Transition Regret, Detransition, and Uncertainty

Bad science seems rife in the opposition to medical care for transgender people

Pictured: Uncertainty, apparently. Gotta love stock photos and symbolism. Photo by Jon Tyson on Unsplash

A Few Notes:

1. This is long. LONG. Brandolini’s Law wins again. If you want something short and vicious written about this, Twitter exists (for now, at least). Alternatively, here we’re trying to be extensive and thoughtful.

2. This is a complex topic, and it demands accuracy. So, we have conferred it. Given that, it’s entirely possible that there are mistakes in this piece. Please feel free to point them out respectfully - we already get yelled at enough online.. 

3. We know a lot about bad science (hopefully). That’s what we’re here for. But remember, we’re cis men[1]. We would prefer to listen rather than talk about transgender healthcare, because we don’t receive it. We’re just here for the screw-ups, like any other issue where science is under public discussion.

[1] According to Uncle Elon, cis is now a slur. But according to us, Elon is a sentient pudding.

The Study

Recently, a study was published arguing that healthcare for transgender people — particularly children — was likely to be more harmful than beneficial. 

The essay argues that a great deal of people who transition later regret this decision, and implies that the majority of treatment with hormones and surgery is completely unnecessary. It also notes that regret and detransition are increasingly common in the transgender space, and that medical practitioners should act to prevent iatrogenic harm (i.e. harm caused by doctors or treatment) which may result from treating trans people.

The essay has had… quite a bit of traction online. 

However, it’s a bad paper. It’s a position that cites untrue, heavily distorted, or just extremely bad science. It’s a deliberately inflammatory position piece.

Citation Laundering

Before we get to the essay, there’s a very common practice in the academic world that you need to know about, which we can call ‘citation laundering’. 

Essentially, 

1. A group of scientists make a claim once, in a very vague and defensible way in an academic journal, where it can be cited. “A might be associated with B”.

2. That paper is cited, using slightly stronger language, removing the uncertainty but keeping the language. but still phrased somewhat reasonably. “A is associated with B”.

3. The above is repeated, maybe more than once.

4. Now, in a citation chain with two or more links, the original claim starts to get cited as proof of the original idea, no matter how strong the initial claim might have been. “A causes B”

It’s basically a game of Telephone, which for some inexplicable reason is on Wikipedia under Chinese Whispers. (No-one ever explained why they were Chinese. Did schoolchildren know that Mandarin has more homophones than any other language?)

There’s a great example of this from 2019. A group of researchers had papers published in leading journals claiming that a unique therapy called YXQ-EQ could potentially cure cancer, but their papers never said what YXQ-EQ was. They simply said that they used it, and then referenced their previous papers for people who wanted to read more about the method. 

Those papers referenced other past papers, and on and on it went. It took a scientific sleuth taking the time and effort to track down the very first YXQ-EQ paper from back in 2004 to find out what the method was:  one dude sitting alone in a room, with a closed door, directing qi (life energy) towards a petri dish.

Pictured: YXQ-EQ simulation. Photo by Ben White on Unsplash

Think whatever you like about qi, but this is not a scientific methodology, which needs to be described in detail for obvious reasons - imagine if it worked and we could never replicate it! But, researchers managed to get papers published on the topic by laundering the citations until it was sufficiently hard to check the facts that no one ever bothered.

Citation laundering isn’t always that egregious, but it’s always a problem. Making something into a little superscript number, or putting some authors names in brackets, lends unearned legitimacy to terrible research.

Checking The References

With all this in mind, the first thing scientists are supposed to do but hardly ever actually do is check claims that are supported by cited references fully. It’s a simple way of ascertaining whether you’re reading a reliable document or something that might be a bit less useful as evidence.

And it turns out that if you look at some of the statements made in this essay about transgender health, they are absolutely not supported by the studies which are referenced.

Let The Annoying Pedantry Begin

The introduction to the essay is pretty innocuous, although the author states that an

“increasing number of people have come forward over the past few years to share their experiences of transition regret and detransition”

This is referenced to:

1. This survey, which does not address the prevalence of people sharing their experience of regret and detransition over time. It actually looks at the assigned sex at birth ratios of people presenting to a gender clinic.

