“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
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.

The problem of extrapolating the idea of “innate gender identity” from MTF folk to FTM folk.

In earlier posts I have been critical of the construct of “innate gender identity”. One problem I have talked about is the problem that low-level instincts and imprinting that may lead to transgender identity are called “gender identity” and the high-level narratives that transgender people use to explain themselves to themselves and others are also called “gender identity”. I use the term identity to describe the high-level narratives, because that is what we generally mean when we use the term identity, say when someone identifies as Irish or a Goth or Republican or something. Even those identities have low-level biological correlates. We know for example that conservatives tend to have a stronger threat response and a stronger disgust response than liberals. The important point is that the high-level narratives are culturally specific and do not necessarily arise from the low level instincts. People with the same low-level instincts can arrive at different identities depending on their circumstances and their environment.

The classic transgender narrative holds that people have an innate gender identity and if their bodies are different than this identity they will undergo tremendous suffering and the only way to end this suffering is to attempt to change your body as much as possible to one of the opposite sex and socially convince people that you are a member of that sex. Only then can you be your true self, and be free of the suffering of gender dysphoria.

There are some good reasons that the idea of innate gender identity came into fashion. The most classic is the tragic story of David Reimer. In short, psychologist John Money had the idea that gender identity was established around age 2 or 3, and established in response to socialization. Therefore, if you raised a natal male as a girl, he would adopt a female identity. John Money found the perfect subject to test his theory on in David Reimer. David Reimer lost his penis in a circumcision accident as an infant. John Money believed that if he was raised as a girl, he would develop a female identity and could be given estrogen at puberty and become a well-adjusted woman, albeit without reproductive organs. Money reported this case as a success, and indeed my undergraduate psychology textbook of 20 years ago referenced this case as support for Money’s theory.

However, in the late 90s, this story was exposed as false. David Reimer did not adjust to life as a girl, hated taking estrogen, and demanded to be put on testosterone and ended up living as a man, eventually marrying a woman. Sadly, his story ends tragically, as he committed suicide in his 30s.

A later study was done on 16 male children that were raised as girls because they were born with the genital abnormality known as cloachal extemony Of these children, 8 out of the 16 identified as male and transitioned, and all 16 had “interests more typical of males” This is half, a very large number, but also illustrates how even though these children were male except for their genital abnormalities they had different outcomes of identity. This is because the identity is a response to these low-level instincts and not the low level instincts themselves. These 16 people with identical histories developed different identities. Much the same way as people with cross-gender feelings or instincts can develop different identities depending on their cultural circumstances and even their own choices.

That is where the idea of “innate gender identity” originated, from studying male children that were raised as girls due to lacking a penis for one reason or another. Then this idea was extrapolated further. If there is some innate gender identity, then natal females must also possess a similar identity, and if they have an innate male gender identity that will cause the same problems. This idea is also being extrapolated onto children, but that is a subject for another post.

There are two assumptions here that aren’t necessarily true. One is that the cross-gender feelings of trans people are from the same cause as the feelings of natal males raised as girls, the second is that natal females with some degree of male identity will have the same dynamics as natal males with some degree of female identity.

I tend to focus more on MTF issues and male detransitioners because that is what my experience is, but I think there will be (and already are) many more female detransitioners, in part due to the way this gender identity idea is even less of a fit for what is actually happening there.

People are identifying as non-binary, outside of gender entirely, identifying as one gender at one time, being dual gender, identifying as a different gender a different time. Taking T for a while and then stopping, inventing new pronouns, etc. So, now the idea as the gender identity is innate, yet sometimes it is fluid, and sometimes it changes and sometimes it doesn’t, but it is still innate and if you try to change it that is wrong, but sometimes it changes on its own. Huh? There are also those with a strong persistent male identity as well. These dynamics exist among MTF-spectrum folk as well, but are more common among FTM-spectrum folk.

Historically, there has been approximately a 3:1 ratio between MTF transitions and FTM transitions. However, a recent study has shown in recent years that the amount of people presenting with FTM issues has grown to even exceed the number of MTFs presenting at gender clinics. Something which suggests social causes are at play.

So, the question is, why is this happening? Why is there a huge increase in the number of FTM transitions (even more than 3x because the number of MTF transitions is increasing as well). Some people say this is because of greater awareness. I think it is because of a shift in the cultural milieu.

There are biological factors correlated with FTM transition. We know that both interest conditions such as CAH and endocrine conditions such as PCOS are correlated with FTM identity. These lead to masculinization of behavior and in some cases physical masculinization and likewise in some cases male identity. Again the presence or absence of these factors don’t make anyone’s transition more or less “real”.

I am believer in behavioral functionalism, which is to say in order to make sense of why a behavior is happening it useful to look at what functions it serves for the person that is engaging in it. So, the question becomes what functions does this process of identifying in these ways serve. First, an important part of identity is being part of a group and creating a sense of affiliation with the group.

So then the question is what is the function of these identities and this community. It is my belief that it is fundamentally a reaction to a conflict between being who they are and the cultural expectations placed on females. A reaction to societal stereotypes of women, objectification, misogyny, and in some cases particular traumatic experiences particularly around men. The particular themes vary but these are common ones.

The reason why behavioral functionalism is so great, is by understanding the function of the behavior it can make things that seem really strange on the surface become clear. For example, it can be puzzling on the surface why there are so many FTM-spectrum folks coming out of women’s colleges, but if you understand the function of safety from men, it makes sense because both transitioning FTM and going to a women’s college both can serve the same function of safety from men and getting away from misogynist expectations.

In fact as I had said once before, a lot of this looks like “lesbian until graduation” of 20 years ago which also served the same function of getting away from misogyny. The difference is that this trend involves testosterone and permanent body changes that can’t be reversed. So that is a disaster. Lesbian until graduation might leave behind a few broken hearts and might be an interesting youthful adventure. Any woman who takes T and returns to female identity will be dealing with the permanent effects of testosterone.

Again just as the existence of “lesbian until graduation” does not deny the existence of those who retain a long-term lesbian identity that is healthy for them, neither does the existence of “trans until graduation” deny the existence of those for who testosterone use and male presentation is right. The difference is that it is important to find better ways to distinguish between the two before people take T if possible. How to do this? I don’t know, but I suspect looking at misogyny, gender schemas, dissociation and trauma is a good place to start.

Also, if we do end up with a lot of female detransitioners, it will eventually lead to a backlash that will also effect those that seek these treatments to improve their quality of life, so everyone should be concerned with this, no matter what your political stance on trans issues.