“regret rates” are not the sole measure of outcomes

I’ve seen the statement made many times that “the rate of regret for gender transition is very low”, generally quoted between 1 -3 % or so. This is used as evidence that we should not be so concerned with the problem of detransition. People identifying with a certain gender and wanting to transition is enough proof that transition is right for them, and therefore there is no need for any in-depth screening.If someone identifies with a certain gender and wants to transition then clearly that is the right thing, as evidenced by low regret rates. Also, there is no reason to look at different ways to deal with dysphoria, because we have this great treatment that already works.

However, there are several problems with this which are:

  • The reported measures of regret rates don’t actually measure regret rates.
  • Regret rates are not the sole measure of good / bad outcomes.
  • The demographics of transitioners today are not the same as those in the past.
  • Gender transition improving people’s quality of life, doesn’t mean there aren’t less invasive ways to get the same improvement.

The reported measures of regret rates don’t actually measure regret rates

An example of a study that shows transgender regret rates is here. This study shows a “regret rate” of 2.2%. However what are they actually measuring? What they are actually measuring is the rate of “legal detransition”. They measure what percentage of people who undergo a legal name and gender change then undergo a second legal name and gender change. They don’t measure people who have regrets but don’t detransition legally, or don’t detransition at all. It is also possible to detransition and not regret the original transition.

Regret rates are not the sole measure of good / bad outcomes

Indeed, regret is an important component of good outcomes. Regret is part of a poor outcome, and satisfaction is part of a good outcome. However, it is not the totality of good outcomes. Good outcomes include social adjustment, economic well-being, mental health, and other measures of health. There hasn’t been any research that I know of on long-term outcomes of gender transition (20+ years), partly because most long-term transitioners are lost to follow up.

Because I transitioned 20 years ago, I know many MTF transitioners that were in my cohort or even 5-10 years before. What I see is concerning. I am the only one out of them that has detransitioned, and most of them would not say that they regret their transition and continue to go by feminine pronouns and feminine names. In terms of life outcomes, I would say economically they are mostly doing well. However, socially they are struggling. Most of them are alone. I see a lot of social anxiety, people being unwilling to leave the house. In addition, they still continue to deal with dysphoria and have emotional difficulties.

This is not a good thing, some people would say these difficulties are due to oppression and by reducing this oppression it would reduce or eliminate these difficulties. I definitely believe that oppression is a large factor in some of the things that are awful about being transgender. I oppose those that intend to make the world worse for trans people. However, I do not think it is the sole source of these difficulties.

The demographics of transitioners today are not the same as in the past

These studies of regret rates are often used as reasons that we don’t need to be too concerned about people with cross-gender identities regretting transition. This is combined with the idea that people have a fixed and essential gender identity and aren’t wrong about it. So, if someone identifies as transgender, then they are transgender, and that can’t be changed.

In particular we should be concerned about two groups, adolescent / young adult FTM transitioners and transitioning children. Historically, the ratio of MTF : FTM transitioners was around 3:1. A recent study showed that FTM transitioners are now exceeding MTF transitioners, a large change. Also, there is a recent
study
showing that many of these are young women dealing with typical adolescent identity issues as seen here. I wrote about this in more detail here There are already more and more female detransitioners and people who take testosterone for a while and then stop. The trouble is we don’t know how to distinguish between the people that are going to be happy with their transitions in the long term and those who won’t. This is a topic that is in great need of further study, and we should proceed with caution until we have it, to make sure we aren’t giving a permanent solution to a temporary problem.

We should also be concerned about transitioning children, as historically 75-90% of children with gender identity issues desisted at puberty. I believe that children that have gender dysphoria that persists into adolescence should be given access to transgender services. I don’t think this point is particularly controversial in the field. However, desistance rates have been declining. This has been celebrated as vindication for the use of puberty blockers, but it seems to me that this is evidence that the experience of puberty itself leads to desistance, and therefore it is important to have these children experience at least some of their natal puberty in order to determine whether they will desist or not.

The wrinkle in all of this is that if someone is to undergo gender transition it is better for them to experience as little of their natal puberty as possible, both for the emotional effects of their puberty, and better physical results from transition. This is one of the things that makes it tricky. I think it would be best to try to figure out how much of the natal puberty they need to experience to determine if they would desist or persist, I don’t know what the answer to this question is.