2. These three opinion pieces from The Atlantic, Quillette, and Reuters respectively.

3. The r/detrans forum on Reddit.

Obviously, these are not reasonable sources to use to argue that there is an increasing number of people who have experienced regret and detransition. There’s almost certainly an increase, because more people are identifying as transgender. The base rate hasn’t changed, and the population is going up. So… yes, the raw number of people who have some form of transition regret is guaranteed to increase - but you wouldn’t know it from the sources the author uses.

This sets the tone for the rest of the paper. The issues with the essay really start when you get to the section on the changes in how many people identify as transgender. There’s been an increase over the last few years of such self-identification, which is part of the reason that more people are presenting to gender clinics across the world.

The essay posits three potential reasons for this: social changes, differences in terminology, and a bizarre moral panic about “maladaptive coping mechanisms”.

The first two reasons are both plausible, and it’s doubtful anyone would seriously argue that they are not at least part of the change. Transgender identities are far more accepted in current society than they were in the 70s, 80s, and 90s, and thus it’s completely unsurprising to see more people engaging with them today than in 1975.

Such a change doesn’t happen in a social vacuum - behavioural scientists should be well familiar with the ‘autism epidemic’, and the hysterical responses to the official figures.

“It’s gone from 1% to 3% of children? It must be something in the water! It’s the 5Gs! Or maybe… children are weak now!”

Bollocks, all of it, not least of all because autism has a strong genetic component. It is a re-evaluation of the diagnostic criteria combined with increased ability to identify and diagnose the condition.

But let’s get to the ‘coping mechanisms’. The essay then goes on to say this:

“Last, there is evidence to support the hypothesis that epidemiological changes could be driven by prevalent maladaptive coping mechanisms together with sociocultural factors and peer influences (Haltigan et al., 2023; Littman, 2018, 2021; Withers, 2020). Many young people adopted a transgender identity in the context of family dysfunction or psychosocial issues (Bonfatto & Crasnow, 2018; D’Angelo, 2018; Kaltiala-Heino et al., 2015; Zucker, 2019). Precursors have included sexual assault and trauma (Evans, 2023; Gribble et al., 2023; Littman, 2018, 2021; Marchiano, 2021; Pullen Sansfaçon et al., 2023; Respaut et al., 2022). Parents have reported the onset of gender dysphoria in the context of heavy engagement with social media and cases have clustered within peer groups where one or multiple members identified as transgender or non-binary (Haltigan et al., 2023; Kornienko et al., 2016; Littman, 2018; Sanders et al., 2023).”

Now, that’s an impressive looking paragraph. We might even call it heavily referenced. I wonder what lies beneath that appearance of respectability?

First, context: according to the text, the increase in transgender people could be caused by underlying “maladaptive coping mechanisms”, which interact with changes in culture to produce trans identities.

To put it another way, as being trans becomes more culturally acceptable, people who are mentally unwell will identify with a different gender as a way of dealing with their mental health. But a brief examination of the references shows the evidence is terrible.

The statement “there is evidence to support… and peer influences” is referenced to two academic opinion pieces and two completely useless anonymous online surveys. These surveys are a perfect example of citation laundering — if you read the methodology of the papers, they’re essentially anonymous opinion polls of people who go online to be angry about transgender youths. This gives us very little useful scientific information, but you’d only know that if you bothered to check. 

The next sentence, “Many young people adopted a transgender identity in the context of family dysfunction or psychosocial issues” is referenced to this 2018 perspective, another 2018 perspective, this 2019 perspective, and finally a retrospective chart review which did not really assess the question of family dysfunction or psychosocial issues.

Perspective pieces are essentially academic opinion. They can be useful for giving you an overview of a topic, and often contain many citations to original research, but they are generally not research, they are opinions which might contain research. Referencing them as evidence for a scientific point is a bit like leaning on the New York Times opinion pages to make an argument - there’s some useful information there, but a lot of it is hot wet garbage, and you wouldn’t trust them to tell you the chemical composition of insulin.

