “detransition” and “detrans” to connect with one another to communicate their shared social or medical experiences.

Gender care researchers, clinicians, and service developers have an obligation to understand these experiences and to develop tailored detransition related health and social care services as one part of comprehensive gender care. To address the current knowledge gaps, we weave together existing literature about those who have discontinued or reversed a gender transition and offer guidance on how to better design future research studies and care.

Understanding the detrans population and their care needs

A lack of certainty in the evidence and methodological limitations such as non-probability sampling or analysis of short term gender care outcomes means it is a challenge to estimate the prevalence of detransition and describe this population. Nevertheless, care providers, researchers, and service developers need to support evidence based care for this group, which is likely to grow as more people choose to transition.

Recent exploratory, non-representative studies show demographic heterogeneity among detrans people, although a high proportion were assigned female at birth, transitioned before the age of 25, and experienced identity fluidity.^{6 13 14 15 16 17} It is difficult to know the extent to which other trans people ever experience identity fluidity—re-identifying—because contemporary research with trans populations rarely collects or reports data on gender identity changes. While some people who detransition continue to affirm a trans identity following discontinuation or reversal of gender care, others re-identify with their birth assigned sex or with their sexual orientation (eg, gay, lesbian, or bisexual).^{6 16 17} Some individuals may be questioning their identity or may prefer to self-label with their sex rather than with any gender identity, and not all would understand themselves as detrans.^{6 16 17}

Those discontinuing gender affirming treatments often report ongoing care needs relating to gender dysphoria or gender incongruence. Existing accounts indicate a continued struggle with pre-transition feelings of gender dysphoria and bodily discomfort despite their decision to detransition, sometimes because of the return of unwanted sex characteristics such as facial hair or menses.^{6 14 16} In some instances, gender affirming hormones are discontinued because of physical or mental health concerns.^{6 14 15} Some people who detransition may re-identify as a protective psychological response to discrimination and social challenges experienced while living as a trans person, which bring them to opt for detransition.^{6 12 14 15 16} Other identified reasons for detransition include changes in the cultural milieu surrounding ideas about gender, gender affirming interventions not resolving gender dysphoria,¹⁴ and gender dysphoria resolving over time, removing the need to transition.^{14 15} There are also reports of iatrogenic gender dysphoria associated with hormonal or surgical treatments, which some refer to as “reverse dysphoria”¹⁶ (eg, people assigned female at birth may have dysphoria about the results of mastectomy or chest masculinisation surgery or the permanent deepening of the voice; people assigned male at birth may have dysphoria regarding breast growth from oestrogen therapy). Following detransition, some people still encounter ongoing gender minority distress such as being continually perceived trans or gender non-conforming, sometimes because of the effects of previous gender affirming interventions.^{14 17}

Like trans people, those who detransition experience unmet mental and physical healthcare needs together with pervasive social exclusion.^{6 ,13,14,16} Studies using retrospective case note analysis, surveys, or qualitative interviews suggest that neurodivergences and complex mental health challenges are associated with detransition, warranting further study.^{14 15 17 18} An international online survey of 237 detrans people (51% from the US; 92% assigned female at birth; mean age 25) found that 57% of respondents expressed a need for support in dealing with negative reactions to their detransition.¹⁴ A qualitative examination of 28 people who detransitioned in Canada (64% assigned female at birth; 71% aged 20-29) identified unique gender minority stressors associated with detransitioning.¹⁷ Participants discussed social rejection and a lack of service provision by LGBTQ+ organisations, and many felt that gender care providers were unprepared to meet their needs.^{6 17} An international qualitative interview based study of 20 detrans participants (aged 16-25; 95% assigned female at birth) described mixed positive and negative feelings about their transition, with some reporting intense negative feelings such as anger about the consequences of gender related treatments.¹⁶ Gender care and LGBTQ+ service providers should be aware not only of how people who detransition feel about their past medical or surgical treatments but also of possible loss of peer support networks and related ongoing physical and mental healthcare needs. Emerging evidence also indicates healthcare avoidance behaviours among people who detransition, perhaps related to fear of judgment.^{6 14 15}

Although there are detransitioned people who feel appreciative of their gender transition process in that it was an opportunity for self-discovery,^{16 19} care services must be able to recognise and hold therapeutic space for complex feelings such as regret and grief. Preliminary studies that have explicitly collected data about regret highlight that some people who detransition require psychological care and peer support groups to manage their regret.^{6 14 15 16} Ambivalence may also be present, including feeling a complex array of emotions about the gender transition and detransition processes, effects of interventions on the body, and worrying about the future and whether another change of identity may occur.^{6 16}

To bolster comprehensive gender care services, sensitive and robust research is needed. Most studies on detransition use purposive and snowball sampling, thus introducing selection bias, and several aspects of research design need to be improved to inform better knowledge development and care.