Also there are those that claim desistance is equivalent to persistence as long as they are well-adjusted. I disagree with this strongly, even if they become well-adjusted trans people. If they could have been well adjusted without this treatment as well that is still a loss. Infertility and a lifetime of dependence on hormone treatment should not be treated lightly. Of course if the choice is between being a well-adjusted trans person and non well-adjusted cis person, we should prefer the well-adjusted trans person.

Gender transition improving people’s quality of life, doesn’t mean there aren’t less invasive ways to get the same improvement.

The research shows that gender transition improves the quality of life of some transitioners, and I do not advocate for eliminating it, or denying access to those who need it. However, this does not mean we shouldn’t continue to look for better ways to work on these issues at the same time. Even though transition does indeed improve people’s quality of life, this is still a community under significant distress. Attempts to help people work on these issues without transition should not be denounced as “conversion therapy”. It is not evil to want people to find better ways to deal with their issues.

24 comments

  1. All GNC people are socially oppressed. This is what we should be focusing on, not on thinking medical intervention can somehow alleviate this, or that people who are treated thusly deserve special treatment. We should be attacking the entire problem of enforced gender scripted conditioning, because that is the route to freedom for all.

    1. Just as nothing necessarily makes the masculine property masculine, or the feminine property feminine, nothing necessarily makes the gendered property bad. Rather then the misguided notion of overthrowing established styles of identity, the strategy should be to show how it is constructed and persists, and to transform it.

    2. I agree that social oppression of GNC people is an important thing to focus on, and reducing that would benefit all GNC people. I don’t think it would completely solve all of the issues, but it would be of benefit.

  2. ” Infertility and a lifetime of dependence on hormone treatment should be treated lightly.”
    Looks like a typo to me, maybe that should be “should NOT be treated lightly.” ?

  3. “An example of a study that shows transgender regret rates is here.”

    The link for ‘here’ in the above sentence is not working.

  4. I totally agree that transition is an invasive treatment, and that when a person can thrive without lifelong dependence on HRT, etc., that’s preferable. I especially think the issues around reproduction need to be addressed with a lot of sensitivity. I am fortunate in that I have a wonderful doctor who worked with me on an informed consent basis and really addressed the implications for having a biological child.

    The tricky question is, who decides? How do we determine who needs this care? Historically, the gatekeeper model enforced very rigid gender norms and was just generally bullshit. People lied about their stories to get access to care, clinicians refused transition to people who would be gay or lesbian after transition. I’ve even heard of male clinicians who would only let trans women transition if they personally found them attractive.

    I think a rigorous informed consent model–which is slowly becoming the norm–is the best solution. People should understand the implications of the medical interventions–what changes are irreversible, implications for reproductive health, etc. Given proper information, I can’t imagine any expert or instrument that would be better suited to decide if a person should transition than the person themself.

    I also think you may be misunderstanding what’s going on with transmasculine folks right now. A lot of people are choosing to transition to some type of in-between–to express themselves as, e.g., masculine queer female people. IMO this is a HUGE improvement from the past–just because a person is very masculine and, say, wants top surgery or a name change, doesn’t mean that person has to claim to be a normative man, has to commit to testosterone for life, etc. Isn’t that exactly the type of solution you’re talking about? People are charting their own courses and I think that’s a very good thing. Re: starting a stopping T, a lot of people are doing that on purpose. Obviously some folks are experiencing regret, being encouraged to transition too young, etc–our community has an obligation to address these issues. But people taking unconventional transition paths is a good thing. They’re actually figuring out what works for them, not being forced to fit a mold.

    1. I agree with you completely about the historical problems with gatekeeping. It still astonishes me that even today there are no evidence-based criteria for factors that will lead to poor or good outcomes, because of that anyone engaging in gatekeeping at best is relying on their own experience, and at worst is purely making things up.

      There are two separate questions here: 1. What are the factors that lead to the possibility of psychological resolution and good/poor outcomes? and 2. Who gets to make the final decision as to hormones / surgery etc.?

      I think it should really be like any other time you go to the doctor for an evaluation. The doctor gives their best expert opinion, ideally evidence-based, and then the client is free to follow that opinion or not.