The implication from the essay — that transition occurs due to mental health problems — is completely unsupported by the evidence that’s presented here.

The statement about sexual assault and trauma can’t really be assessed. It’s so general that it could mean anything. The final statement in this paragraph is also a bit meaningless, unless you can find an as-yet undiscovered tribe of ‘youths’ who aren’t on social media. 

The essay then moves on to … well, speculation. After describing how many modern gender clinics operate — which involves relying on the individual patient’s wishes, and loosening the medical requirements for providing hormones — you get to this passage:

However, the minority stress model has been challenged recently by a growing number of studies that reveal high rates of mental illness and childhood adversity pre-dating the onset of gender-incongruent feelings (Becerra-Culqui et al., 2018; Kaltiala et al., 2020b; Kaltiala-Heino et al., 2015; Kozlowska et al., 2020; Littman, 2021). This may explain why people with preexisting mental health problems continue to struggle when social transition, hormones, or surgery fail to alleviate other problems that are frequently tied up with feelings of gender dysphoria (Kaltiala et al., 2020b; Morandini et al., 2023).

This is a bit of a chicken and egg problem. If you assume that gender incongruence is not itself a medical problem, then you ask people what gender they’d prefer to be and treat any comorbid issues appropriately. Someone turns up to the service and says they have strong and persistent feelings of being a gender not assigned to them at birth, you help with their transition and additionally treat any issues they may have picked up on their journey through a difficult world.

But if you think that mental health issues precede the gender incongruence, you might instead act as if the mental health problems caused the gender differences. Instead of hormonal treatment to assist people with their gender transition, you might assume that they need lengthy counselling to improve their mental health and thus make the whole transition unnecessary.

This is a central claim of the essay, and thus you’d expect the idea that mental health problems precede gender incongruence to be incredibly well-supported. And, if this passage represented measurements collected in the same people over time, it might be evidence!

But.

Here are the references:

1. A retrospective study looking at medical records for trans-identifying youth. This paper did not assess the onset time of gender-incongruent feelings.

2. Another retrospective review which suffered from the same issue.

3. A cross-sectional study where researchers recruited children who were on average assessed at age 16 and reported feeling gender-incongruent before this. There are no specific time points in this study, so it’s impossible to know if the feelings came before any psychological issues.

4. Another cross-sectional study which compared children presenting to a gender clinic to the children of hospital employees. This paper also did not assess whether kids started to feel gender-incongruent before or after they had mental health problems.

5. The same extremely bad anonymous online survey from before.

The first two studies simply don’t address the question at hand. They took databases of young people with gender incongruence, and looked at whether those people had diagnoses of mental health issues at any time. But there’s no discussion in the papers about whether these trans kids had mental health problems that preceded, coincided with, or followed their initial feelings of gender incongruence.

The cross-sectional surveys also don’t ask these questions. Cross-sectional studies are, by definition, not really evidence of one thing following another, because you’re just asking people about stuff at a single point in time.

Finally, we have the silly survey. We’ve already spent enough time on this paper, it proves nothing much.

Thing is, it’s possible that mental health problems sometimes precede feelings of gender incongruence. Even if, say, depression doesn't cause people to feel that their gender is wrong, it’s entirely possible for someone to feel depressed before realising they’re trans. But the studies that the essay puts forward don’t even address that. It’s just more citation laundering, reassuring the reader that there is evidence for the claims even though the evidence doesn’t say anything of the sort.

The next section of the essay, entitled “Gaps in Medical and Mental Healthcare” posits two related concepts - the idea that mental health issues cause people to transition, and the lack of services for people who do decide to detransition. This makes it a bit more complicated than the previous, because it’s hard to argue against the statement that services for trans people need more funding, and the evidence certainly supports the idea that people who detransition struggle to engage with healthcare services. For example, you’ve got the statement:

“Gaps in the quality and accessibility of medical and mental healthcare have consistently been highlighted in studies and personal testimonies of detransitioners (Littman, 2021; MacKinnon et al., 2022b; Vandenbussche, 2022)”

This is referenced to the same terrible Littman survey (sigh), and another almost identical anonymous online survey from 2021. But it also includes this very interesting qualitative paper where researchers interviewed 28 adults who talked about their experiences of detransition. In this interview series, people who detransitioned did actually talk about gaps in healthcare, particularly with mental health support when they decided that they no longer wanted to continue their transition. So, some support for the argument, although the ‘gaps’ aren’t necessarily the ones that the essay seems to imply.

