Detransition Among Transgender and Gender-Diverse People-An Increasing and Increasingly Complex Phenomenon.

Although transgender and gender-diverse (TGD) people have been receiving hormone therapy and surgical interventions for several decades, information and public discourse on discontinuation rates of hormones, detransition, and regret were sparse until around 2016. Detransition refers to the stopping or reversal of transitioning which could be social (gender presentation, pronouns), medical (hormone therapy), surgical, or legal. Although they are sometimes mistakenly viewed as synonymous, detransition and regret are different concepts that may overlap in some people.

Roberts et al examined rates of continuation of gender-affirming hormones among TGD adolescents and adults in the U.S. Military Healthcare System (1). The study sample included 627 transmasculine and 325 transfeminine individuals who were children or spouses of active-duty, retired, or deceased military members. International Classification of Diseases codes were used for diagnoses and pharmacy records determined hormone use. Discontinuation of hormones was defined as failure to obtain another prescription > 90 days following completion of the most recent prescription. This study found that the 4-year gender-affirming hormone continuation rate was 70.2% with 81% for the transfeminine group and 64% for the transmasculine group. Using a Cox regression model, increased discontinuation rates were independently associated with transmasculine gender identity (hazard ratio 2.4) and starting hormones ≥ age 18 (hazard ratio 1.69). Important limitations of this study were that it was unable to assess the reasons why 30% of their sample discontinued hormonal therapy for more than 90 days, the short period of 90 days, and the inability to capture prescriptions filled outside of the military healthcare system. It would be interesting to know what proportion discontinued due to detransition versus other reasons such as an adverse effect of a medication or cost. Of note, the mean age in this study was 19.2 years.

Historically, rates of regret in TGD people following hormone therapy and surgical interventions were thought to be quite rare. From 1972-2015, 6793 people sought gender-affirming services at the multidisciplinary gender identity clinic at the VU Medical Center in Amsterdam (2). All patients were screened by mental health specialists who determined whether patients were eligible for hormone therapy. Seventy percent were started on hormone therapy and 78% of this group went on to have gonadectomy. Among those that underwent gonadectomy, rates of regret were 0.6% for transwomen and 0.3% for transmen with an average time to regret of 10.8 years. The rate of regret may be an underestimate due to a high rate (36%) of loss to follow-up. The reasons for regret were true regret (n = 7), social acceptance (n = 5), and feeling nonbinary (n = 2). Another study reported 8 cases of detransition and/or regret among 796 patients seen from 2008-2018 at a multidisciplinary gender identity clinic in Valencia, Spain (3).

The largest study to look at detransition was the U.S. Transgender Survey from 2015 which was a cross-sectional nonprobability study of 27 715 TGD adults (4). This survey included the question “Have you ever de-transitioned? In other words, have you ever gone back to living as your sex assigned at birth, at least for a while?” The survey found that 8% of respondents had detransitioned temporarily or permanently at some point and that the majority did so only temporarily. Rates of detransition were higher in transgender women (11%) than transgender men (4%). The most common reasons cited were pressure from a parent (36%), transitioning was too hard (33%), too much harassment or discrimination (31%), and trouble getting a job (29%).

Although the literature is sparse on the topic, the study by Roberts et al highlights the important issue that a proportion of our TGD patients elect to discontinue hormonal treatment. As endocrinologists, we may overlook this aspect of care as many patients who detransition no longer present to our clinics for follow-up. In fact, one study of 100 detransitioners found that only 24% of respondents informed their clinicians that they had detransitioned (5).

As endocrinologists, we have an important role to play when it comes to the medical management of TGD patients who transition or detransition. Because the informed consent model has made it easier for people to access gender-affirming therapies, we should ensure that our patients have received adequate and comprehensive information on the potential benefits and risks of gender-affirming therapies, especially regarding irreversible changes such as voice deepening with testosterone and hypogonadism after gonadectomy. A cross-sectional online survey of 237 detransitioners found that this population had important psychological needs and needed accurate information on stopping/changing hormonal treatment (6). This particular study recruited participants through social media, particularly through websites and groups for female detransitioners. The average age was 25 years, 92% were assigned female at birth, 65% transitioned both socially and medically, and 46% of those who medically transitioned underwent gender-affirming surgeries. The average duration of transition was 4.7 years. The most common reason for detransitioning was the realization that their gender dysphoria was related to other issues (70%). The participants in this study had high rates of mental health comorbidities including depressive disorder (70%), anxiety (63%), post-traumatic stress disorder (33%), attention deficit disorder (24%), autism spectrum condition (20%), eating disorder (19%), and personality disorder (17%). Most respondents described their detransition as a very isolating experience in which they did not receive adequate psychological or medical support. Many lost support and friendships from the LGBT community and some experienced hostility after announcing their decision to detransition. This study has the major limitation of selection bias.

With the increase in numbers of persons presenting for gender-affirming care, shift to informed consent, likely reduced proportion of TGD people receiving an adequate mental health evaluation, and a change in the distribution of TGD people to more assigned female at birth and nonbinary individuals, there is reason to believe that the numbers of detransitioners may increase. It is quite possible that low reported rates of detransition and regret in previous populations will no longer apply to current populations. More research is needed to compare care and outcomes between the less restrictive informed consent model and the stricter interdisciplinary model pioneered in the Netherlands. Although the rates of discontinuing hormones and detransition may change over time, our compassionate care can remain a constant.