      This is also tied into age-appropriateness, we restrict adolescents from doing many things, particularly things that have permanent consequences, because we understand they are not completely mature and don’t always have an understanding of long-term consequences of their decisions. This certainly doesn’t feel true when you are an adolescent though!

      You are right that I am not a transmasculine person, nor am I a young person so there is both generation gap and a gender gap going on in my understanding of transmasculine issues. I am indeed talking about these solutions other than binary transition existing and people finding their own way through it. I am glad that there are more people finding a middle ground, and do think that is good way. Also sometimes it just takes exploration to find out where you want to end up.

      However, being an older person and part of the previous queer generation, I am also aware of how so many of the ideas that we hold when we are younger and that seem like essential truths turn out not to be. I was very active in the bi community in my 20s, and I remember being angry at the idea that it was “just a phase”. But for some of us, it really was just a phase! Some now are heterosexual in identity and practice, some are gay/lesbian and for some the bisexuality is indeed a life-time orientation (and some of those are in monogamous relationships with one gender or another).

      Even 18-25 year olds, are not fully formed yet in many ways, and hormones will have permanent effects, some of which I suspect will be unwanted as people are older. Doctors were historically reluctant to give sterilizing treatments to people in theirs 20s for just that reason, as we knew that many of the people who felt they would never want children would turn out otherwise when they reached their 30s.

      So it is tricky, you are right about that.

      1. Thanks for the thoughtful reply! You are indeed my elder and I enjoy learning from your perspective as an older queer person. At almost-26 I have recently become aware what a sandcastle identity really is–lord knows mine changes every few years–and the spiritual idea that the self doesn’t exist has new meaning for me. At the same time, transition has truly been a live-saver, and has freed me in so many ways. I don’t have to think about gender anymore; now I think about gender for fun. And that is a precious thing indeed.

        In reading this thread, I am aware what a different proposition transition is in the MTF vs FTM direction. For trans women, there is an intense pressure to transition as young as possible in order to be read as female; HRT causes infertility; trans women are far and away the main targets for transphobic violence of all kinds; and you describe a trend of loneliness and social isolation. For trans men, there is no need to transition early to be read as male, so we can take our time exploring nonbinary options for years and still transition to male if we choose (and this is what all the trans guys I know have done); we generally have the option to go off hormones and have a biological child years after transition if we want to; we are usually invisible and many people don’t even know we exist so we are insulated from transphobia and benefit from male privilege; and I see no trend of loneliness or isolation among the middle-aged, decades-past-transition men that I know. Quite the opposite–these guys are in fact very well-adjusted, involved in the community, doing work they love, happily partnered, etc.

        My personal approach to transition is “start small and go no further than needed.” What I did and what I tell people to do is to start by experimenting with little things like clothes and haircuts and see how that goes. Slowly, try out bigger steps, closely monitoring dysphoria and overall wellbeing, and stopping whenever dysphoria gets to a tolerable level. So to use myself as an example, I started on low-dose testosterone and gradually upped the dose, listening closely to my body (and my lab work, of course). I find I feel great when my levels ride the very bottom of the “male” range/the very top of the “in between” range–so I stay there and feel no need to be solidly in the “male” range just to make some kind of point or to masculinize myself as much as possible. By the same token, if I could wave a magic wand and have instant, free, zero-healing-time bottom surgery, I would do it–but I can’t, and it’s just not necessary for me to have such an invasive treatment given how low my levels of dysphoria are. I found a sweet spot where I can thrive. Some people will be able to find this special balance with no medical treatment, others with just a little, and others only with the whole suite of procedures.

        1. Yeah, I agree that the equations are different for FTM and MTF transitioners and that is a very important consideration. In particular, like you say age has a very large effect on MTF folk and the ability to social integrate. Even 18 will often cause significant problems, and if someone is going to transition MTF, ideally they would do it shortly after the beginning of puberty if possible.

          I also as I said before believe in the importance of experiencing at least some of the natal puberty for the purpose of determining persistence and desistance, which unfortunately is in a direct contradiction to the goal of early treatment for someone who is transitioning MTF. It would also cause an increased amount of distress for that purpose, so balancing these goals is very tricky.

          I have also seen much less of these problems of loneliness and isolation on the FTM side of the equation, particularly if they are looking for female partners it doesn’t seem to be as much of a problem.