But the ideas here get really tricky. 

The statement that: “Many detransitioners reported not feeling properly informed about health implications of treatments before undergoing them” is referenced to the same anonymous online Littman and Vandenbussche surveys as before. Ignoring the problems with these samples, the essay glides over the fact that in both of these studies about half of the people surveyed said that they didn’t feel properly informed…and about half felt that they were either partially or fully informed. 

Another one of the references used is to this qualitative study where 20 young people who detransitioned discussed their experiences with researchers. This paper doesn’t really get into how well-informed these youths were about transition, but it does present a very complex picture of detransition: “Regrets and feelings of satisfaction can both coexist. The processes of transition and discontinuation or detransition appear to be non-linear and participants do not necessarily return to a cisgender identity.” So some people who detransition felt inadequately informed about potential health consequences, but others didn’t, and all of this is much more complicated than the simple model of social contagion.

Of course, there are also some parts which are just completely unsupported. The essay states:

“However, many therapists were reluctant to be involved in the care of detransitioners due to fears that they would be accused of performing conversion therapy if they deviated from the affirmative approach (Griffin et al., 2021)”

But Griffin et al 2021 is not a survey of therapists involved in the care of transgender people - it is an opinion/perspective piece from a psychiatric journal. There’s no information at all suggesting that therapists are “reluctant to be involved in the care of detransitioners”. There are currently clinics in the world that explicitly advocate against transition, so the statement isn’t just unsupported, it’s overtly false.

Further on, there are more problematic claims made about transgender youth. The statement:

“In the past, 61% to 98% of cases diagnosed with gender identity disorder/gender dysphoria in early childhood reconciled their gender identity with their birth sex through the natural course of puberty, if not earlier (Drummond et al., 2008; Ristori & Steensma, 2016; Singh et al., 2021)”

These three studies derive their figures from clinicians working in gender clinics attempting to follow-up their patients from the 80s and early 90s decades later. The papers were fraught with loss-to-follow-up, with many, sometimes most, patients not being contacted. In addition, a substantial proportion of the children in these studies were not diagnosed with either gender identity disorder or gender dysphoria — in both Singh et al and Drummond et al, only about 60% of the participants met the clinical threshold for these diagnoses as children. The 61%-98% figures are at best substantial overestimates that count children who were not clinically dysphoric as ‘desisters’ from transition because they were also not dysphoric as adults.

It’s also important to note the specifics here — in these studies, some proportion of children who were diagnosed with either GID or GD no longer met the threshold for classification as adults for these conditions. But that’s not really the same as reconciling their gender identity — people who no longer experience clinical levels of dysphoria may still identify as trans, non-binary, etc. They also might not be entirely keen to open up about their current gender identity to the clinicians who treated them as children, for a variety of reasons.

The essay then argues that social transition, where people change their gender expression in social settings but don’t necessarily use medical treatments to do so, is problematic:

“…many of today’s youth undergo some form of gender social transition (e.g., change in clothes, haircut, name, and pronouns; breast binding; use of opposite sex facilities, etc.) before contemplating medical interventions (Morandini et al., 2023; Olson et al., 2022; Zucker, 2020). Although social transition is often described as a neutral intervention with little, if any, long-term consequences, several studies support the hypothesis that it can concretize gender dysphoria (Olson et al., 2022; Turban et al., 2021a; Zucker, 2020).”

This argument seems to imply that, without social transition, young people would not go on to have gender dysphoria and require medication. It’s hard to see how social transition can itself cause harms — there are no specific iatrogenic or other negative effects to using a different bathroom, name, or wearing different clothes — but the implication is that some youth would not feel dysphoric if they didn’t socially transition.

