Jun 19 2023

Regret After Transitioning

In my last post I noted that even mentioning general vague support for the LGBTQ community was enough to trigger very specific feedback, often making erroneous scientific claims. Each claim requires a deep dive and article-length discussion. Even though the discussion that followed in the comments was better than I thought it would be, it still filled with additional dubious claims. I suspect there are two main reasons for this. The first is that the topic of gender identity is complex and not intuitive. It may feel intuitive, as if your immediate gut reaction is all that is necessary to deal adequately with the topic, but it really isn’t. Ultimate this topic deals with how our brains construct our own sense of self, identity, and reality. These are always tricky concepts to deal with – and as I have pointed out before in other contexts, our brain constructs are counterintuitive by their very nature. In other words, our brains evolved for these constructs to feel real and automatic, and for the subconscious processes that create them to be invisible to us.

Second, the issue of gender identity has been highly politicized. This has resulted in any discussion of the topic being flooded with biased and deliberate misinformation. The usual FUD (fear, uncertainty doubt) strategies apply. And of course – science is hard. Even seemingly straightforward questions are actually quite complex. This makes it easy to create confusion by “just asking questions” or selectively applying skepticism.

One question at the heart of the trans issue is this – what is the rate of regret or even detransitioning after medical transition? One narrative is that adolescents (often conflated with “children”) are being prematurely herded down a road to transition, which they later regret. The other narrative is that, generally speaking, making the decision to transition is taken very seriously, with very low levels of later regret. Which is true?

Spoiler – the short answer is that the latter is much closer to the truth. Overall rates of regret and detransition are low, while satisfaction and positive health outcomes are high. But let’s delve into some details.

One highly cited study is a 2021 systematic review and meta-analysis. This looked specifically at gender affirming surgery (GAS). They found:

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% transfeminine procedures. The prevalence of regret among patients undergoing transmasculine and transfeminine surgeries was <1% (IC <1%–<1%) and 1% (CI <1%–2%), respectively.

A 2023 study looking at requests for detransitioning after GAS found:

Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2–0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons’ experience with patient regret and request for reversal was consistent with the existing literature.

A broader review of 55 studies, including international studies as medical transition, found:

This search found a robust international consensus in the peer-reviewed literature that gender transition, including medical treatments such as hormone therapy and surgeries, improves the overall well-being of transgender individuals. The literature also indicates that greater availability of medical and social support for gender transition contributes to better quality of life for those who identify as transgender.

We see a range of outcomes in the literature, ranging from about 0.3% to 3.8% with an average of about 1% or even less. That is a remarkably low number for any surgical outcome. But of course, we can ask a number of questions about the methods used in the studies. Critics have pointed out that many studies have a high rate of subjects lost to follow up. Or the follow up period was too short – perhaps people regret GAS after more time as gone by. It is also possible that the recent increase in people requesting GAS may mean that older numbers are no longer accurate.

Some of these criticisms don’t really hold up in the literature. For example, long term follow up studies, like this 40 year follow up, found that satisfaction rates and psychological outcomes remain very good long term. Also, the reviews above show that, if anything, rates of regret are decreasing over time with greater acceptance and improved surgical techniques.

Also, as the 2023 study above and other studies show, there are different types of regret. A third to a half of regret in most studies is social regret, stemming from a lack of social support after transitioning from family, friends, and colleagues. A percentage is “medical regret” meaning that they are not happy with the details of the surgical outcome. This is improving as surgical techniques improve. The minority is true regret, where people feel they made the wrong decision for themselves, and either question their gender identity or the decision to transition. There is an association with lower rates of true regret and the degree of screening and counseling prior to GAS.

Definitely, the conversation will benefit from more and better research, which is almost always the case. But there is a strong and consistent signal in the existing evidence that rates of regret after transition (medical or surgical) are extremely low, especially true regret. Overall health and psychological outcomes from transitioning are positive. They are better than many surgeries we take for granted. But of course, any case of regret is tragic and we need to make every reasonable effort to minimize that number. Efforts should be, and are, focusing on improving methods of evaluation and counselling, including proper follow up. These efforts, of course, have to be balanced against the rights of trans individuals to access proper health care. Everything in medicine is a risk-vs benefit analysis. You will never get negative outcomes to zero, and as you push lower you get diminishing returns for greater effort, eventually causing more harm than good. Being denied transition when it can genuinely help someone is also tragic.

But this gets back to the first issue I pointed out above – we all have visceral reactions to the notion of gender identity. It can be very difficulty for people raised with traditional attitudes to wrap their head around what is happening in the mind of someone who identifies as trans or non-binary. We also have innate emotional reactions to any violation of bodily integrity, and altering what seems “natural”.  There are also issues of maturity and decision-making. There is a lot to wrestle with here.

Meanwhile, the conversation should be based on a fair and good-faith reading of the evidence. Unfortunately, we rarely see that once an issue becomes ideological or political.

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