Bad Science: Transition Regret

It's real. It's rare. It's not a good reason to ban gender-affirming care

“I think there is a huge risk” of transition regret, [Burgo] says. He deals with this in his practice, and it haunts him. “What do you do with a gay man who had full surgery — bottom surgery — and realized when he was 27 that he was actually a gay man? And now he doesn’t have — he has no genitals, really.” Burgo’s speech is halting. His voice is tight. “When you see people that have been ruined by a rush to medicalization, it makes you worry about more kids being harmed.”

-James Burgo, Gender Critical: quoted in Lux Magazine

That’s right, we’re doing gender science again.

Original Post
Part 1: “Rapid Onset Gender Disorder”

This is the last time, folks. One final substack, divided into two parts (part 2 is already written and drops next Monday). As I have said before, I did not choose political science over real science on accident. My science writing aversion is why there’s been radio silence for three weeks (sorry about that). If you want more gender stuff after this, go read Erin In The Morning. She’s absolutely killing it over there.

We’re talking about desistance, detransition, and trans regret today. Quick definitions:

• Desistance: when someone who previously identified as trans begins to identify as cis

• Detransition: when someone begins the process of medical transition, then stops or attempts to reverse treatment

• Transition regret: Exactly what it sounds like: the feeling that transitioning was a mistake

Transition regret is obviously a big deal if the transition has gone far enough, for the exact body dysmorphia reasons that make gender-affirming care so important for trans people. If the nightmare scenario Burgo describes above were a common outcome of gender-affirming care, or a rare but significant outcome, even, we’d have a serious problem. However—and this will come as no surprise to anyone who read Part 1—there’s no good evidence of widespread post-treatment transition regret, plenty of evidence suggesting the percentage of regretters is extremely small, and even more evidence that the benefits of gender-affirming care vastly outweigh the risk of trans regret.

First, though: there are several different questions at play here that often get treated as a single amalgamated issue. This is the same problem that afflicts the debate about gender-affirming care writ large, where social, hormonal, and medical transition all get lumped in together as the same thing. They are not the same thing. That’s how you get absurdities like “Children are being transed at age 5!” and people assume that means surgery when what it actually means is a name and pronoun change: two measures that take about 15 seconds to reverse.

Here are the questions that get mashed together when Gender Criticals talk about trans regret:

• How often do people who elect to undergo hormonal or medical treatment regret their decision?

• Are the benefits of providing gender-affirming care worth the risk of trans regret?

• How often do children who identify as trans desist and return to identifying as their birth gender?

• Are children able to opt for hormonal and medical procedures before having enough time to decide whether to desist?

And finally, a bonus question:

• Are detransitioners receiving adequate care and support?

Strap in. We’ve got papers to read

Rates of Transition Regret are very low

There have been a couple great studies on transition regret, and they suggest that regret is very rare.

In 2014, Swedish scientists analyzed all 767 submitted applications for “sex reassignment surgery” between 1960 and 2010: a great sample size. 89 percent of applicants were approved and underwent surgery. 3.3 percent had their applications denied. The remainder did not follow up on the application.

Of the people who ultimately did go through with it, 2.2% of both men and women experienced transition regret. To put that into perspective, let’s look at regret rates for some other types of body-altering surgeries:

• Gastric Bypass: 3%

• Knee Replacement: 7.5%

• Botox: 4% regret

• Breast augmentation: 5% regret

• All surgeries, on average: 14.4% regret

It’s never good to jump to conclusions based on one study, even if the sample size is good and the methodology is sound. Luckily, scientists in the Netherlands conducted an even larger study of all the patients that visited the Amsterdam Gender Identity Clinic between 1972 and 2015: a whopping 6,793 people. This study found even lower rates of transition regret: 0.6% for trans women, .3% for trans men. That’s fourteen people total out of nearly 7,000. Good luck finding any medical intervention with lower rates of regret. I couldn’t. 

Not only that: the statistic captures regret due to social pressures, not just a patient realization that they were their assigned gender all along. The study lists regret reasons for all 14 patients: of those, only seven felt “true regret.”

The study is not perfect. It gauges regret based on notes in medical charts, and does not specify whether people who failed to show up for follow-up visits were excluded from the study or assumed to not experience regret. If the study did not exclude patients with incomplete records, these numbers might be low: after all, some people may have stopped coming in after experiencing regret. Because the rest of the study is so robust and the sample size so large, though, I still think the conclusion of low regret rates holds up, even if true regret levels are slightly higher.

At this point, Gender Criticals are rushing to the comments section to raise three objections, so I will save some time by rebutting them here:

1. “These studies don’t take the recent exponential rise of patient reporting gender dysphoria into account.”

   Actually, the Amsterdam study does take this into account: not the entire exponential rise, of course, but the start of it. Patients reporting gender dysphoria have increased dramatically since 1975, when the study began. What these scientists found is that regret has decreased as patient numbers increased. 
   