          Also because as you say, the need for early transition is less important on the FTM side, it seems like a good idea to slow things down with the teenagers, especially if there are other mental health / identity issues present. This has to be highly individualized and I’m not sure you could come up with any hard rules or anything, because the person could very well not be able to deal with their other mental health issues without dealing with the gender issues first. I just want people to have appreciation for the complexity, and not just treat their identifications as the last word. I do hope more people are taking the slow approach you describe, and taking time to explore things.

          The worst outcomes seems to come from the “cross dreaming” flavor of MTFs, and that is where I see most problems, especially if their are either physical or personality reasons that make social adjustment difficult.

          I suppose one benefit of going through all this is being able to set your hormone levels to whatever you want. I actually ended up reaching the same conclusion as you with regard to T-levels, I also maintain a low normal level, which is enough for vitality but minimizes the negative effects.

    2. I don’t understand why trans persons or potential trans persons believe that they should be exempt from medical gatekeeping. If you try to get a cochlear implant, or weight loss surgery, or a vasectomy before you have any biological children of your own, or even spinal fusion surgery for your chronically painful back, you WILL face several roadblocks starting with the person making the appointment and who asks the purpose of your visit. Some gatekeepers will decline you outright, while others will require you to take several additional steps including a waiting period and/or therapy. None of those procedures cause anywhere near the life changes that changing genders does.

      No, doctors are not always right. Some of them bring personal biases to their jobs with them. They often resist change. But, all other things being equal, I’m more likely to trust the care plan recommended by an MD with years of experience and training rather than a depressed 13-year-old’s care plan.

  5. This is a very thought provoking article, TWT. I especially like the suggestion of looking at adjustment/adaptation/regret in more detail, not just asking, “Are you glad you transitioned?”. Check it out from multiple angles, dimensions . . . Many post ops, for example, I suspect, are isolated, lonely, etc. In addition, it disturbs me professionals are not doing more searching for less invasive ways to deal with GD. Way too many think they’ve got it all figured out, medical transition is seen as the golden path. The line is, “Let’s get started on this today!” One approach is to talk more about AGP, identiying it as early developmentally as possible, correlates, etc.; then perhaps intervene with, e.g., anti androgens, social skills training, shyness reduction, secrecy issues, discussion of unwanted consequences, etc. Let’s see more presentation and development of the ideas you present in this fine article. Kudos!

    1. Those are all great potential interventions, and one of the problems is we can’t really talk about AGP because it is such a heated concept. It is just the general medical principle of using less-invasive interventions before more-invasive ones.

      I don’t know how to transform that. I think the term AGP has the wrong connotations, and in any case has become so polluted since Bailey’s book came out that we have to find both more accurate and less charged terms to talk about the phenomena, which is one of things I try to do in the blog.

        1. I think looking for interest in feminization/sissification/AGP themed porn/fantasies and erotic cross dressing would be a good place to start. I

          There is also some correlation between AGP and nerdiness, and while they often can be soft and gentle as boys they aren’t usually what you would describe as feminine per se.There is also some correlation with nerdiness, but neither of those are absolutes.

  6. This is a very, very interesting post. As time goes by, I am buying into the idea that transitioning is not for everyone. While always leaving the door for a future transition, I still feel that I should have transitioned in my late teens. I didn’t because of my strict Catholic upbringing and my old-world parents who probably would have disowned me. Nevertheless, I read everything I could get my hands on at the time. The inner thoughts demanding that I transition, and that includes any and all necessary surgeries have never left me and never will. I rarely crossdress…perhaps once a year…and have never been out in public presenting as female. I get absolutely nothing out of it. I always use the “window dressing” analogy with my crossdressing friends who try to figure out what I am. I don’t have the right kind of window, so why dress the wrong parts.

    What did happen is that after being basically asexual, I found a woman who taught me how to respond as a male. We later married, had kids and a transition now would simply be selfish on my part, ruining a family. I’ve seen too much of this. Instead, I deal with this in many ways including keeping myself incredibly busy with work and many service organizations I belong to, a health diet, exercise, trans friends, and I absolutely love to read books written by female authors.