Using preferred language and self-conceptualisations

Perhaps the most obvious example of neglecting people who detransition in research is through language evasion. Despite mounting evidence that many use the words detrans and detransition to describe their experiences and care needs,^{6 14 15 16 17} some articles use euphemisms for detransition (such as dynamic desires) or even discourage its use.¹² This could have several detrimental effects, from limiting researchers’ ability to discover studies when conducting literature reviews, through risking incomplete searches of patient medical records when seeking to understand outcomes after gender affirming interventions, to discouraging participation in studies when investigators display negative attitudes towards the language detrans people apply to themselves.

Though some researchers fear the concept of detransition because of the political environment and debates about gender affirming care,¹¹ care providers and researchers neglect robustly examining detransition by erasing the language detrans people are likely to use when describing their needs. Furthermore, conceptualisations of detransition as always comprising regret,²⁰ requests to reverse treatments,²¹ or treatment non-compliance^{22 23} do not accurately reflect, and may even exclude, the diversity of self-understanding and experiences among people who detransition. Conducting qualitative studies to explore preferred language, and which social or medical experiences are understood as detransitioning, could help overcome the erasure of detransition in gender care.

Tackling methodological limitations

The use of relatively short 1-2 year follow-up periods in gender care research risks missing people who detransition, which typically occurs several years after medical or surgical interventions. Studies show the interval between transitioning and detransitioning varies from months to decades,^{14 15 20 24} so accurate estimates of treatment discontinuation or detransition require a follow-up of at least 5-10 years after interventions. Given that many recent research studies have follow-up times of less than five years, this also disproportionately favours knowledge creation about trans people who are in the early stages of transitioning while at the same time denying detrans people important research benefits, including specific knowledge necessary to improve care services.

Research in high income nations should now prioritise studying the health outcomes and identity development of people who started medical or surgical gender care at least 5-10 years previously, with sampling based on having received treatments rather than a current trans identity. These data are vital to understand long term health and wellbeing and to inform people currently seeking gender care. This will require overcoming the structural barriers to extended follow-up in many jurisdictions such as those that arise when patients change insurance providers or their record in the healthcare system, emigrate, or elect for private gender care in response to long waitlists in the public system.

Finally, it is crucial to avoid drawing definite conclusions about gender care outcomes based solely on the subpopulation of patients who remain attached to their clinics and who respond to follow-up. Those who disconnect from care or who refuse to participate in gender care follow-up studies, over 30% in some studies,²⁰ are poorly understood because they have not been adequately researched. Although researchers should not presume a higher rate of detransitioning among those lost to follow-up,^{6 14 15} data analysis that conversely presumes that everyone who does not participate in outcome studies continues to identify as trans or has no other healthcare needs risks misunderstanding the detrans population. Indeed, a qualitative study of 28 Canadian adults with experience stopping, shifting, or reversing a gender transition points to healthcare avoidance behaviours at the point of detransitioning despite uncertainty and psychological distress, in part, because of feeling shame.⁶ Non-judgmental professionals, in whom both trans and detrans people can find trust and support, may reduce care avoidance, thus allowing future studies to capture a more realistic picture of detransition outcomes.

Trans and detrans health allied goals

It is increasingly necessary to transform gender care research in order to understand the impact of changes in gender care delivery and to reflect greater awareness of detrans people in society. Rigorous and nuanced detransition research is indispensable. Investigating the experiences of people who detransition will provide a better understanding of the development of gender identity, as well as all health and psychosocial outcomes following gender care. This aligns with priorities identified by trans health experts.²⁵ Unfortunately, ongoing debates and politicisation of gender care have resulted in the depiction of trans and detrans people as completely distinct groups with divergent needs and experiences, and who are doomed to conflict. However, we believe that trans and detrans people are more similar than different, and that detransition research holds value for advancing the healthcare of all those who transition, and for responsibly moving gender care research and practice forward.

Key messages.

• Research and care services have overlooked people who detransition—those who discontinue or reverse gender care treatment

• Unmet physical and mental healthcare needs are commonly reported among the detrans population

• Short term studies into transitioning may have unintentionally excluded and erased detransition

• Robust research is needed to inform the development of accurate knowledge, practice guidelines, and care services to support people who detransition