The money sentence is obviously the last one, the statement that social transition “concretize[s]” gender dysphoria. Well, in at least one case, the authors of the paper disagree with this portrayal of their research.

It doesn’t seem as if there’s any real support within these papers that children were made more dysphoric by socially transitioning. If anything, they seem to contradict this idea — for example, the Turban 2021 study found that people who socially transitioned as children were less likely to have had hormone therapy than those who only transitioned as adults.

Further on in the paper, there is a whole segment on detransition where the two aforementioned entirely anonymous online surveys which were run through anti-transgender websites are given greater weight than a 27,000-person sample of transgender adults in the US. The 27,000-person study does have some weaknesses, but far fewer than a study of 300 parents who frequented online forums dedicated to complaining about their transgender children.

The essay also spends some time noting that regret rates after medical/surgical transition are probably higher than the lowest estimates. It’s hard to disagree here — the very low numbers found in some studies of <1% of people who transition ever regretting it are probably due largely to issues with follow-up. There are plausible estimates suggesting that somewhere between 5–10% of people regret their transition to some extent, and plausibly up to 30% stop taking hormonal medication for some period after starting it.

But what the essay fails to mention is that most medical care has discontinuation/regret rates well above that for transgender health. If 5.3% of children referred to a British pediatric endocrine clinic cease hormones and re-identify with their birth sex, it is a drastically lower proportion than the rate of people who, say, stop taking their diabetes meds. The discontinuation rate for some medications in children is >50%!

Procedures, treatments, medications fail. They fail a lot! Sometimes because they aren’t effective to start with, because they address the wrong problem, because they were inexpertly performed, because they have unacceptable side-effects. 

Of course, these things are not perfectly comparable, but it’s remarkable to focus so much on what would generally be considered to be very good rates of desistance with medical care. 

There is a tendency, as well, to promote any gender-related medical care as a kind of monstrously unnecessary and unique form of 'mutilation'. This, too, trends hysterical - medicine does 'mutilative' things to people all the time, sometimes with evidence that is deeply insufficient, and sometimes with nothing more than blind hope that the side effects are tolerable. Do you sweat chronically from your hands? We go into your spinal column and cut the nerves off your spine that enervate your upper body. Do you have scoliosis? We fill your spinal column full of metal lego. Psychosis? You get drugs that are so astonshingly powerful that your friends might not recognise you. Medicine often isn't nice. Rather, it can be an uneasy, painful, and expensive decision between proven benefits and likely risks.

Anyway, at a certain point, you have to stop interrogating every sentence — suffice it to say that most of the factual claims in the essay are unsupported, misleading, or, in some cases, wrong.

Moving Forward

This essay is just one of many discussions that are ongoing about trans healthcare across the world. See the disclaimer at the top again: we’re not experts. All that gets us out of bed is looking into specific claims to see if they are well-supported by evidence.

What can be said is that a lot of the evidence that is provided to support arguments against gender-affirming healthcare is absolutely atrocious. It’s amazing that so many people arguing against medical transition reference bizarre, anonymous online surveys of people recruited from subreddits and Facebook, especially considering that one of these surveys has just been retracted due to ethical concerns.

None of this is necessarily supportive of gender-affirming care, although to us it does seem to provide some comfort that the care isn’t as harmful as many are claiming online. It’s clearly true that people who have medical issues or later regret their transition need support and assistance. It’s much less clear that there’s any evidence that doctors are harming vulnerable kids with hormones.

This could easily change in the future. The evidence in this space is very new, because the huge stigma that transgender people face has stymied efforts to investigate many of these questions with properly funded longitudinal work - if you want to know how a phenomenon changes over time, then raise the money and measure it over time. No other area of medicine is decided by surveying angry people on Reddit. 

Perhaps detransition and regret rates will rise. Having looked at the evidence to date, this seems unlikely, because the mechanics of treatment are still being researched and legislated over, and higher regret rates are in no-one’s interest - not the doctors and researchers in gender clinics, not governments or funding bodies, certainly not the patients - but it’s possible. Medical issues that align everyone’s incentives have a tendency to be solved in the long run, which is probably cold comfort for anyone being legislated out of existence at present.