    I am deeply involved in the trans community, both locally and via T-Central. I know many crossdressers, emerging transsexuals and those who have transitioned. I have friends who I knew before, during and after transitioning. In some cases, years after transitioning, some of these friends are incredibly unhappy, bordering on suicidal.

    You hit the nail on the head when you mentioned loneliness. Without exception, those who are happy after transition are NOT lonely. Those who are not happy have no love in their life and seem to have a very difficult time finding love. I can’t begin to tell you how many times I have been told by someone who had transitioned, and is unhappy, that if I have love now, stick with it, fight it, and do whatever it takes to not transition.

    I am going to feature this post on T-Central.

    1. Loneliness is a huge problem particularly for MTF transitioners of the cross-dreamer type who have difficulty finding partners. Almost all of the ones that I know that have partners either have a partner from before their transition that stayed with them, or are partnered with each other.

      That is certainly my greatest regret, is that I have never had a long-term partner (longer than 2 years, anyway) and difficulties with dating. Plenty of people were attracted to me, but not usually as a primary partner, and I had my own difficulties with bonding with others as I was so attached to my image of myself as a woman.

      It is interesting the things you describe family, service, relationships, engagement in life are precisely the things that line up with the factors that lead to a happy life in the research. Somehow most of the thinking around this issue has gotten to the idea that the transition is everything, and those factors are secondary. This might be true if the person is in severe enough distress, but is not true in all cases.

      It makes me sad to see how socially cut off so many of my cohort of transitioners are. Is it going to be different for the young people today? I don’t know, the social climate is very different, but I am concerned about it.

  7. The reason that so Many T’s are lonely and poorly adjusted socially is that they simply do not fit into ‘normal’ society. Gays tend to prefer other gays as lovers; as do lezzies.
    ‘Straight/normal’ people, also prefer those with complimentary preferences. Trannies and queers are just that, queer, and so they are left with only those that share their queerness. That might work if you are truly queer and can find someone of like mind, but the available pool of eligible/compatible partners is much smaller than in the general, “normal/straight/gay” population.

  8. I’m a young (18) trans guy. I very much did not transition in the Milo Stewart informed consent social context. I came out at 13 in a conservative area where you were legally only allowed to see one single therapist and had to win a court case to get blockers, let alone hormones. I eventually did get blockers at 15 and hormones at 17, and due to a naturally high passability experimented with being stealth offline pre-T.

    Because I don’t pass for an 18 year old man, a lot of my friends are the queer generation kids. AAPs, transtrenders, nonbinaries, all kinds of brilliant things in our brave new world. I try to grit my teeth and ignore it when people are talking about 76 genders or how trigger jokes are destroying the world, and I know they’re good people besides, but I’ve met enough detransitioners to know how this will go.

    Gotta say, every time someone says ‘age is not a major factor for natal females’ I wonder if the speaker has eyes. For AAP trans guys (who look more feminine than HSTS) the cutoff is around 15-16, for HSTS it’s early twenties for the particularly lucky ones. Past that you can convince people who aren’t particularly skilled at identifying natal female traits on men, but the baseline level of skill required is increasingly lower, just as it decreased during the 80s and 90s for trans women with increasing social awareness. This is why despite using Blanchard’s language I think the man is insane (that and missing that the overwhelming majority of FTM transitioners are AAP, though I’ll give him that this wasn’t true in the 80s), and why my response to ‘desistence rates are dropping and all these young FTMs are autistic butches!’ is ‘let’s give blockers to all autistic or notably masculine natal females so if they transition they aren’t fucked over!’. (As someone who fits the ‘young, autistic, used to be a butch lesbian’ profile, I’m also trying to figure out how ANYONE can look at the crop of young FTMs coming out and think more than 10-20% are HSTS-in-different-words.)

    1. You are right that people can spot FTM folk more easier in the past, especially if you travel in queer spaces or live in an area with a lot of FTMs.

      I don’t think that age doesn’t have any effect at all for natal female transitioners. I think it does make a difference whether someone starts before the end of puberty or not. It is just that there is not that much difference between say a 17 year old and a 21 year old. Part of that is because females finish puberty earlier than males, so a 17 year old natal female is likely done with puberty where a 17 year-old natal male is likely not. Also masculinzation of the skull for males is often not complete until the early 20s which makes a big difference in outcome.

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