2. “These studies don’t measure long-term regret: it usually take trans people years to realize their mistake.”

   
   Again, the Amsterdam study absolutely takes this into account. One of the fourteen people who experienced regret reported that regret almost 19 years after their transition. It’s true that the study does not take into account long-term trans regret for more recent transitioners, on account of that’s not how time works. I don’t think we should make policy decisions based on how Gender Criticals imagine things will shake out.
   

3. “Sweden and Amsterdam have higher minimum ages for medical transition.”
   
   You’ve got me there. We’ll talk about gender-affirming care for minors on Monday. But first…

Gender-Affirming Care Saves Lives

If you’ve been paying attention even a little bit over the last decade or so, you’ve heard that failure to access gender-affirming care leads to suicide. But is that true?

Genspect, the organization I wrote about for Lux, doesn’t think so. “The best quality evidence on suicide comes from a Swedish Governmental Authority report, which places it at 0.6% — lower than many mental health conditions and/or other challenges,” their Brief Guide for Parents states. No word on why that’s the best quality evidence–maybe because it supports their policy position? Curious!

As you might expect, the Swedish Governmental Authority report is in Swedish, but through the magic of Google Translate I have been able to read something approximating the paper. It looks like a well-done study to me. As with the Swedish and Amsterdam studies in the previous section, it looks at all patient records over a period of time: in this case, 6,334 people who were diagnosed with some type of gender dysphoria in all of Sweden from 1998 to 2008. Of those people, 39 people have died of suicide: just .6% of the trans population of Sweden. Checkmate!

A couple things, though. First of all: if suicidality results from a failure to receive gender-affirming care, and if this sample size, by definition, received a diagnosis that made them eligable for gender-affirming care, we are looking at a sample size for whom the problem has been solved. If anything, the .6% statistic bolsters the claim that gender-affirming care saves lives: as the study points out, .6% is a lower suicide rate than most mental health conditions.

Also: this study looks exclusively at completed suicides. In fact, all of the Gender Critical stats on suicidality in trans people look exclusively at completed suicides. When we widen our lens to look at suicidality in general—thoughts of suicide and attempted suicide—we find a very different set of statistics.

In 2015, the National Center for Transgender Equality hired a polling company to conduct a massive survey of trans people. Based on responses from a staggering 27,715 participants from all 50 states, the report found that 40 percent of trans people have attempted suicide at least once in their lives: over eight times more often than the average population. 

If you’d rather focus specifically on trans youth, the Trevor Project has your back: their National Survey on LGBTQ+ Youth found that, in 2022, 14 percent of LGBTQ youth attempted suicide and 45 percent—almost half—seriously considered ending their lives. The survey also found that these numbers dropped dramatically with a gender-affirming environment.

Genspect has dismissed this report as as a “poorly-designed survey” but does not explain why, which is unfortunate, because I can’t find the problem. This is an IRB-approved survey of nearly 34,000 LGBTQ youths between the ages of 13 and 24. Participants were recruited through social media ads and not the Trevor Project website (Lisa Littman could learn a thing or two), and the survey screened for auto-generated responses. Maybe you can find something wrong with it: you can read the methodology here.

A lot of things we’re talking about in this report are understudied, but suicidality in trans people isn’t one of them. You don’t have to go all the way to Sweden to find study after robust study which show that trans people experience suicidal ideation at higher rates than almost any group, and gender-affirming care mitigates that risk. 

Why do Gender Criticals focus on completed suicides and not suicidality generally? The easy answer is that statistics on completed suicides come closer to supporting their case, but I think the choice goes deeper than that. There is a callousness amongst many Gender Criticals towards the pain that gender dysphoria inflicts. “It’s kind of an alien idea to many people, that you just have to suffer your pain,” Joseph Burgo, from that intro quote, said on gender-critical podcast A Wider Lens in June of 2022. Co-host Sasha Ayad echoed his sentiment. “We don't know how [suffering] might transform, how it may teach [trans youth] something valuable. And like you said, Joe, how they might develop a healthy way of coping or growing from it.”

(To be fair, the podcast does take some pain seriously. "I think it's understimated how devastating it is for familes,” co-host Stella O’Malley said earlier in that same episode. “It’s only when you meet parents that you think oh my god, what has happened to families in this world?")

If you think that the suffering of trans kids builds character, then I suspect you have never experienced suicidality yourself and that nothing in this section will persuade you. If, however, you think that people should not walk around wishing they could stop existing and daydreaming about how to do it, then the risk/reward balance of gender affirming care comes into focus. Detransition happens. So does suicidality. Suicidality happens orders of magnitude more often than detransition. So, yes. I think it’s worth the risk.

…Continued on Monday, September 25th

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